By Michael Anestis
E. Edward Grey: Why
do you cut yourself, Lee?
Lee: I don't know.
E. Edward Grey: Is it
that sometimes the pain inside has to come to the surface, and when you see
evidence of the pain inside you finally know you're really here? Then, when you
watch the wound heal, it's comforting... isn't it?
Lee: That's a way to
put it.
- From the movie Secretary
Non-suicidal self-injury (NSSI), defined as intentional damage to one's body without suicidal intent (Nock & Prinstein, 2004), is a behavior that, for many people, eludes understanding. It seems almost counter-intuitive that individuals who are suffering would add physical insult to already overwhelming emotional struggles. As foreign as this behavior may seem to some, it is actually fairly common, with approximately 4% of adults in the general population reporting having engaged in NSSI and 21% of adults in inpatient psychiatric facilities reporting a history of NSSI (Briere & Gill, 1998). The behavior is even more common in adolescents, with 9-17% of adolescents in the general population (Ross & Heath, 2002) reporting a history of NSSI along with 40-61% in inpatient facilities (Darche, 1990). Researchers interested in better understanding this seemingly paradoxical behavior have made great strides clarifying the matter in recent years. In 2004, Matthew Nock of Harvard University and Mitchell Prinstein of the University of North Carolina published an article on what they termed a functional model of self-injury.
In this article, the authors indicated that, when individuals self-injure, they do so for automatic or social reasons and attain either positive or negative reinforcement. Automatic reasons refer to goals within oneself and social reasons refer to goals related to interactions with other people. Positive reinforcement involves the addition of something otherwise absent and negative reinforcement involves the removal of something that would otherwise be present. Nock and Prinstein thus concluded that individuals self-injure for automatic positive reinforcement (e.g., to feel something, even if it is pain), automatic negative reinforcement (e.g., to reduce negative emotions), social positive reinforcement (e.g., to obtain a response from somebody else), or social negative reinforcement (e.g., to avoid an anticipated interaction). An individual can certainly self-injure for more than one reason, but these distinctions are important, as they provide a framework within which clinicians and researchers can better understand why individuals are motivated to injure themselves.
A model like this also serves to change perceptions of individuals who engage in such behaviors. There is an unfortunate, common misperception that individuals who self-injure do so in an effort to manipulate others. This perception leads individuals to develop negative views about people who self-injure. This is unfortunate or several reasons. First, it adds additional stress to the lives of individuals who self-injure. Second, it perpetuates harmful stereotypes and makes it more difficult for individuals who self-injury to seek help. The reality of self-injury, it appears, is significantly different from these misperceptions. Nock and Prinstein (2005) found that the most commonly endorsed function for self-injury among adolescents was automatic negative reinforcement. In other words, at least in the case of adolescents, when individuals engage in self-injury, they are most often doing so in an attempt to alleviate their own suffering, not to induce suffering in or change the behaviors of others. This fact presents a picture of adolescent self-injurers as individuals who are overwhelmed by their emotions and lacking in the skills needed to effectively alter how they are feeling. In this same study, Nock and Prinstein reported that, while the experience of pain varied amongst self-injurers, a substantial proportion of individuals who self-injure do not experience pain during the behavior. As such, punishment can not really be seen as the motivation behind the behavior either. Instead, these individuals are in need of help in developing effective methods for changing their affective state.
Individuals who engage in NSSI are vulnerable to a variety of dangerous behaviors. Hilt, Nock, Lloyd-Richardson, and Prinstein (2008) reported that, in a sample of 508 children in 6th, 7th, and 8th grade, individuals who self-injure were more likely to have smoked cigarettes, taken drugs, or utilized maladaptive eating behaviors (e.g., binge eating and purging). In addition to an overall lack of skills in regulating emotions, researchers have reported several other vulnerabilities that help explain why people feel compelled to use behaviors that, to the untrained eye, appear illogical. Nock and Mendes (2008) found that individuals who self-injure experience more physiological reactivity to stressful events. In other words, individuals who self-injure feel more physical sensations (e.g., increased heart rate) in response to stress than do individuals who do not engage in NSSI. Additionally, the authors found that individuals who self-injure are less able to tolerate distress than are individuals who do not self-injure. In simpler terms, this means that individuals who self-injure are feeling more when they are stressed and become overwhelmed more easily. This, obviously, is not an ideal combination of factors. Fortunately, contrary to the belief of those who view self-injury as a purely manipulative tactic, there are effective therapeutic interventions capable of helping individuals develop skills for handling their emotions. In particular, Dialectical Behavior Therapy (Linehan, 1993) has been shown to be effective in the treatment of individuals with Borderline Personality Disorder, which is often characterized by frequent self-injury.
Although treatment is not perfect, there is reason to be hopeful that we are learning more about what drives individuals to self-injure and what can be done to effectively treat this behavior. Overcoming misperceptions about why individuals self-injure and directing people to effective treatments will go a long way towards further improving this situation.
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