Pain and deliberate self-harm
Deliberate self-harm is a troubling aspect of adolescence (and possibly even adulthood) that appears to be on the increase. Its relationship with pain is uncertain, but for many self-harm is not so much about the inflicting of physical pain as the cessation of emotional pain.
For many people the idea of deliberately harming oneself is difficult to conceptualize. Many of us may spend our time attempting to avoid harm to ourselves either in the short-term (wearing a seat-belt) or in the long-term (exercising regularly, eating a healthy diet). Many of us would flinch from the idea of wilfully inflicting acute damage to our own bodies. How then can we understand individuals for whom harming the self is not something that they avoid or find aversive but is something that they seek out?
Deliberate self-harm is a term that covers a wide range of behaviours some of which are directly related to suicide and some that are not. This is a relatively common behaviour that is little understood.
What is deliberate self-harm?
An act with a non-fatal outcome in which an individual deliberately did one or more of the following:
Two elements are crucial: there is acute damage to the self (this excludes, therefore, behaviours such as smoking or eating an unhealthy diet); and damage is intentional (therefore, excluding accidents or behaviours such as starving where the motive is to lose weight as in anorexia nervosa).
Some clinicians and researchers draw distinctions between forms of deliberate self-harm where there is or is not an intention to die, distinguishing attempted suicide from self-harm or self-mutilation. There is some validity to this distinction. For some people, deliberate self-harm is more about finding a way of coping with life rather than ending it.
Nevertheless, regardless of the method or motive, harming the self seems to put people at risk of more severe forms of self-harm over time. In addition, even for people who primarily think of self-harm (e.g. cutting) as a way of coping, they may at other times harm themselves in other ways where they do have the intention to die. The potential lethality of a method adopted by an individual is not always an accurate indicator of his or her intent. Very few people who harm themselves have sufficient knowledge about how the body works to judge the impact of their actions.
How common is deliberate self-harm?
While deliberate self-harm is particularly common among adolescents and has been on the rise in recent years, it continues into adulthood. Its incidence and prevalence in adulthood is also difficult to estimate accurately, and figures based on hospital attendance again probably underestimate its impact. One review (Favazza and Rosenthal, 1993) reported prevalence estimates of between 400 and 1400 per 100 000 of population per year.
While there is an increasing awareness of the risk of suicide in older adults, less is known about deliberate self-harm in the older population. It has often been assumed that the behaviour declines as people age. It may be, however, that the behaviour is even more taboo in older adults than in the young.
Who is at risk?
Not everyone that experiences these events goes on to self-harm. So what are the links between these experiences and the development of deliberate self-harm?
There are a number of different theories but two common themes are apparent. The first is the experience of intense and distressing emotions. These may be related to particular experiences, such as sexual or physical abuse.
The second factor is the absence of the right kind of emotional support. In other words, the child (or in some cases the adult) is not provided with the assistance to recognize and understand their responses to the events they are experiencing. In some cases, for example sexual abuse in childhood, the fact that the experience occurred at all may be denied. The absence of recognition and support in the context of extreme and distressing events leads to a sense of powerlessness, and an incapacity to understand and manage painful feelings. Linehan (1993) refers to these environments as 'invalidating' because the individual's experience of reality and their responses to it go unrecognized and unsupported.
Why do people deliberately self-harm?
Deliberate self-harm and pain
The biological bases of the relationship between self-harm and pain is, as yet, unclear. Some theorists have argued that early experience of trauma damages certain neuroanatomical pathways in the brain related to the release of endorphins, which are implicated in the regulation of emotional states. In individuals whose neural pathways are affected in this way, it is suggested that deliberate self-harm may offer a means of releasing endorphins. Others have noted changes in the brain systems utilizing the neurotransmitter serotonin in both suicide and deliberate self-harm. The role of these systems in both the development and maintenance of deliberate self-harm behaviours remains to be fully elucidated.
There is some debate among therapists and people who self-harm about whether deliberate self-harm should form a primary focus of treatment. Some therapists advocate addressing the underlying problems in the past (and also in the present) that lead to the behaviour, rather than focusing on the behaviour itself. They argue that when these problems are resolved the behaviour will cease.
Other therapeutic schools suggest that the deliberate self-harm should be a primary focus for treatment, particularly when the behaviour is especially frequent or particularly severe, or associated with significant mental health disorders, as failure to do so places the person at risk. Which is the effective option for any one individual is likely to depend on a number of factors, such as the severity of the self-harm, whether the individual is highly suicidal or not, their capacity to function generally, their own preference for therapeutic approach and a thorough understanding of how the deliberate self-harm relates to other aspects of the person's life.
For individuals who harm themselves who also present with very severe
and complex mental health problems that would fit the diagnostic criteria
known as borderline personality disorder, there is relatively
good evidence for the effectiveness of dialectical behaviour therapy
(Linehan, 1993). This therapy recognizes the importance of both managing
problematic emotions and situations when they arise, by using a wide range
of techniques derived from cognitive behaviour therapy, as well as understanding
why it is that deliberate self-harm and other behaviours that may also
be considered impulsive are effective for people with very traumatic pasts.
Centers for Disease Control (1990) Attempted Suicide among High School Students United States.
Favazza A R and Rosenthal R J (1993) Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44(2), 134140.
Gratz K (2003) Risk factors and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology Science and Practice, 10, 192205.
Hawton K, Rodham K, Evans E and Weatherall R (2002) Deliberate self-harm in adolescents: self-report survey in schools in England. British Medical Journal, 325, 120711.
Linehan M (1993) Cognitive-Behavior Therapy for Borderline Personality Disorder. New York: Guilford Press.
Williams J M G (2001) Suicide and Attempted Suicide: Understanding the
Cry of Pain. London: Penguin.