Friday, August 2, 2013

Cutting Does NOT Make You "Borderline:" Understanding Non-Suicidal Self-Injury

All too many clinicians (and sometimes the general public) hold stereotyped and inaccurate assumptions about self-injury, based on outdated "clinical data." In particular, there are some who automatically assume anyone who "cuts" has Borderline Personality Disorder (BPD) - arguably the most stigmatized diagnosis among mental health professionals. It's time to set the record straight about self-harm.

Non-suicidal self-injury is defined as intentional tissue damage that:

  1. does not have suicidal intent (in other words, self-injury, by definition, is not a suicide attempt or suicidal gesture; however, if the self-injury is serious enough, it can lead to accidental death.
  2. is not culturally-sanctioned (in other words, tattoos, piercings, ritual scarring in certain cultures, and things like that aren't included). 

Forms of self-injury are wide-ranging, and include scratching, cutting, skin-picking, hair-pulling, burning, bruising, even breaking bones.

Several decades ago, self-injury was pretty much only seen in individuals with serious mental illnesses, including BPD and psychosis. That was then. This is now: it is estimated that 20% of all adolescents and young adults will at some point engage in self-injury, and the number has been rising. In fact, a study by Cornell Research Program on Self-Injurious Behavior found that almost half of college students who self-injure do not have a diagnosable mental disorder. Those who do have a mental health condition are in fact most likely to have eating disorders, but self-injury is also seen in conjunction with anxiety disorders, depression, bipolar, substance abuse, and PTSD. More severe (e.g., deeper) and more frequent injury may be linked to more serious mental illness, and to later suicide attempts, in contrast to infrequent and/or superficial injury, which does not have the same links.

It's also often assumed that only females self-injure. While it is true that females report more self-injury than males, about 30-40% of those who self-injure are male. The actual numbers may be even more balanced than that, however, because male self-harm is more likely to outwardly resemble externally-focused aggression. Boys and men are more likely to fight, punch or kick things, etc., as an intentional form of self-injury, seeking to bruise or break something. Males are also more likely to begin self-injuring through a group or social context (i.e., where multiple boys or men self-injure together).

Self-injury functions as a coping mechanism, in a way similar to substance use and other addictive behaviors: it releases endorphins that reduce physiological arousal. In other words, it mitigates feelings of agitation or distress, and helps people calm down and feel better. It can also give people a sense of control, and means of expressing intense emotions. For people with trauma histories, it can be grounding.

Treatment, then, focuses on developing healthier coping skills to regulate emotions, tolerate distress, express feelings effectively, experience control and mastery, and ground oneself. At the same time, once self-injury has become a habit, managing urges and thoughts about injuring without injuring are crucial skills. Dialectical Behavioral Therapy, Acceptance and Commitment Family, and other mindfulness-based approaches, sometimes in conjuction with Motivational Interviewing and/or Cognitive Behavioral Therapy, are promising approaches to treatment and recovery.

However, none of these approaches can be effective if people don't engage in treatment - something that can be strongly influenced by their initial interactions with professionals. Responses that are biased and stigmatizing are only likely to drive people away from treatment, and back to self-injury. In contrast, a non-judgmental, empathic approach characterized by unconditional positive regard (i.e., Rogers' "facilitative conditions") opens the door - literally and metaphorically - for people who self-injure to engage in treatment and move forward into recovery.

No comments:

Post a Comment