"Causes of Self-Harm" is the first article in a series of about self-harm.
Self-Harm is an increasingly pervasive symptom of emotional distress among adolescent girls. Because it involves physical damage to the sufferer, cutting understandably evokes distress and fear in others. Viewed on a continuum, self-harming behavior can easily—though not always accurately—be interpreted as a precursor to suicidal behavior. Dustin Tibbitts, LMFT, has written a three part series to help parents better understand and address this behavior.
Why do troubled teens physically harm themselves? What are the causes of self-harm? There plenty of scholarly articles on this subject, but as a therapist, I’ve found it most helpful to get the answer straight from those who have struggled with it, rather than from stuffy researchers in white lab coats. So a few years ago I posted this question on Facebook for some of my former clients. One young woman, Susan, responded somewhat critically, citing “attention-seeking” as the primary reason.
“The gross misconception about cutting in young females is that they use it as a ‘coping skill’. This may be true in some degree but not in the way most people think. Cutting is simply an immature and childish way to get a need met, and the need, much more often than not, is attention. The attention and special treatment received from their habit is absolutely intoxicating.
“It has become so amazingly common in society now, with it on TV shows, and in popular teenage magazines, that what pre-teen/teenage girl wouldn't get the idea that it would get her attention? If all these people on TV and in their favorite magazine are so worried about it and focused on it, then they know if they started the habit, they would be focused on, too.”
Susan maintained that, as a troubled teen experiencing emotional pain, even her own cutting was for attention. Yet, it would be a mistake to assume that all forms of self-injury are attention-seeking behaviors. Consider Carin’s more moderate answer to Susan’s post:
“I think you have to figure out the TYPE of attention the person is after . . . . Because I didn't want people to know I cut. I was very embarrassed by it. I went to great lengths to hide it. However, I did want attention. I wanted people to know something was wrong and to somehow see beneath the facade that I put up. There are people who cut for obvious attention-- they do it then show their friends, etc, but you have to remember people like me who did it as a way to get attention but not directly.”
Many troubled teens who self harm describe the addictive quality of cutting. This corroborates research which suggests that cutting the body releases endorphins that provide a mild “high” or “rush”. Here is Betsy’s reason for cutting:
“I found it addictive. In the midst of it, I wanted to do it even without a clear ‘reason.’ I LOVED buying/stealing new razors. I thought about it all the time. Some of that might have been a way to get attention, like you said, Susan, but I also think it can be addictive just like losing weight/not eating/purging is addictive in those with eating disorders.”
Causes of Self-harm:
In his book, Cutting, Steven Levenkron lists some reasons that troubled teens engage in the most common form of self-harm—cutting:
- trading emotional pain for physical pain
- guilt and shame
- and comfort seeking
His most important contribution to the literature about self-harm, early on, was his view of how attachment issues infuse almost every part of cutting. Additional reasons troubled teens engage in self-harm are listed below:
- Increased Attention
- Cope with emotional pain in a physical way
- Addiction to the “rush” of self-harm
- Dissociate from something scary or overwhelming
- Acceptance of other “cutters”
- Pre-suicide gesture
- Cry for help; expression of inner turmoil
- Art – to some, blood is beautiful
- To punish self or loved-ones
- A form of religious worship to expiate guilt
- To feel again, to drive away apathy
- To sense if self is real
- Sexual pleasure
I found these comments from other troubled or formerly troubled teens especially enlightening:
Janice: “I cut because I didn't like the way I felt when I didn't; I cut because I didn’t want to deal with the emotional pain, and it felt so good to cut. I still don’t really know why it felt so good. I did it for a lot of reasons, which I think evolved over the time I did it.”
Suzette: “Mostly I did it for this reason: coping with emotional pain in a physical way because physical pain is easier to deal with. Especially to get out anger and frustration.”
Farrah: “I did it most frequently when I felt hurt or belittled by my father...I was never good enough for him. And once it's addictive and habitual, it's difficult to stop. I felt relief afterward.”
Sammy: “I did it as an outward expression of inner anxiety and depression, to punish loved ones, to punish myself, out of impulse, and for art. Not really for art, but I was fascinated with watching the blood drip down the sink and makes patterns and designs with it. Messy, messy hobby.”
Cecelia: “I loved it. I looked forward to when I would have a moment to myself to cut. I loved the way it made me feel. I think I, too, wanted attention. I wanted people to know how bad I was hurting but I didn't want them to know I cut.”
Jill: “I was very ashamed when people found out. But yet it felt good to be cared about when they made a big deal about it. For so long I felt so lonely and unnoticed that when people made a big deal about it I finally felt worth something.”
Tara: “I felt miserable and screwed up and my family wanted to keep all of my problems very private, but I thought that my body should reflect how I felt. I felt like if I cut then people would understand that my family wasn't as perfect as they acted.”
Kelsey: “Male attention: I had a teacher at school that would baby me and treat me like his daughter (sort of) when I cut and that made me feel good.”
Lara said: “I certainly felt like things were "too good" and that I didn't deserve my family, friends, or life. I think it's linked to the self-punishment component- I was depressed and didn't understand why. I became angry at myself and blamed myself for all my problems (which stemmed from self-blame in the first place...Oy! I used to tie myself up in knots, that's for sure). I didn't attribute any of my internal issues to external influences on me and almost idealized those around me instead. So cutting and acting out on myself became my way of punishing myself because I felt undeserving of my family/life in general and that no one with my life had any right to hurt like I was hurting.”
As with any issue afflicting troubled teens, understanding the “why” behind their behaviors is a critical first step for understanding how to treat those behaviors as well as the issues that drive them. In the case of self-harm, those reasons vary widely and differ from teen to teen; for this reason, as we’ll discuss in the next article in this series, trusting relationships are the key to effective treatment. Only by getting to know a patient and her own specific motivators for self-harm can we hope to effectively treat this complex issue.