Focus on response to self-injurious behavior, not cause.
Estimates of SIB in the general U.S. population range from 14 to 600 per 100,000 annually, or less than 1 percent. Given the current U.S. population of 280 million, this indicates that between 39,200 and 1,680,000 people engage in SIB each year. Rates are higher among adolescents and young adults, including an estimated 12 percent in college populations.
SIB is on the rise throughout our country, especially among teenage girls with eating disorders. In eating disorders, prevalence ranges from 25 percent to 45 percent. In one study, SIB had simultaneous onset with the eating disorder in 48.5 percent of patients, later onset in 40 percent of patients, and previous onset in only 11.5 percent. At Remuda Ranch, approximately 40 percent to 50 percent of the women and girls we treat have either reported a history of self-injury or are presently engaging in these behaviors.
Defining, understanding SIB
SIB relates to any socially unacceptable behavior involving immediate, deliberate, direct and usually repetitive physical injury to one's own body. This behavior results in mild to moderate harm, usually without suicidal intent.
SIB typically includes behaviors such as scratching, cutting, carving, burning, rubbing, abrading, punching, pinching, biting, head banging, and hair pulling. In cutting, the tool most often used is a razor blade. The most common body parts cut are the wrists and forearms, followed by the legs.
Similar to eating disorders, cutting is often mystifying to many people and can be frightening to families when someone they love is struggling. We often hear: "Why would she starve herself, or harm her own body? What do we do?"
One patient admitted that her eating disorder is her "pain" and the cutting is her "voice." However, it is difficult to understand the triggers and influences of SIB in eating disorders.
Similar to the forces that influence one's vulnerability to developing an eating disorder, self-harming tendencies evolve and are reinforced through a blend of biological and environmental factors. However, both are complex.
The truth is that the powerful urge to cut can emerge out of nowhere, and the relief experienced is often described as addictive. A series of crises, difficulty managing life stressors, a unique predisposition to impulse and emotional dysregulation, and traumatic and abusive histories all powerfully influence the tendency toward self-harming behaviors.
We realize that cutting serves a very important purpose and can quickly become a maladaptive coping tool, one that has an immediate, short-term effect in attempts to just "feel," to bring relief during an uncomfortable situation, or to dull negative and painful thoughts and emotions.
The most common functions have been explained well by authors Vanderlinden and Vandereycken (1) as follows:
* Emotional release: Attempts to regulate strong negative emotions that overwhelm. Cutting can provide an outlet for feelings of anger, fear, shame, weakness, or guilt.
* Relaxation/escape: Attempts to reduce stress and self-soothe. There can be a sense of pleasure from the warmth of the blood and the sensation of pain providing comfort and control.
* Stimulation/grounding: Sometimes people cause pain to reassure themselves that they are "still here." They need to feel feelings and their own bodies in order to feel alive, or re-ground themselves in reality.
* Diversion: The act of self-harm can produce a trance-like state. This allows the individual to avoid unpleasant feelings, emotions or suicidal thoughts.
* Cry for help: Most of those who harm their bodies do it in areas that will not be seen: the inside of the thighs or upper arms, the lower abdomen, even the breasts. However, if the result of the action is highly visible, it can be the only way one is able to cry for help.
* Scarification/alteration: Making one's body unattractive may serve as a protective measure in attempts to ensure they will not be assaulted again.
* Social motives: Many of those who have anorexia perceive themselves as strong because they have "conquered" the need for food. Similarly, cutters may view their action as one of great strength and believe it makes them appear powerful.
Treatment for SIB
Sometimes we may not know why people engage in their destructive behaviors; it is important not to get too bogged down with trying to figure it out. Diving into the cause of psychopathology might take you on a wild goose chase and thus prove unproductive. It was once said, "You take an aspirin because you have a headache, not because you have an aspirin deficiency." Regardless of the reason for the self-harm, we need to move forward in treatment.
It is important to validate the patient and her family in that SIB is understandable and reasonable given the pain and agony she may be experiencing. This does not mean you are encouraging or condoning the behavior. You are simply saying that given the pain she is experiencing, you as the therapist understand why she cuts.
Further, we have to help families recognize that dealing with the issue effectively is not as easy as eliminating sharp objects from the home. The puzzle is so much bigger.
Comprehensive, holistic assessment is critical to healing. As the saying goes, "If we fail to plan, we plan to fail." At Remuda Ranch, we hear this mantra over and over again. We know from research and experience that assessment is critical to good outcomes. The assessment involves asking those who are struggling about their history, frequency, urges, methods, severity, subjective experiences, triggers, and consequences of self-harm as well as their motivation to change and their perceived level of control over the behavior.
Safety is a guiding principle behind thorough assessment. All gears turn toward safety when an individual is struggling with SIB. The safety plan is used to support individuals with resources to prevent them from engaging in self-harm. They are coached on preventive skills, identification of triggers, and healthier responses to them.
Successful treatment for self-injury includes a combination of cognitive and dialectical behavior therapies, family and experiential therapies, and psychopharmacological interventions. Treatment provides new tools to identify patient emotions and learn new ways to deal with them.
Therapy provides a safe and secure setting to build skills and practice them in gradated challenges. The experience of self-mastery and insight, along with family members learning ways to support and communicate with their loved one, increases the chances for a successful recovery from cutting and eating disorders.
If you know someone who is intentionally hurting herself on the outside, then she is desperately hurting on the inside. It is important to validate those in pain. These individuals are not viewed as manipulative or as victims, but as people capable of change.
One researcher's definition gives a glimpse into the world of those suffering with self-injury, viewing it not as a self-destructive act but one of self-preservation. That is often what those with eating disorders admit. Individuals who are helped to understand what is driving their self-harm and eating disorder behavior, and then are taught life management skills, go on to live without these maladaptive behaviors. It is in this process that they can begin to see that life can be managed without SIB, anorexia, bulimia, or other disordered eating.
Dena Cabrera, PsyD, is Director of Educational Outreach for Remuda Ranch Treatment Programs in Wickenburg, Arizona. Her e-mail address
(1.) Vanderlinden J, Vandereycken W. Trauma, Dissociation, and Impulse Dyscontrol in Eating Disorders. New York City: Brunner/Mazel, Inc.; 1997.
BY DENA CABRERA, PsYD
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|Title Annotation:||Understanding eating disorders and cutting|
|Date:||Mar 1, 2011|
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