Self-Injury
Created | Updated Oct 20, 2010
Re-produced with the kind permissiono of Deb Martinson. Copyright 1999-2002.
<b><u>General Facts<p></b></u>
<b>About Self-Injury </b><BR/>
Self-Injury is also termed self-mutilation, self-harm or self-abuse. The behavior is defined as the deliberate, repetitive, impulsive, non-lethal harming of one’s self. Self-injury includes: 1) cutting; 2) scratching;3) picking scabs or interfering with wound healing; 4) burning; 5) punching self or objects; 6) infecting oneself; 7) inserting objects in body openings; 8) bruising or breaking bones; 9) some forms of hair-pulling, as well as other various forms of bodily harm. The behaviors, which pose serious risks, may be symptoms of a mental health problem that can be treated. <p>
<b>Incidence & onset.</b><BR/>
Experts estimate the incidence of habitual self-injurers is nearly 1 % of the population, with a higher proportion of females than males. The typical onset of self-harming acts is at puberty. The behaviors often last for 5-10 years but can persist much longer without appropriate treatment. <p>
<b>Background of self-injurers.</b><BR/>
Though not exclusively, the person seeking treatment is usually from a middle to upper class background, of average to high intelligence, and has low self-esteem. Nearly 50% report physical and/or sexual abuse during his or her childhood. Many report (as high as 90%), that they were discouraged from expressing emotions, particularly, anger and sadness. <p>
<b>Behavior patterns.</b><BR/>
Many who self-harm use multiple methods. Cutting arms or legs is the most common practice. Self-injurers may attempt to conceal the resultant scarring with clothing, and if discovered, often make excuses as to how an injury happened. A significant number are also struggling with eating disorders and alcohol or substance abuse problems. An estimated one-half to two-thirds of self-injurers have an eating disorder. <p>
<b>Reasons for behaviors.</b><BR/>
Self-injurers commonly report they feel empty inside, over or under stimulated, unable to express their feelings, lonely, not understood by others and fearful of intimate relationships and adult responsibilities. Self-injury is their way to cope with or relieve painful or hard-to-express feelings and is generally not a suicide attempt. But relief is temporary, and a self-destructive cycle often develops without proper treatment.
<p>
<b>Dangers.</b><BR/>
Self-injurers often become desperate about their lack of self-control and the addictive-like nature of their acts, which may lead them to true suicide attempts. The self-injury behaviors may also cause more harm than intended, which could result in medical complications or death. Eating disorders and alcohol or substance abuse intensify the threats to the individual’s overall health and quality of life.
<p>
<b>Diagnoses.</b> <BR/>
The diagnosis for someone who self-injures can only be determined by a licensed psychiatric professional. Self-harm behavior can be a symptom of several psychiatric illnesses: Personality Disorders (esp. Borderline Personality Disorder); Bipolar Disorder (Manic-Depression); Major Depression; Anxiety Disorders (esp. Obsessive-Compulsive Disorder); as well as psychoses such as Schizophrenia.
<p>
<b>Evaluation.</b><BR/>
If someone displays the signs and symptoms of self-injury, a mental health professional with self-injury expertise should be consulted. An evaluation or assessment is the first step, followed by a recommended course of treatment to prevent the self-destructive cycle from continuing.
<p>
<b>Treatment.</b><BR/>
Self-injury treatment options include outpatient therapy, partial (6-12 hours a day) and inpatient hospitalization. When the behaviors interfere with daily living, such as employment and relationships, and are health or life-threatening, a specialized self-injury hospital program with an experienced staff is recommended.
<p>
The effective treatment of self-injury is most often a combination of medication, cognitive/behavioral therapy, and interpersonal therapy, supplemented by other treatment services as needed. Medication is often useful in the management of depression, anxiety, obsessive-compulsive behaviors, and the racing thoughts that may accompany self-injury. Cognitive-behavioral therapy helps individuals understand and manage their destructive thoughts and behaviors. Contracts, journals, and behavior logs are useful tools for regaining self-control. Interpersonal therapy assists individuals in gaining insight and skills for the development and maintenance of relationships. Services for eating disorders, alcohol/substance abuse, trauma abuse, and family therapy should be readily available and integrated into treatment, depending on individual needs.
<p>
In addition to the above, successful courses of treatment are marked by 1) patients who are actively involved in and committed to their treatment, 2) aftercare plans with support for the patient’s new self-management skills and behaviors, and 3) collaboration with referring and other involved professionals.
<hr>
<b><center> A Bill of Rights for Those Who Self-Harm</b></center>
<p>
<b><u> Preamble:</b></u>
<p>
An estimated one percent of Americans use physical self-harm as a way of coping with stress; the rate of self-injury in other industrial nations is probably similar. Still, self-injury remains a taboo subject, a behavior that is considered freakish or outlandish and is highly stigmatized by medical professionals and the lay public alike. Self-harm, also called
self-injury, self-inflicted violence, or self-mutilation, can be defined as self-inflicted physical harm severe enough to cause tissue damage or leave visible marks that do not fade within a few hours. Acts done for purposes of suicide or for
ritual, sexual, or ornamentation purposes are not considered self-injury. This document refers to what is commonly known as moderate or superficial self-injury, particularly repetitive SI; these guidelines do not hold for cases of major
self-mutilation (i.e., castration, eye enucleation, or amputation).
<p>
Because of the stigma and lack of readily available information about self-harm, people who resort to this method of coping often receive treatment from physicians (particularly in emergency rooms) and mental-health professionals that can actually make their lives worse instead of better. Based on hundreds of negative experiences reported by people who self-harm, the following Bill of Rights is an attempt to provide information to medical and mental-health personnel. The goal of this project is to enable them to more clearly understand the emotions that underlie self-injury and to respond to self-injurious behavior in a way that protects the patient as well as the practitioner.
<p>
<b><u>The Bill of Rights:</b></u>
<p>
<b>1. The right to caring, humane medical treatment.</b><BR/>
Self-injurers should receive the same level and quality of care that a person presenting with an identical but accidental injury would receive. Procedures should be done as gently as they would be for others. If stitches are required, local anesthesia should be used. Treatment of accidental injury and self-inflicted injury should be identical.
<p>
<b> 2. The right to participate fully in decisions about emergency psychiatric treatment (so long as no one's life is in immediate danger).</b><BR/>
When a person presents at the emergency room with a self-inflicted injury, his or her opinion about the need for a psychological assessment should be considered. If the person is not in obvious distress and is not suicidal, he or she should not be subjected to an arduous psych evaluation. Doctors should be trained to assess suicidality/homicidality and should realize that although referral for outpatient follow-up may be advisable, hospitalization for self-injurious behavior alone is rarely warranted.
<p>
<b> 3. The right to body privacy.</b><BR/>
Visual examinations to determine the extent and frequency of self-inflicted injury should be performed only when absolutely necessary and done in a way that maintains the patient's dignity. Many who SI have been abused; the humiliation of a strip-search is likely to increase the amount and intensity of future self-injury while making the person subject to the searches look for better ways to hide the marks.
<p>
<b> 4. The right to have the feelings behind the SI validated.</b><BR/>
Self-injury doesn't occur in a vacuum. The person who self-injures usually does so in response to distressing feelings, and those feelings should be recognized and validated. Although the care provider might not understand why a particular situation is extremely upsetting, she or he can at least understand that it *is* distressing and respect the self-injurer's right to be upset about it.
<p>
<b> 5. The right to disclose to whom they choose only what they choose.<BR/></b>
No care provider should disclose to others that injuries are self-inflicted without obtaining the permission of the person involved. Exceptions can be made in the case of team-based hospital treatment or other medical care providers when the information that the injuries were self-inflicted is essential knowledge for proper medical care. Patients should be notified when others are told about their SI and as always, gossiping about any patient is unprofessional.
<p>
<b>6. The right to choose what coping mechanisms they will use.<BR/></b>
No person should be forced to choose between self-injury and treatment. Outpatient therapists should never demand that clients sign a no-harm contract; instead, client and provider should develop a plan for dealing with self-injurious impulses and acts during the treatment. No client should feel they must lie about SI or be kicked out of outpatient therapy. Exceptions to this may be made in hospital or ER treatment, when a contract may be required by hospital legal policies.
<p>
<b>7. The right to have care providers who are not afraid of SI.<BR/></b>
Those who work with clients who self-injure should keep their own fear, revulsion, anger, and anxiety out of the therapeutic setting. This is crucial for basic medical care of self-inflicted wounds but holds for therapists as well. A person who is struggling with self-injury has enough baggage without taking on the prejudices and biases of their care providers.
<p>
<b> 8. The right to have the role SI has played as a coping mechanism validated.<BR/></b>
No one should be shamed, admonished, or chastised for having self-injured. Self-injury works as a coping mechanism, sometimes for people who have no other way to cope. They may use SI as a last-ditch effort to avoid suicide. The self-injurer should be taught to honor the positive things that self-injury has done for him/her as well as to recognize that the negatives of SI far outweigh those positives and that it is possible to learn methods of coping that aren't as destructive and life-interfering.
<p>
<b>9. The right not to be automatically considered a dangerous person simply
because of self-inflicted injury.<BR/></b>
No one should be put in restraints or locked in a treatment room in an emergency room solely because his or her injuries are self-inflicted. No one should ever be involuntarily committed simply because of SI; physicians should make the decision to commit based on the presence of psychosis, suicidality, or homicidality.
<p>
<b> 10. The right to have self-injury regarded as an attempt to communicate,
not manipulate.<BR/></b>
Most people who hurt themselves are trying to express things they can say in no other way. Although sometimes these attempts to communicate seem manipulative, treating them as manipulation only makes the situation worse. Providers should respect the communicative function of SI and assume it is not manipulative behavior until there is clear evidence to the contrary.
If you wish to know more please contact the following website http://www.selfinjury.org/docs/brights.html.
<b><u>General Facts<p></b></u>
<b>About Self-Injury </b><BR/>
Self-Injury is also termed self-mutilation, self-harm or self-abuse. The behavior is defined as the deliberate, repetitive, impulsive, non-lethal harming of one’s self. Self-injury includes: 1) cutting; 2) scratching;3) picking scabs or interfering with wound healing; 4) burning; 5) punching self or objects; 6) infecting oneself; 7) inserting objects in body openings; 8) bruising or breaking bones; 9) some forms of hair-pulling, as well as other various forms of bodily harm. The behaviors, which pose serious risks, may be symptoms of a mental health problem that can be treated. <p>
<b>Incidence & onset.</b><BR/>
Experts estimate the incidence of habitual self-injurers is nearly 1 % of the population, with a higher proportion of females than males. The typical onset of self-harming acts is at puberty. The behaviors often last for 5-10 years but can persist much longer without appropriate treatment. <p>
<b>Background of self-injurers.</b><BR/>
Though not exclusively, the person seeking treatment is usually from a middle to upper class background, of average to high intelligence, and has low self-esteem. Nearly 50% report physical and/or sexual abuse during his or her childhood. Many report (as high as 90%), that they were discouraged from expressing emotions, particularly, anger and sadness. <p>
<b>Behavior patterns.</b><BR/>
Many who self-harm use multiple methods. Cutting arms or legs is the most common practice. Self-injurers may attempt to conceal the resultant scarring with clothing, and if discovered, often make excuses as to how an injury happened. A significant number are also struggling with eating disorders and alcohol or substance abuse problems. An estimated one-half to two-thirds of self-injurers have an eating disorder. <p>
<b>Reasons for behaviors.</b><BR/>
Self-injurers commonly report they feel empty inside, over or under stimulated, unable to express their feelings, lonely, not understood by others and fearful of intimate relationships and adult responsibilities. Self-injury is their way to cope with or relieve painful or hard-to-express feelings and is generally not a suicide attempt. But relief is temporary, and a self-destructive cycle often develops without proper treatment.
<p>
<b>Dangers.</b><BR/>
Self-injurers often become desperate about their lack of self-control and the addictive-like nature of their acts, which may lead them to true suicide attempts. The self-injury behaviors may also cause more harm than intended, which could result in medical complications or death. Eating disorders and alcohol or substance abuse intensify the threats to the individual’s overall health and quality of life.
<p>
<b>Diagnoses.</b> <BR/>
The diagnosis for someone who self-injures can only be determined by a licensed psychiatric professional. Self-harm behavior can be a symptom of several psychiatric illnesses: Personality Disorders (esp. Borderline Personality Disorder); Bipolar Disorder (Manic-Depression); Major Depression; Anxiety Disorders (esp. Obsessive-Compulsive Disorder); as well as psychoses such as Schizophrenia.
<p>
<b>Evaluation.</b><BR/>
If someone displays the signs and symptoms of self-injury, a mental health professional with self-injury expertise should be consulted. An evaluation or assessment is the first step, followed by a recommended course of treatment to prevent the self-destructive cycle from continuing.
<p>
<b>Treatment.</b><BR/>
Self-injury treatment options include outpatient therapy, partial (6-12 hours a day) and inpatient hospitalization. When the behaviors interfere with daily living, such as employment and relationships, and are health or life-threatening, a specialized self-injury hospital program with an experienced staff is recommended.
<p>
The effective treatment of self-injury is most often a combination of medication, cognitive/behavioral therapy, and interpersonal therapy, supplemented by other treatment services as needed. Medication is often useful in the management of depression, anxiety, obsessive-compulsive behaviors, and the racing thoughts that may accompany self-injury. Cognitive-behavioral therapy helps individuals understand and manage their destructive thoughts and behaviors. Contracts, journals, and behavior logs are useful tools for regaining self-control. Interpersonal therapy assists individuals in gaining insight and skills for the development and maintenance of relationships. Services for eating disorders, alcohol/substance abuse, trauma abuse, and family therapy should be readily available and integrated into treatment, depending on individual needs.
<p>
In addition to the above, successful courses of treatment are marked by 1) patients who are actively involved in and committed to their treatment, 2) aftercare plans with support for the patient’s new self-management skills and behaviors, and 3) collaboration with referring and other involved professionals.
<hr>
<b><center> A Bill of Rights for Those Who Self-Harm</b></center>
<p>
<b><u> Preamble:</b></u>
<p>
An estimated one percent of Americans use physical self-harm as a way of coping with stress; the rate of self-injury in other industrial nations is probably similar. Still, self-injury remains a taboo subject, a behavior that is considered freakish or outlandish and is highly stigmatized by medical professionals and the lay public alike. Self-harm, also called
self-injury, self-inflicted violence, or self-mutilation, can be defined as self-inflicted physical harm severe enough to cause tissue damage or leave visible marks that do not fade within a few hours. Acts done for purposes of suicide or for
ritual, sexual, or ornamentation purposes are not considered self-injury. This document refers to what is commonly known as moderate or superficial self-injury, particularly repetitive SI; these guidelines do not hold for cases of major
self-mutilation (i.e., castration, eye enucleation, or amputation).
<p>
Because of the stigma and lack of readily available information about self-harm, people who resort to this method of coping often receive treatment from physicians (particularly in emergency rooms) and mental-health professionals that can actually make their lives worse instead of better. Based on hundreds of negative experiences reported by people who self-harm, the following Bill of Rights is an attempt to provide information to medical and mental-health personnel. The goal of this project is to enable them to more clearly understand the emotions that underlie self-injury and to respond to self-injurious behavior in a way that protects the patient as well as the practitioner.
<p>
<b><u>The Bill of Rights:</b></u>
<p>
<b>1. The right to caring, humane medical treatment.</b><BR/>
Self-injurers should receive the same level and quality of care that a person presenting with an identical but accidental injury would receive. Procedures should be done as gently as they would be for others. If stitches are required, local anesthesia should be used. Treatment of accidental injury and self-inflicted injury should be identical.
<p>
<b> 2. The right to participate fully in decisions about emergency psychiatric treatment (so long as no one's life is in immediate danger).</b><BR/>
When a person presents at the emergency room with a self-inflicted injury, his or her opinion about the need for a psychological assessment should be considered. If the person is not in obvious distress and is not suicidal, he or she should not be subjected to an arduous psych evaluation. Doctors should be trained to assess suicidality/homicidality and should realize that although referral for outpatient follow-up may be advisable, hospitalization for self-injurious behavior alone is rarely warranted.
<p>
<b> 3. The right to body privacy.</b><BR/>
Visual examinations to determine the extent and frequency of self-inflicted injury should be performed only when absolutely necessary and done in a way that maintains the patient's dignity. Many who SI have been abused; the humiliation of a strip-search is likely to increase the amount and intensity of future self-injury while making the person subject to the searches look for better ways to hide the marks.
<p>
<b> 4. The right to have the feelings behind the SI validated.</b><BR/>
Self-injury doesn't occur in a vacuum. The person who self-injures usually does so in response to distressing feelings, and those feelings should be recognized and validated. Although the care provider might not understand why a particular situation is extremely upsetting, she or he can at least understand that it *is* distressing and respect the self-injurer's right to be upset about it.
<p>
<b> 5. The right to disclose to whom they choose only what they choose.<BR/></b>
No care provider should disclose to others that injuries are self-inflicted without obtaining the permission of the person involved. Exceptions can be made in the case of team-based hospital treatment or other medical care providers when the information that the injuries were self-inflicted is essential knowledge for proper medical care. Patients should be notified when others are told about their SI and as always, gossiping about any patient is unprofessional.
<p>
<b>6. The right to choose what coping mechanisms they will use.<BR/></b>
No person should be forced to choose between self-injury and treatment. Outpatient therapists should never demand that clients sign a no-harm contract; instead, client and provider should develop a plan for dealing with self-injurious impulses and acts during the treatment. No client should feel they must lie about SI or be kicked out of outpatient therapy. Exceptions to this may be made in hospital or ER treatment, when a contract may be required by hospital legal policies.
<p>
<b>7. The right to have care providers who are not afraid of SI.<BR/></b>
Those who work with clients who self-injure should keep their own fear, revulsion, anger, and anxiety out of the therapeutic setting. This is crucial for basic medical care of self-inflicted wounds but holds for therapists as well. A person who is struggling with self-injury has enough baggage without taking on the prejudices and biases of their care providers.
<p>
<b> 8. The right to have the role SI has played as a coping mechanism validated.<BR/></b>
No one should be shamed, admonished, or chastised for having self-injured. Self-injury works as a coping mechanism, sometimes for people who have no other way to cope. They may use SI as a last-ditch effort to avoid suicide. The self-injurer should be taught to honor the positive things that self-injury has done for him/her as well as to recognize that the negatives of SI far outweigh those positives and that it is possible to learn methods of coping that aren't as destructive and life-interfering.
<p>
<b>9. The right not to be automatically considered a dangerous person simply
because of self-inflicted injury.<BR/></b>
No one should be put in restraints or locked in a treatment room in an emergency room solely because his or her injuries are self-inflicted. No one should ever be involuntarily committed simply because of SI; physicians should make the decision to commit based on the presence of psychosis, suicidality, or homicidality.
<p>
<b> 10. The right to have self-injury regarded as an attempt to communicate,
not manipulate.<BR/></b>
Most people who hurt themselves are trying to express things they can say in no other way. Although sometimes these attempts to communicate seem manipulative, treating them as manipulation only makes the situation worse. Providers should respect the communicative function of SI and assume it is not manipulative behavior until there is clear evidence to the contrary.
If you wish to know more please contact the following website http://www.selfinjury.org/docs/brights.html.
