James Donaldson on Mental Health - Why some people intentionally cut, burn or bruise themselves

By Kristen Rogers and Matt Villano, CNN

Emergency department visits for self-harm have spiked since the pandemic. Experts explain the psychology behind the behavior and how to overcome it.

Editor’s Note: This story contains details of self-harm that some readers may find upsetting or triggering. Help is available if you or someone you know is struggling with suicidal thoughts or mental health matters.
In the US: Call or text 988, the Suicide & Crisis Lifeline.

Megan walked the halls of her suburban Houston junior high in shame. It was the first time she had to attend school with bruises on her face from the abuse by her father, who was an alcoholic.

“I was really frustrated about that and just how unfair it was, and how embarrassed I was,” Megan — who is now 35 and asked that her last name not be used due to the sensitivity of the subject — said of that moment that occurred over 20 years ago. “And I couldn’t escape having to continue to go to (my dad’s) house.”

When Megan got home from school and found herself alone, she grabbed a kitchen knife, locked herself in the bathroom and cut her forearm open. She had just recently learned about self-harm after asking a friend about her many bandages and long sleeves.

“It was always after the visits to (my dad’s) house,” Megan said. “I would come back (to my mom’s house) and just have all of this frustration and not know what to do with it. … At my dad’s house, there was no control. I had no control. So (harming myself) was more of a way that I was in control.”

Over the next few years, Megan’s father continued to abuse her and she self-harmed to cope, as it helped her focus on the physical pain instead of the emotional pain. After getting kicked off the cheerleading squad at age 15, she ran upstairs to her bathroom with a knife in tow, Megan said. But her mother had caught on and tried to break the door down, “scared sh*tless that I was trying to kill myself.”

A couple days later, Megan began therapy to hash out her trauma and learn different ways to process her pain. Though her mother feared Megan was suicidal, Megan insisted the behavior had nothing to do with wanting to die — instead, she said, self-harming was a desperate attempt to keep her unbearable feelings of anger, sadness, guilt and shame from running wild.

What is self-harm?

Self-harm commonly takes the form of cutting or scratching until the body bleeds, but it can also include burning, bruising or even intentionally breaking bones, said Dr. Janis Whitlock, founder and director of the Cornell Research Program on Self-Injury and Recovery at Cornell University in New York state. Some experts refer to the behavior as non-suicidal self-injury, or NSSI.

In 2019 there were 363,000 emergency department visits for self-harm, according to the US Centers for Disease Control and Prevention. The following year saw a 48.5% drop, likely due to the tendency to avoid medical care to not overburden medical providers or risk getting sick during the Covid-19 pandemic, Whitlock said.

But in 2021, there were 660,000 visits — a nearly 253% increase from 2020 and roughly an 82% spike from 2019.

These increases align with reports of rates of mental health challenges climbing before the pandemic, which only made things worse for many people, Whitlock said. Also, the proximity to loved ones during lockdowns may have made parents more aware of self-harm, potentially contributing to more emergency department visits.

Inside the minds of those who self-harm

Most experts agree that self-injury is a cry for help and arises from a person trying and failing to process stress, said Dr. Jeremy Jamieson, professor and chair of psychology at the University of Rochester in New York state.

If someone is feeling disconnected from the world, Megan said, they might self-injure to try to reconnect. If someone is feeling less than human — known as depersonalization — they may self-harm to feel human again. Self-harm can also be a form of self-punishment among those feeling guilt or shame and thus like they deserve physical pain.

There’s also a neurophysiological explanation for why people hurt themselves, said Dr. Vibh Forsythe Cox, director of the Marsha M. Linehan Dialectical Behavior Therapy Clinic at the University of Washington in Seattle. It involves the body’s endogenous opioid system, a neurochemical system with key roles in pain modulation, reward, stress responses and more.

When the body realizes it’s experiencing damage, the opioid system sends out endorphins that act as painkillers so the body can escape whatever the danger is. Self-harm triggers this same response, Cox said.

“The data suggests a neurological link between the perception of physical pain and the perception of emotional pain — where there is a spike and drop in one, there may be a spike and drop in the other,” Whitlock said.

The dangers of self-harm

When people self-harm, they run the risk of accidentally causing a much more serious problem — such as irreparable damage or infection that could lead to death, Whitlock said.

Secondly, while self-injury isn’t necessarily a suicide attempt, data suggests the former can sometimes be a precursor to suicidality.

The suicide rate among adults who self-harmed was 37 times greater than the suicide rate in the general population, according to a 2017 study. And in Whitlock’s own research, she has found that 65% of teens who self-injure likely will also be suicidal at some point.

“The very act of engaging in self-injury reduces inhibition to suicidal behavior if someone becomes suicidal,” said Whitlock, senior adviser for the JED Foundation, a suicide prevention and mental health organization in Boston. “Having ‘practiced’ injuring the body repeatedly makes it easier to injure the body with suicidal intent.”

Effective therapies for self-injury

Self-injury, like many mental health issues, takes time to treat, experts said, and people who self-harm usually don’t stop until they’re ready. Typically, this happens when they learn other coping skills and find motivating reasons for living.

One effective treatment is dialectical behavior therapy, or DBT, experts said. Sometimes conducted in group settings, the approach is designed to help people overcome black-and-white thinking and develop emotional regulation skills, which are key for healthily managing emotional pain instead of turning to self-destructive habits.

This rewiring of the brain to react and respond differently takes time, usually a year or more, Cox said.

But the results can be impressive. A 2018 study investigated the effects of DBT — versus individual and group supportive therapy — on rates of suicide attempts and self-harm among 173 adolescents who had attempted suicide at least once before and had three or more criteria for borderline personality disorder (the disorder for which DBT was created).

After six months, nearly 57% of the DBT participants were able to stop self-harming, compared with 40% of those who had done individual and group supportive therapy. More than 90% of the DBT participants had no suicide attempts after treatment, compared with nearly 79% of the other group.

For around 93% of adults   in a 2021 study based in Norway, DBT helped them stop self-harming within the first year. Another study, published in 2015, assessed the effects of various DBT interventions on 99 women who had borderline personality disorder and experienced suicidality — all participants experienced reductions in frequency of self-harm and found reasons for living after a year of treatment.

Advice for overcoming self-harm

If you’re struggling with self-harm, reach out to a mental health professional you can find through your doctor, insurance or crisis helplines, Whitlock said.

Also try identifying your triggers and warning signs then writing them down, she added. “Keeping a mood journal can help (you) recognize patterns and allow you to intervene early with healthy coping skills before urges become overwhelming.”

Some helpful coping techniques include practicing mindfulness, such as by focusing on your five senses to stay present and ride out intense emotions, or deep breathing, Whitlock said. A “coping skills box” filled with items such as stress balls, coloring books or photos of loved ones can also comfort you.

And “when feeling the impulse to self-injure, commit to waiting 15 minutes first,” Whitlock said. “Use this time to try alternative coping strategies. Over time the intensity of the urge will decrease.”

Lastly, don’t be too hard on yourself. “Rather than aiming for ‘never again,’” Whitlock said, “focus on extending the time between incidents. Celebrate progress while being gentle with setbacks.”

How to support someone else

If you’re trying to help a child or adult who’s self-harming, Whitlock doesn’t recommend going through the house and removing every sharp object, she said.

You should of course use common sense and not let someone have their self-harm toolkit in their bedroom, for example, Whitlock added. But full restriction could create a power struggle between you and the person self-harming — and that could rob you of the critical opportunity to meet that person’s need for connection and support that addresses the root of self-injurious behavior long term. People who are desperate to self-harm may also do so by any means necessary.

Those deeper realities get obscured and potentially squashed when power struggles ensue and a person feels like they’re being punished, Whitlock said.

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“We also really highly recommend taking a collaborative approach whenever possible,” added Whitlock, author of “Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones.”

It’s important to validate, rather than criticize, your loved one’s strong emotions while also emphasizing that there are safer ways to manage that emotional pain, said Dr. Michele Berk, associate professor of psychiatry and behavior sciences at Stanford University in California, via email.

Don’t ask “Why did you do that?” said Australian psychiatrist Dr. Benjamin Veness. That question could amplify a person’s shame and make them feel worse, whereas judgment-free questions about their state of mind in general and when they self-harmed are a much better approach.

Ensuring loved ones, especially children, see you as supportive and accepting can help them tell you if they’re at risk for self-harm, Berk added.

Be honest about your confusion, fear or worry, and get your own professional support so you can work through those feelings instead of channeling them into anger toward your loved one, Whitlock said.

Life after self-harm

Though the tunnel that is the journey to stop self-harming may be long and challenging, there is light at the end of it.

Some families have said that while they wouldn’t wish the experience on anyone else, it did help them learn and grow as a family “because they had to work through some of the challenges around communication and authentic connection (or) whatever stuff hadn’t been dealt with that may be part of why self-harm showed up in the first place,” Whitlock said.

That’s true in Megan’s case. The time her mother caught her self-harming was the last time she ever did it, she said. Journaling using a red ink pen, per her therapist’s recommendation, was also critical for her, Megan said — the emotional release from seeing blood on her arms was replaced by the symbolic release of her pain onto the pages.

Megan now runs a successful company in Las Vegas, and doubles as a fashion influencer on social media. She doesn’t have urges to self-injure anymore, she said, since she has learned other mechanisms for dealing with pain.

“I often interpret people who self-injure as people who have a high degree of perception and sensitivity in ways that are actually gifts,” Whitlock said. “So, I always try to let people know … the urge to feel better and to come back into a sense of stability and centeredness is good.”

“They just need additional support to understand what’s happening,” she added, “and then to use the perceptual abilities they have.”

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