Self-harm on the net

Mental Health Nursing,  May/Jun 2002  

• E-mail
• Print
• Link

Remote therapy

Some self-harmers prefer not to seek help in the conventional way, or require further support and asistance beyond that which is offered by health services. Sarah Osborne provides an overview of the different types of self-harm and the help available on line

Self-harm/mutilation SHM is described as including eye enucleation, castration and limb amputation. It is usually associated with psychosis, alcohol or drug intoxication and transexualism. There are often underlying religious or sexual themes. Stereotypical SHM, which may include monotonous, repetitive or rhythmic behaviour, is usually associated with head banging, hitting or self-biting. A link often exists with autism, learning difficulties or Tourette's syndrome.

Superficial/moderate SHM is the most common form of SHM and cuts across all social classes and is present worldwide. Most common are skin cutting and/or burning, but bone breaking, needlesticking, interference with wound healing and hair pulling may also be present. The most usual psychiatric diagnoses applied to those who self-harm are personality disorders (particularly borderline personality disorders), post-traumatic stress syndrome, eating disorders and dissociative disorders.

SHM may be seen as a morbid form of self-help. Cutting may bring rapid but temporary relief from distressing symptoms such as mounting anxiety depersonalisation, racing thoughts and rapidly fluctuating emotions. Cutting may become an overwhelming preoccupation that is repeated over and over again, assuming a life of its own. Many cutters see themselves as addicted. The average course of a cutting problem is 10 to 15 years before resolution. Often, cutting will go hand in hand with an eating problem, alcohol/substance abuse and/or shoplifting. It is important to note that most self cutters do not want to die and are not making a suicide attempt. However, many cutters do become demoralised, depressed and/or suicidal as they come to feel that their behaviour is out of control and that others do not understand.

Strong (2000) notes that 50 to 60 per cent of self-harmers have suffered childhood physical and/or sexual abuse. These people cut, not to inflict pain, but to relieve pain. The sight of blood gives the cutter literal proof of being alive. Here, it is suggested, the cutter can play out the role of victim, perpetrator and finally loving caretaker, soothing wounds and watching them heal. Most injurers are from families where values are twisted, for example inappropriate sexual attention being equated with love. Neglect may also be apparent.

In some instances, parents may be well meaning but their own extensive problems mean that they do not recognise their children's needs and consequently the child 'shuts down' its feelings. Some parents do not respect their children's boundaries and thus damage the child's sense of safety and trust. In this situation, the child often finds other ways to communicate and survive, ways that may be primitive or destructive.

Parents can express a wide range of reactions to self-injuring actions taken by their child: anger, annoyance, alarm, concern, dismissal (`teenage bullshit' is how one father in Strong's work responded to his daughter's cutting). If a child has been sexually abused this may be kept secret until well into adulthood; the child may see the abuse as being their own fault and children often feel responsible for protecting and caring for their abusers even after terrible violence and sexual violation. The `typical' self-injurer

Favazza and Conterio's study (1988) of 240 chronic self-mutilators showed that the 'typical' self-injurer was a white female in her late twenties. The cutting began at around age 14 and there had been at least 50 episodes. The cutting gave the individual temporary relief from anxiety, depersonalisation and racing thoughts. Eating disorders and substance abuse often were reported also. Abuse was reported by 62 per cent of the sample; sexual abuse by 50 per cent. Either divorce or a family death had occurred in a third of the group's families. Feeling empty and not being able to express feelings in words was a common experience. Other commonly reported features included fear of closeness, a desperate desire to stop emotional pain and the experience of coming from families who were full of anger and double messages. Many hated parts of their anatomy.

An early study by Graff and Mallin (1967) depicted the injurer as having a cold, rejecting mother and a distant, hypercritical father. Cutters often say that they gain a sense of comfort from their stash of razor blades, a vial of saved blood or dried bloodstains pressed in to a journal. Currently, the most typical diagnosis applied to a cutter is borderline personality disorder.

Treatments

Acute symptoms may need to be brought under control by medication or behaviour modification so that the person is able to tolerate exploring deeper issues. It is strongly believed that if the underlying trauma is not resolved, the cutting/harming behaviours will return or be replaced by another destructive coping behaviour. Clearly, other selfdestructive behaviours that go hand in hand with cutting must also be treated. The most successful treatment is likely to be a combination of medication, psychotherapy and cognitive behavioural techniques. Psychotherapeutic interventions are likely to be required long term and are often not available in a health system where resources are limited.