Cutting and Self Injury - Issues and Intervention in Adolescence

Introduction



The lone voyage of self-destruction is becoming all too common. As a teenager, I experienced its sadness along with several of my closest friends. This painful and devastating issue is now close to me once again, as my 5 year old daughter appears to be practicing this disorder. I feel that researching this topic will help me find the best way to help her. I hope to better understand this often misunderstood phenomenon.



In this paper, I will discuss what self-harm looks like, as well as what researchers have to say about it. Although there are several intervention techniques to deal with self-injurious behaviour, research on the subject shows that Dialectical Behaviour Therapy is the most effective, and therefore the most widely used. This may be the case but, I will also discuss the various other methods to treat self-injurious behaviour.



What is Self-Injury?



Self-injury is defined as the dangerous, physical release of intense feelings of traumatic experiences that have become intolerable for the adolescent boy or girl to express verbally and/or emotionally. Adolescents hurt themselves as a coping strategy, although the long term results lack effectiveness and interfere with a teen's happiness, productivity and mental state. It is also a very powerful form of silent communication for a young teen (Motz, 2009). In my line of work, I have heard several teens admitting that the acronym C.U.T. refers to Coping Until Tomorrow. Some people believe that self-injury is not an addiction over which one is powerless for a lifetime; rather it is a seemingly uncontrollable compulsion that must be transformed into a choice, thus shifting the control of the person suffering, empowering them to overcome. (S.A.F.E. Alternatives, 2007) .



There are three types of classification for self-injurers; Major, Stereotypic and Superficial. Amputation such as castration is the most severe form of self-injury and falls under the classification of Major. This is generally associated with persons suffering from psychotic episodes or heavily intoxicated states of consciousness. Schizophrenics, autistic and individuals suffering from repetitive and rhythmic movements usually display self injury such as head banging and self-biting, this falls under the classification of "Stereotypic". For the purpose of this essay, we will be discussing the "Superficial" form of self-injurious behaviour that is most commonly found in the teenage population. There are two sub-categories which can be defined as impulsive and compulsive. These categories include self-injurious acts such as cutting/carving, burning and hair pulling also known as trichotillomania. The most common form of superficial self-harm is cutting because it creates an "immediate sense of order, sensation and release in what was otherwise a pure state of distress and anxiety" (Motz, 2009, p. 17). Nevertheless, all forms of violence towards one's body are troubling and intricate because it is the way many young people communicate their ambivalence and suffering. Other teens can relate, making them feel a sense of belonging.



Early in the 1970's, eating disorders were at the time, the new pathology, but today self-harm is being dubbed as a new psychopathology. It is being coined as the new anorexia of our time, because both eating disorders and self-injurious behaviours indicate similar psychological characteristics (D`Onofrio, 2007). Self-harm is also known as a cyclical process; the teenager is triggered by a conflict whether interpersonal or academic which then leads to their feeling emotional tension, usually distorted, along with negative thoughts. The adolescent begins to feel like they may explode and this is usually followed by a sense of panic which leads to the initial act of harm. Once the harmful act is completed, the teen feels at ease, the tension decreases enormously. At this point they return to a state of normalcy. This calm allows them to react better to situations but at the same time the calm begins to be replaced by guilt and shame and eventually a communication breakdown, within themselves and then with others. This process is known as the cycle of self-injury (Enns, 2008). For example, a teen may be provoked to self-harm after going through a terrible breakup (in the home or with friends), or family fight and consequently may feel the urge to punish his or her self. These painful feelings start slowly, but over time, build, and begin to escalate in severity.



There are numerous signs that could indicate that an adolescent is self-harming. For example, covering up parts of their skin, even in hot weather and a combined resistance to participating in activities that require undressing or exposing (like physical education); they experience extreme mood swings and have emotional detachment from both their peers and family. There exists some early warning sign that can contribute to a later potential problem such as being from a family where communicating about feelings is strongly discouraged and problems are swept under the rug. Sexually abused children often experience self-harm behaviours since living in a fear evoking environment often leads to difficulty in managing one's feelings.



Research



Researchers estimate that the rate of self-injury has risen by 150% over the last twenty years (Enns, 2008, p. 11). The numerous factors that contribute to this staggering number are associated with the family breaking down and community and cultural breakdowns: There is more pressure on adolescents to be involved in and to excel in many activities this pressure, combined with the socially disconnected lifestyle due to personal computers, cell phones and video games, encourages further isolation.



While perusing the latest copy of the Diagnostic and Statistical Manual of Mental Disorders IV, I noticed that there is no mention of self-injury as a mental disorder. It is not widely recognized by health practitioners as a primary disorder, rather one that accompanies others disorders. According to the Handbook of Cognitive-Behaviour Group Therapy with Children and Adolescents, clinicians have associated self-injury with several diagnoses, some of which are Borderline Personality disorders such as depression, post traumatic stress disorder and conduct disorders (page 374). The relief from emotional distress due from self-injury is a coping strategy used by adolescents whether or not they have suffered from the criteria for diagnosable DSM-IV psychological or personality disorders (Selekman, 2009-2010). This information or lack thereof, is incredibly astonishing for me. I feel that self-injurious behaviour is so rampant in our society that it should be recognized and addressed on a level that is understood by teens.

After researching self-mutilation on the Statistics Canada site and even speaking with several different departments, I was surprised to discover that no research has been conducted on the causes, symptoms and effects of self-injurious behaviour among teens. This demonstrates to me that this issue is not taken seriously in Canada. My extensive research on-line did locate several sites that can assist parents, teens and professionals. What shocked me most was the 'how to' self-harm videos I came across. I found several helpful books and journal articles tucked away in libraries, not at all easily accessible.



However, I did discover that one Canadian institute conducted two surveys, one in Canadian urban cities and one in Victoria, British Columbia. The first one found that of the 13.9% involved in self-harm acts 64% were females while males made up 39%. In BC, the numbers were higher with a 16.9% indicating self-harm behaviours. The hope in this Canadian research is that 56% sought help for their problem (Enns, 2008, p. 10). In another research project done in a Québec high school, it was found that 72.6% of the student population who self-harm are suicidal, while only 15.9% do it as a coping mechanism (Pommereau, 2005).



No research I came across had studies stipulating the ethnicity and socio-economic status among self-harmers, only that the majority of non-whites were 26% compared to 9% whites. Moreover, trichotillomania appears to be much more common among females than among males. This may reflect the true gender ratio of the disorder. Also, some reviews suggest "that the prevalence of self-injury is three or four times higher in females than in males (D`Onofrio, 2007)." Cutting seems to be more popular among the adolescent female population but this disorder is not exclusive to them; in general, an equal percentage of boys and girls self-injure (Hollander, 2008, p. 4).



Stressors play a major factor in why teenagers engage in harmful behaviour. The bottom line, from my research, suggests that it is mainly done as a coping mechanism. The behaviour provides relief from emotion pain and creates further emotional numbness, permitting the teen to put traumatic experiences to the back of their mind, and find a quick fix solution. It is also a seen as a form of self-punishment because of feelings of unworthiness, loneliness and invalidation. Further reasons for self-injury are fear of the future, lack of communication skills and because they feel emotionally disconnected from others. When it comes to trichotillomania, "stressful circumstances frequently increase hair-pulling behaviour, but it can also occur in states of relaxation and is a form of distraction. There is gratification, pleasure, or a sense of relief when pulling out the hair" (1994, p. 618).



Investigation of Interventions



While conducting my research I discovered that there exist numerous forms of treatment that could aid and assist adolescents with their destructive, harmful behaviour. Of these, I will discuss the main therapies found and will offer some suggestions about the techniques I would use to counsel those practicing in this behaviour.



Emotional



Since self-harm has several links to psychiatric disorders, it is important for counsellors and parents to address the underlying problem without emphasizing the behaviour. They must suggest healthier ways of allowing the teen a form of self expression, and one way is through counselling in general. Whether it consists of family therapy, group therapy or individual therapy, studies show that it is important that the healing start at the emotional level. Also, activities done with the intent to change behaviours are most likely to be positive over a longer period of time.



One aspect of emotional healing that has proven beneficial is journal writing because it is a creative outlet which allows for the effective promotion of feelings. This type of strategy increases the teen's self awareness and may offer helpful insights. By writing their thoughts and feelings, and later referring to them, they can assess their emotional state before and after self-harming incidences. It is done with the hope that they will see where their triggers lie, and begin to work on the solution rather than focusing on the problem.



In one research project done on women self-mutilators, it was found that simply revealing their secretive behaviour allowed them to stop the behaviour completely. They also found that building long term, healthy relationships with counsellors was an effective way to reduce self-harm and allow the production of positive, trusting emotions (Hicks, 2009).



Social



There have been several social strategies applied to self-injury such as assertiveness training, cognitive behaviour therapies and problem solving. Sometimes, a contract may be introduced to a teen as a means of their staying accountable for their behaviour. The goal of the contract must be clear, concrete and short term; often rewards are given when the contract is upheld.

Dialectical Behaviour Therapy stood out for me as one that is most commonly used as almost every article and book I read promoted it. The philosophy behind it is that that "clients are doing the best they can and they need to be more effective, rather than the client is either functional or dysfunctional (DeLuca, 2009)." Another belief is that while clients haven't caused all their problems they nevertheless need to solve them anyway. This understanding seems more productive than working out whether or not the client is soley responsible. In DBT, the skills that are taught involve learning " distress tolerance, emotional regulation and interpersonal effectiveness training (Dyl, 2008)." These skills are meant to be applied in their everyday lives as well as by the therapist and client in session. Though this therapy was originally designed to assist clients with Borderline Personality Disorder, it has proven to be equally effective in the treatment of self-harmers as group therapy and as individual counselling. Group sessions are often held in addition to individual sessions. DeLuca emphasizes that "Skills are taught in group sessions but are also reviewed and utilized in the individual sessions (DeLuca, 2009)." The goals of this therapy are to learn how to help clients build a life worth living by "reducing and eliminating behaviours that are harmful or that interfere with therapy, both on the part of clients and therapist (DeLuca, 2009)."



Biological



Through both research and personal experience, I have come to understand that physical activity is imperative to rehabilitating destructive patterns. The releasing of endorphins sets one into a realm of serenity which more often than not, calms the adolescent down. The release after the physical activity gives the same sensation as cutting, burning and hair pulling (Hicks, 2009).

I also found data that suggested pharmaceuticals would be beneficial in controlling the negative outbursts displayed by adolescents. There is an outpatient program called psychopharmacology that is used to assist clients in gaining control over their mental and emotional states and reduce their behaviour. Selective serotonin reuptake inhibitors, also known as SSRI's are the first medication prescribed to a self-injuring adolescent who also experiences depression and anxiety. Some of these medications include Prozac, Celexa and Paxil. For clients that do not respond well to these medications, "anxiolytics may be tried (Hicks, 2009)", such as Xanax, Valium or Ativan. It also has proven helpful to introduce neuroleptics at low dosages, such as Haldol, Risperadol and Seroquel, when the other medications do not seem to be helping (Hicks, 2009). Prevention of further self-injury must involve therapy if one is prescribed medications. You cannot offer band aid solutions to major problems; the underlying one must be repaired in order for self-injurers to have a successful life free from self-induced physical pain.



Conclusion: Intervention Elaboration



After considering the therapies described above I conclude that effective communication skills and coping mechanisms must include learning to tolerate, self-regulate and love themselves despite their real or imagined imperfections. Counsellors and parents alike must not just stop the behaviour; rather, they must educate the teens about themselves and inform them about having accurate perceptions of themselves and the world around them. By offering parental support, group support and individual support, we would allow the self-mutilator to feel cared for, understood and encouraged. Unfortunately, there a stigma attached to self-injury and the behaviour is most often seen as a fad of Gothic or Emo culture.



I would like to see future research of this disorder and its treatments more readily available to the public. What is needed are more in-depth studies and surveys for the promotion of healing self-injurers rather than promoting the behaviour in the media. Films such as Girl, Interrupted and Thirteen, could help to "create an atmosphere that gives other injurers courage to come forward and seek help (D`Onofrio, 2007)."



It is difficult to see the light at the end of the tunnel when involved in self-injury but breaking the cycle of self-abuse is possible if the adolescent reaches out to someone they trust. Finding new ways of coping with their feelings can help to tone down the intense urge to self-harm. Recovery is a continuous process and learning how to stop this addictive behaviour is within their reach if they work at it.



I believe that if we introducing open forum discussions in school classrooms will shed light on the subject and will show the teen that hurting themselves is not a way of expressing their feelings in a productive manner. I think by showing them picture s of the effects and hearing real life stories might open their eyes to the negativity of this behaviour. Having help lines, other than Suicide Action would also be beneficial. Support groups, like 12 step programs are also helpful when trying to recover from destructive behaviour, so introducing a teen group in the community would prove helpful.



Bibliography



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Christner, R. W., Stewart, J., & Freeman, A. (2007). Handbook of Cognitive-Behavior Group Therapy with Children and Adolescents. New York: Routledge.

D`Onofrio, A. A. (2007). Adolescent Self-Injury: A comprehensive guide for counselors and health care professionals. New York: Stinger Publishing Company.

DeLuca, L. C. (2009, July 5). Suite 101.com:Insightful Writers. Informed Readers. Retrieved April 2, 2010, from Dialectical Behavior Therapy Defined: http://borderline-personality.suite101.com/article.cfm/dialectical_behavior_therapy_dbt_defined

Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. (1994). American Psychiatric Association.

Dyl, J. (2008, March). Understanding cutting in Adolescences: Prevalence, prevention and intervention. Brown University Child & Adolescent Behaviour Letter , pp. Vol. 24, No. 3.

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Hollander, M. (2008). Helping Teens who Cut. New York: The Guilford Press.

Motz, A. (2009). Managing self-harm: Psychological Perspectives. London and New York: Routledge.

Pommereau, X. (2005, April). Scarification a l'adolescence: Nouveaux rites ou signes de mal-etre? No. 76 , pp. 36-39.

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WebMD: Better Information. Better Health. (2005-2010). Retrieved March 20, 2010, from http://www.webmd.com/mental-health/features/cutting-self-harm-signs-treatment?page=2

Williams, M. (2008). Self Mutilation: Opposing Viewpoints. Farmington Hills: Gale Cengage Learning.



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