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raised high up into the air and yells “I’m the King of the World!” This is a wonderful depiction of an individual who is experiencing a sense of “feeling and being alive.” Self-injurers strive to create this experience through their acts of bodily harm. Because they often do not believe that they can achieve this feeling without self-injury, they develop a pattern of its use.

      2. As Punishment

      A second common reason why individuals self-injure is for punishment. Self-injurers seek to punish themselves, either for what they perceive as their own failings (internal reasons), or because of external events. Internal reasons for punishment include things like failing a test, missing the winning goal or saying something that you later regret. As a result, the person feels angry, frustrated and disappointed in themselves. For example, Brian states, “When I mess up in a game or on a test, I look for a way to punish myself. Self-injury provides me with that way.”

      External reasons for punishment might include a friend being rude, a fight with parents, a flight being cancelled, a car breaking down, or the weather ruining plans. As a result, the person feels angry, frustrated, and disappointed with something or someone in the outside world. Elaine explains, “A client changes his mind about a deal due to financial constraints, or it rains during my only vacation of the year, and I cannot help but turn to my trusted friend, my piece of glass. Using it during those times is a way to purge myself of all my anger and disappointment.” Or, according to Sara, “When a friend at school gives me a dirty look, or talks about me behind my back, or when I get into a fight with my parents, the anger and sadness I feel is so big that I cut to deal with it.”

      3. To Numb Feelings

      A third common reason that people self-injure is to numb uncomfortable feelings. In this case, one of two things happens. Either emotional pain is turned into physical pain because it is easier to deal with, or the person masters numbing the physical pain which in turn helps them to achieve their ultimate goal of relieving their emotional pain. In either case, however, the same goal is achieved. The emotional pain is managed by finding a way to numb it or avoid it completely.

      Joey exemplifies this point. He expresses his pain physically by burning. He comments, “I do not like the sight of blood or the way it feels to slice my skin. Cutting causes me too much pain, so I burn instead.” Joey does not self-injure to feel pain. He self-injures to numb pain. He states, “I can numb the burning sensation on my arms or legs whenever I put a lighter or cigarette to my skin. I like the power and control I feel when I make the pain go away.” For Joey, mastery over physical pain is followed by mastery over emotional pain.

      4. To Decrease Tension

      The last common reason that people self-injure is to decrease tension and stress. This is one of the most prevalent indicators for self-injurious behavior and the one cited most often when patients first come into my office. Many of my patients are struggling with intense pressure and stress in their lives. During the initial intake interview, these patients often admit to utilizing self-injury as a way to relieve those feelings. I hear statements like “It calms me down,” “It relieves tension,” or “I feel at peace with myself when I do it.”

      This calming technique, although very unhealthy, seems to work in the short term. The problem is that it does not work in the long term and can lead to very dangerous consequences. Aside from the reasons behind self-injurious behavior, the behavior itself can be highly detrimental both physically and psychologically. However, when used to relieve tension and stress, there is an added component which makes it more dangerous and potentially lethal.

      In my professional experience, I have found that there is a significant correlation between increasing tension and increasing severity of the self-injurious behavior. In other words, the more stress and tension that the individual feels, the greater the severity of the self-injurious act. As discussed above, it is not uncommon for these patients to end up in the hospital because their behavior becomes so dangerous and out of control.

      For example, Kathy was admitted to the hospital following an incident of self-injurious behavior where she cut so deep that she stated, “I even scared myself.” She explained, “I needed to cut more deeply to get the same effect. The tension I was feeling was so powerful that superficial cutting did not seem to get rid of all my stress. I needed something more.” Nadia found herself in a similar situation. She was hospitalized right before a family reunion. She cut so deep, she could see bone. She did not want to go to the hospital, but knew that it was what she needed. She was afraid that she would take things too far as a way to try to get the relief she was looking for. She stated, “The cuts I made on a daily basis were not enough. I needed something more. It was like I built up a tolerance to the pain and couldn’t get the same feeling unless I dug deeper into my skin.”

      5. A Coping Mechanism

      In summary, self-injurious behavior is a coping mechanism. As defined, it is a way for individuals to manage overwhelming feelings that are too painful or difficult to verbalize. The first step in helping a loved one who is self-injuring is understanding her pain and recognizing that she is attempting to manage it. The remainder of this book will focus on identification of self-injury as well as prevention and intervention. Specific guidelines and techniques that can help self-injurers learn to manage painful emotions in a way that is safer, healthier, and more productive will be addressed.

      Identifying Self-Injury

      “Cutting became my cry for help when words could not do it for me. I don’t think I would have stopped if my coach hadn’t noticed. She picked up on the warning signs and identified the problem. Only then did I get the help I so desperately needed but could not ask for.” - Jessica, age 15

      Perhaps you are reading this chapter because your teen self-injures, or maybe you know someone else that does. Maybe you are reading it because you have suspicions that your child is engaging in self-harming behaviors. In any case, I would like to applaud your willingness to examine the problem and identify the severity of your child’s situation. With self-injury is becoming as widespread as substance abuse and eating disorders, it is not uncommon for most people to know someone who struggles with this problem. Yet parents generally have little information as to what they can do to help. The first step is identifying the problem and simply acknowledging that it exists.

      In the past 18 years, I have worked with more individuals who self-injure than I can count. What was once thought of as a teenage phenomenon is now recognized as a struggle faced by individuals of all ages. It may surprise you to know that the incidence of habitual bodily harm is approximately 1% in our country. With a reported 2 million cases in the United States alone, it is clear that this disorder has become rampant and affects a diverse population. This number is growing at a fast rate and there is evidence it is beginning to occur among younger and younger individuals.

      While some of the individuals that have walked into my office have been as young as nine, it is still more common among teenagers. If left untreated, this behavior often continues into adulthood. In addition, the longer the individual struggles with the problem, the harder it is likely to be for them to stop the behavior. Therefore, getting help as soon as possible is very important. This is a serious problem that should be treated aggressively when first identified.

      Warning Signs

      There are several signs that may indicate an individual is engaging in self-injurious behavior. One of the biggest red flags is when the individual always wears long sleeves and pants, even when the weather is warm. Another red flag is frequently unexplained or justified injuries such as scratches, cuts or burns. Amber recalls how she attempted to hide her self-harm from people at school. She states, “My solution was long sleeves and pants, and at soccer practice I cleverly used a sock which I said was a sweat band.” In addition, she remembers having to explain why she had scratches on her body. “I made up crazy stories about my cat to answer some of the questions,” she recalls.

      Other warning signs include low self-esteem, a feeling of being easily overwhelmed,

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