Why do people self-injure or self-harm? Especially when it seems to contradict our instinct for self-preservation? The simple answer is that for the majority of those who engage in nonsuicidal self-injury (NSSI), it helps them to feel better; it’s a coping strategy. But of course, the answer is often more complex than that.
Self-injury does not reflect typical behavior, but it is also not uncommon. One in five adolescents across the globe reports having self-injured, and one in twenty adolescents in the United States reports having self-injured 6 or more times in the past 12 months. Self-injury isn’t limited to adolescents: 13% of young adults and 6% of adults also report having engaged in self-injury.
But why? According to research, there are two primary categories: emotional reasons and social reasons. In this inaugural episode of The Psychology of Self-Injury, Dr. Nicholas Westers delves into these two categories and asks leading experts, an individual with lived experience of self-injury, and a parent of a teen who self-injures: "Why do people self-injure or self-harm?"
Follow Dr. Westers on Instagram and Twitter (@DocWesters). To join ISSS, visit itriples.org and follow ISSS on Facebook and Twitter (@ITripleS).
TRANSCRIPTION GRACIOUSLY PROVIDED BY LIAN J. ARZBECKER (THE OHIO STATE UNIVERSITY)
The Psychology of Self-Injury Podcast
Why Do People Self-Injure?
January 1st, 2021 | 26:02 | S1:E1
Lexi: I self-injured for lots of different reasons as well at different times in my life. When I was a teenager it was really about self-punishment and then later on in my life, in my early twenties, it was different again. So, there's lots of different reasons that came along.
Dr. Westers: Why do people self-injure? Welcome to the inaugural episode of the Psychology of Self-Injury Podcast where we explore the psychology behind nonsuicidal self-injury, or NSSI for short. Whether that be cutting, burning, biting, hitting, severely scratching, or some other form of NSSI. I'm your host, Dr. Nicholas Westers, Clinical Psychologist at Children's Health, Associate Professor at UT Southwestern Medical Center in Dallas, TX, and Chair of the Media and Communications Committee of the International Society for the Study of Self-Injury, or ISSS or simply I Triple S.
Dr. Westers: The purpose of this podcast is to be a resource for parents, professionals, and people with lived experience, as well as anyone else who may have interest in the topic. Here, I interview the leading experts in the field of self-injury, as well as individuals with lived experience of self-injury, and parents and family members of those who self-injure or have self-injured. Self-injury doesn't reflect typical behavior, but it's also not uncommon. In fact, 1 in 5 adolescents across the global report having self-injured. And 1 in 20 adolescents in the United States report self-injuring 6 or more times in the past 12 months. And self-injury isn't limited to adolescents; 13% of young adults and 6% of adults also report having engaged in self-injury.
But why? Especially when it seems to contradict our instinct of self-preservation. In general, the simple answer is that for the majority of those who engage in NSSI, it helps them to feel better. It's a coping strategy. But of course, the answer's often more complex than that. But let's be honest; pretty much all of us have engaged in behaviors we know we're clearly not in our best interest in order to feel better in a given moment. Remembering that can help keep us empathetic and compassionate toward those who self-injure. Our behaviors serve a function, (that is, we do what we do for a reason), even if that reason is out of our conscious awareness. I asked Dr. Penelope Hasking, who's from Curtin University in Australia and the current president of I Triple S, "why do people self-injure?"
Dr. Hasking: People self-injure for a number of different reasons. Most commonly, people talk about using self-injury to cope with intense or unwanted emotions, or when they're feeling particularly anxious or depressed. I think it's important to realize that people self-injure for different reasons at different times. So, an individual person may self-injure for a number of different reasons at different points in their life.
Dr. Westers: And most people who self-injure endorse doing it for more than just one reason. We'll hear more from Dr. Hasking in an episode on self-injury and stigma. Research has consistently shown that the reasons people give for self-injury fall under two categories: intrapersonal reasons (that is, emotional reasons) and interpersonal reasons (that is, social reasons).
Dr. Whitlock: In a nutshell, it tends to boil down to emotion regulation. Pretty much everybody who injures—especially if they injure more than once or twice—will eventually be able to articulate that they do it to manage emotion, either because emotion feels overwhelming, or they feel dissociated from emotion at all. That's the dominant bucket. And then the other thing that comes up once in a while is the interpersonal piece. So, they do it to communicate something to another person, or even communicate to themselves things that they can't otherwise communicate.
Dr. Westers: That was former I Triple S President, Dr. Janis Whitlock from Cornell University in New York. Let’s first talk about the emotional reasons for self-injury. Then we'll turn to the social reasons. What are some common reasons people give for self-injuring to cope emotionally?
Dr. Whitlock. Some of our studies we’ve asked this, and the kinds of things people will say regularly is to deal with hard feelings—like anger, frustration, or sadness and grief. Sometimes it's just a distraction because they don't, they want to take their mind off something. Sometimes it's a form of self-punishment because they feel like they’ve done something wrong, and this is something they can do to amend for it in a way or to hurt themselves back. Sometimes it’s to feel something when they feel nothing.
Dr. Westers: This is in line with our research at Children's Health and UT Southwestern Medical Center. We recently asked 124 adolescents with a history of self-injury who were admitted to our psychiatric inpatient program—not necessarily for their self-injury—about why they self-injure. What does it do for them? Consistent with other research, the top two most commonly cited reasons they gave were to cope with difficult emotions (that is, to regulate and find relief from intense emotions or emotional pain) and to self-punish. Dr. Stephen Lewis, who’s from the University of Guelph in Ontario, Canada, and the immediate past president of I Triple S, has found the same.
Dr. Lewis: Understanding why people self-injure is a really fundamental question. And unfortunately, it’s also one that’s quite misunderstood. What we know through research, through clinical work, and through the work that we do in terms of outreach, the most common reason that we hear for self-injury is that it’s used as a way to obtain temporary relief from really intense, often very painful, emotions. And then this way we can sort of look at it as a way to cope—often the way to cope when maybe other ways of coping are not known, or not maybe accessible in a given moment.
In addition to using it to cope, for some people, they also use it as a means to express or even to cope with really intense feelings of self-hatred or self-loathing or self-dislike. So for some people, they might use it as a means to punish themselves. And I hear this a fair bit in terms of people thinking as though they deserve pain of some kind. And in some way, self-injury is used as a way to express this. Or if those feelings come up, it’s used as a means to cope with those feelings. So, those are probably the two most common reasons. Again, to cope with and obtain relief from highly intense, painful emotion, but also as a means to either self-punish or to express this sense of self-loathing or self-hatred.
Lexi: For me, I guess I self-injured for lots of different reasons as well at different times in my life. When I was a teenager, it was really about, it was about self-punishment, but it was more just like I was so, I hated myself so much. I was so angry at myself, that I wanted to kind of take that out on myself. So, it wasn’t like this kind of “I’m going to punish myself” kind of thought process, it was more just like expression of self-hatred.
And then later on in my life, in my early twenties, it was different again. So, there's lots of different reasons that came along. A lot of it was emotion regulation. I was really—well I was really struggling with depression and anxiety—and I didn’t know how to manage my emotions so this was a way that I could do that. It was getting things out—sort of like pent up frustration that I could expel, I guess. Which I know some people find confusing.
Dr. Westers: That was Lexi in Australia, current I Triple S Student Representative and an individual with lived experience of self-injury sharing her story, which we’ll hear more about in an upcoming episode.
But why intentionally cause pain? What role does pain have in regulating emotion or punishing oneself? First, regarding emotion regulation, research has shown that in general, almost everyone’s mood improves after the removal of painful stimuli—regardless if they self-injure and regardless of the source of pain. So, when someone who self-injures is feeling overwhelmed with unpleasant emotions, self-injury may decrease the unpleasant emotions and bring about positive feelings. And it’s less about introducing pain and more about finding relief upon the removal of pain. This is called pain offset relief.
Second, regarding self-punishment, many who self-injure to punish themselves also have a highly critical view of themselves and, like what we just heard from Dr. Lewis, may believe they deserve it. Here, research has shown that those high in self-criticism are more willing to endure pain for longer periods of time and even experience improvements in mood during pain. And consistent with pain offset relief, among those lower in self-criticism, mood tends to improve following the removal of pain. So, for a lot of people, the purpose of self-injury is to self-punish or to find emotional relief. But what about those individuals who feel no emotion at all? Or experience a sort of numbness that seems to leave a hole in their sense of humanness?
Lexi: Sometimes it was about feeling something. So, it wasn’t always this like really ramped up and emotional experience. Sometimes it was just “I feel nothing, and I want to feel something” you know. That was part of it.
Dr. Ammerman: One of the reasons that people might engage in self-injury is to generate feelings. So, after we experience either stressful or traumatic events, a lot of times our positive and negative emotions might be blunted. And so, individuals might engage in self-injury as one of the ways to help generate that feeling—to help them feel something again, to get rid of a feeling of numbness is what some people say. And so self-injury can serve as that, to kind of spark some sort of emotion, um, some sort of arousal and kind of generate some emotion, some, some feeling again. And that can serve as a sort of a very reinforcing property of the behavior.
Dr. Westers: I Triple S Member, Dr. Brooke Ammerman, who we just heard from, is an assistant professor at the University of Notre Dame in Indiana. Much of her research focuses on how and why individuals who self-injure choose to disclose their self-injury to others. We’ll hear more from her in an upcoming episode on disclosures of self-injury. We’ve talked about NSSI, or self-injury, serving as a coping strategy, a way to cope with difficult or intense emotions (so, emotion regulation), to self-punish as a form of self-hatred, and even a way to feel something because for some people they would rather feel pain than nothing at all. For many of these individuals, physical pain is more tolerable and more controllable than emotional pain. Yet there is another function of self-injury that is not as well-known but is perhaps most concerning. Former I Triple S President Dr. Jennifer Muehlenkamp from the University of Wisconsin-Eau Claire provides some insight here.
Dr. Muehlenkamp: There's a lot of reasons why people self-injure. We have seen a wide variety of reports from different people, but there are some unique features that others don't often identify. One that comes to mind is that sometimes people use self-injury to avoid suicide or to stop themselves from attempting suicide.
Dr. Westers: Earlier I had mentioned that we had surveyed 124 adolescents in our psychiatric inpatient program about why they self-injure. Self-injuring to avoid acting on suicidal thoughts was the third most commonly endorsed reason for self-injury in our sample. This is not necessarily the case for most people who self-injure because our sample was a clinical sample, meaning it consisted of those seeking treatment and who are at a higher level of care. It may come as no surprise though, that those who self-injure to avoid suicide are at increased risk for attempting suicide—but by no means should NSSI be confused with suicide. Listen to my interview with Dr. Muehlenkamp in our next episode, Episode 2, to learn more about the link between self-injury and suicide, and why it's important to distinguish between the two.
Now let's turn to the second category of reasons people give for engaging in self-injury: the social reasons. One of the most commonly endorsed beliefs people have about self-injury is that it’s for attention. Yet, self-injuring to get attention is one of the least commonly endorsed reasons for self-injuring. Dr. Lewis addresses this myth and one other.
Dr. Lews: We also know, unfortunately, is that there’s a lot of myths and misconception about why people self-injure. And in this regard, there’s really sort of two primary myths that I hear about, which I think are highly unfortunate. The first of which—which is probably one that many people have heard before—and that is that somehow self-injury is attention-seeking. And I think this is problematic for a few reasons. One of which, it clearly just doesn’t align at all with what we know—through again research, clinical work, and outreach. So, it doesn’t align with what people with lived experience actually experience. The other big issue is that in many ways it’s reductionist. And it sort of just takes the reason for self-injury and simplifies why it’s actually done. And the work that I do, whenever I hear, “attention-seeking” my immediate response—in addition to wanting to correct that—is well, attention for what? So, is there is an underlying need in the individual’s life that is unmet? And perhaps they’re using self-injury as a means to express that need. So, thinking back to even the emotion regulation function or reason for self-injury, people may self-injury as a means to obtain relief. Relief from what? Well, relief from pain. So, they may be using self-injury at times to also communicate the pain they might be experiencing internally. So that’s one of the common myths, this attention-seeking myth.
The other one is this notion that somehow, it’s manipulative. And again, I think that’s highly problematic. Again, it doesn’t align with what we know, but also it again it’s quite reductionist in terms of simplifying the reason. And it also, it kind of blames the individual—which really is not the way we’d want to start a conversation about self-injury, with blaming the individual when they may be doing all they know with what they have in the given moment. Again, thinking about maybe the only way they know how to cope.
Dr. Westers: Let’s just say someone does self-injure to seek attention. Can you imagine feeling so unheard and lonely that the only way you know how to obtain the care and attention you need is to intentionally hurt yourself? I’m sure some of you can. And these cases, I would say, let’s give them attention. But a better way of viewing this is to reframe this and ask: what are they trying to communicate? And then actively listen, which, in essence, is providing attention. I love how Dr. Muehlenkamp puts it.
Dr. Muehlenkamp: Other times people self-injure because they’re trying to activate resources in their environment and to have people take them seriously.
Dr. Westers: Trying to activate resources in their environment and have people take them seriously. I think it’s worth pointing out, however, that if you have a friend or a loved one who self-injures, it can seem to them like a catch-22 if you ask them to tell you when they’re struggling with self-injury and then turn around and say they’re doing it for attention when they do tell you. Even if it seems this way, it’s probably better for us not to say it out loud. Same thing with calling self-injury manipulative. I asked Dr. Lewis to share an example of when self-injury could seem like manipulative behavior but is not.
Dr. Lewis: An example I like to often give here when we think about manipulation is: let’s imagine that we have a young couple. And they’ve been dating and in a relationship now for quite some time. But with time, they are having more and more arguments. And let’s say that they’re both in their respective homes and they’re texting and messaging back and forth on their phones. One of those partners engages in self-injury, the other one does not. And let’s say they get in a very heated argument and the partner who is not engaging in self-injury says that they’ve had enough, this is too intense, it’s too much, and they want to end the relationship. And they do it via text. Probably not the best way to break up with someone and end a relationship. Understandably, for someone, for anyone, that’s a really upsetting experience to have. For someone who engages in self-injury, that might be tremendously painful. So, we know that self-injury coexists with high levels of distress, high degrees of anxiety, depression, and other kinds of difficult emotions. So, if they experience a negative event, like the breakup of a relationship, that’s going to be experienced perhaps quite intensely.
So that individual may in that moment feel very overwhelmed and they may resort to self-injury as a means to cope with that intensity of what they’re feeling. And they may text back to their partner and say, “I’m feeling really overwhelmed and I’ve just self-injured.” That individual could, on the surface, view that as being very manipulative. I wouldn’t. Instead, how I’d view that, is that the partner who was just broken up with, who has self-injured, and who’s communicated that back to their ex-partner, is doing all they can in that moment. They’re in immense and very acute emotional pain. And they may not have another means by which to express that or to cope with it. So, they use self-injury because that’s what they know at the time. And in some ways actions can speak louder than words and they may not be able to articulate how they’re feeling, that they feel, that they can’t cope with that intensity of what’s going on, so they may use self-injury to do that. So, I think to reduce that to “oh they’re just being manipulative” is highly problematic. And it does not account for the context in which self-injury occurs.
Dr. Westers: We’ll hear more from Dr. Lewis in an upcoming episode on self-injury and the internet. I would add that calling a behavior or person manipulative is problematic for several additional reasons. First, if someone were to call you manipulative, how would you feel? The word “manipulative” is inherently pejorative. Next, we can’t infer the intent of anyone’s behavior—doing so is simply speculation. Manipulation also requires a level of sophistication and purposeful planning.
Finally—I know not everyone may not agree with me on this—but basic principles of behavioral psychology don't allow for manipulation to be applied to non-coercive behavior. That is, with the exception of legitimate threat like violence or compromised safety, there’s little room for the word manipulation when it comes to behavioral psychology. For example, let's say a child accompanies their parent, their caretaker, to the grocery store and sees a candy bar in the checkout lane. The child asks their caretaker for it, and the caretaker says no. The child throws a fit in public, and in embarrassment, the caretaker gives in and buys it for them in order to quiet them. This might sound familiar. Next week, same thing happens. One might say the child manipulated their caretaker into buying the candy bar. Behavioral psychology says the child was inadvertently reinforced by their caregiver for throwing a tantrum. This is called operant conditioning—not manipulation. The takeaway here is that we can do a better job of conceptualizing self-injury and move it away from calling people who engage in it manipulative.
In line with the interpersonal social reasons people give for self-injuring, a small number endorse doing it to symbolize pain. Dr. Whitlock has interviewed some of these individuals.
Dr. Whitlock: I’ve heard some interesting stories about, especially about younger teens saying that they self-injure as a symbolic gesture of wounds for when they have felt hurt by somebody else. A young woman told me a story about her boyfriend starting to go out with someone else and she was really upset, so she cut as a symbolic gesture of the wound that he had inflicted upon her.
Dr. Westers: We’ll hear more from my interview with Dr. Whitlock in Episode 3. Specifically, about how parents can respond to their teens who self-injure. When asking our sample of 124 adolescents why they self-injure, we used the Inventory of Statements About Self-injury, which includes 5 emotional reasons for self-injury and 8 social reasons. As you might guess, and consistent with research, the top 5 reasons they gave for self-injuring were the 5 emotional reasons, followed by the 8 social reasons. The top social reason? Self-care. The 3 items comprising the self-care function of self-injury included: “giving myself a way to care for myself by attending to the wound”, “creating a physical injury that’s easier to care for than my emotional distress”, and “allowing myself to focus on treating the injury, which can be gratifying or satisfying”. This is one way it helped Lexi.
Lexi: It was the process, right? So, it was like, self-injury, but the process of it, it was, it’s quite intimate. It’s like—and I know that sounds really weird because, you know, you’re hurting yourself so how can that be like an intimate thing? But it was also just this, almost like a connection with self and then looking after myself afterwards I found really therapeutic because I didn’t know how to look after myself emotionally or psychologically and so that kind of concrete physical way of caring for myself was really soothing, I think, yeah. Lots of reasons.
Dr. Westers: One last point. Sometimes people may not be able to articulate or pinpoint exactly why they self-injure. I mean, how many of us have done things and we have no idea why we did what we did—or do what we do?
Lexi: And I think there’s lots of different catalysts, I think. People have lots of different struggles or challenges that they’re trying to manage or cope with and yeah really difficult to I think pinpoint “this is why”. So, I think the range of reasons is so broad.
Dr. Westers: And when it comes to NSSI, I think not being able to pinpoint why or identify why is okay is at times. My friend Dee shared this about her daughter when she was in middle school.
Dee: I think from her perspective, she doesn’t quite have a clear answer for why she cut or what it was doing for her. It was a time where she was a little upset and had seen videos of it somewhere. I don’t know if that was social media or a movie, something along those lines. And she tried it out to see what it would do. And I don’t know if she really articulated whether or not she got any benefit from it—and I think the ramifications were pretty swift—so maybe it was, if she thought she was going to get benefit from it, it didn’t really turn out that way.
Dr. Westers: If you’re a parent, you’ll definitely want to hear my interview with Dee in an upcoming episode.
So, why do people self-injure? Well, in summary, people self-injure for a lot of reasons, more than we've discussed here, but research supports 2 primary categories: emotional reasons and social reasons. And those who start off self-injuring for social reasons often begin to self-injure for emotional reasons. So, it's important for us to always take seriously self-injury when it occurs—regardless of the reason why.
If you're interested in learning more about self-injury, then subscribe to our podcast where at the end of each episode, I attempt to make things practical as I ask the person I'm interviewing what they would recommend to parents, to professionals, and to people with lived experience of self-injury. So, for parents of those who self-injure, hang in there. My hope is that this podcast will be helpful as you journey with your child through their self-injury. I try to keep you in mind during every episode, so please share this podcast with your friends and family members that are parents. And remember if your child self-injures, they do it for a reason. So, make it a point to listen to understand that reason. For clinicians, like therapists and psychologists, we’ll talk about different treatment modalities over time, so stay tuned. In the meantime, let's be sure to better conceptualize self-injury based on function of the behavior—rather than calling it manipulative or even gaming. Our training in basic and counseling skills will go a long way, especially since we know the therapeutic relationship accounts for the greatest variance in treatment outcomes. For researchers, I would say the same thing. Additionally, I would love to see more individuals with lived experience of self-injury help guide studies. If you're a researcher and have a topic you'd like us to address on this podcast, send me a message.
Finally, to those with lived experience of self-injury–whether you have a past history of self-injury or currently engage in it. I know each of you is different and each of you is unique. Talking about self-injury and self-injury research in science in broad terms in this podcast may seem somewhat detached or dismissive of your unique experience at times. It is my genuine hope that it does not come across this way; I'm an ally and advocate, and I'll do my best to remain empathic in each episode. Also, although your experience of self-injury is unique, you're not alone even when it feels that way. We as people are changed by stories, so your story matters. Over time, I'll be interviewing individuals with lived experience who share their stories, which I hope inspire, challenge, and encourage you. Coming to a close, if you're a parent, a clinician, a researcher, or someone with lived self-injury experience, you won’t want to miss an episode. Join me as we explore the psychology of self-injury. Thanks for listening.
We hope you enjoyed this episode of the Psychology of Self-Injury Podcast. It is not considered therapy or meant to be a replacement for therapy, so if you or someone you love is in crisis and needs to talk to someone, you can reach out to the crisis text line—a global, not-for-profit organization providing free mental health texting service through confidential crisis intervention by texting home to 741-741. If you found this podcast helpful, please subscribe, give us a rating, and tell your friends. For all things psychology, follow me on Instagram and Twitter @DocWesters. For all things self-injury, follow I Triple S on Facebook and Twitter @ITripleS. I’m Dr. Nicholas Westers, thank you for listening to the Psychology of Self-Injury.