Here’s what I remember about the first time I cut myself: I was mad. As a writer, I wish I could come up with something more literary, such as: ‘The cuts provided a route through my skin for the emotions to escape.’ Or maybe: ‘I used it to translate emotional pain into physical pain.’ Or even, perhaps: ‘I engraved my suffering into my skin, turmoil writ large for all the world to see.’
These are, to some extent, true. But that’s not what I was thinking the first time I picked up a pair of scissors and slashed at my thighs. Mostly, I was pissed off.
I had argued with my mom over something so banal it has long since disappeared into the dustbin of memory. And, in a fit of adolescent fury, I stormed into my bedroom and slammed the door. Blind with rage, I picked up a pair of scissors and turned them over in my hand. The next thing I knew, I was staring at tiny pearls of blood on my leg. The fog of anger had lifted.
I quickly patched myself up, rather shamefaced. The scissors were old and the blades were dull, so I had done minimal physical damage. Then or now, I couldn’t explain what had come over me. I vowed never to do it again. Within two weeks, I had broken that vow.
Over the years, I’ve tried to explain self-injury to my therapists, my parents, my friends and, most recently, my husband. Everyone has the same plaintive question: ‘Why?’ Mostly, I just shrug my shoulders and mutter: ‘Dunno.’ I don’t tell them that I am asking the same question of myself. I don’t enjoy the process, nor do I like the scars. It’s shameful and embarrassing. I desperately wanted to stop, but one thing kept getting in my way: after I cut, I felt better.
Although I have written extensively about my mental health history – I have a psychiatric rap sheet that stretches as long as my arm – I rarely mention self-injury. Depression, anxiety, anorexia, even suicide attempts – all of those feel infinitely more explicable than the recurrent pull of the razor. I am not alone in my shame or my struggles. A 2006 study in Pediatrics estimates that nearly one in five college students have deliberately injured themselves at least once. Approximately six per cent of young adults will injure themselves repeatedly. Although death caused directly by self-injury is relatively rare, even occasional self-harm dramatically increases the risk of suicide attempts and completed suicides.
Why so many of us keep hitting the self-destruct button still isn’t clear, but a new era of studies in psychology and neuroscience offer a richer picture of why, for some of us, feeling bad means feeling good.
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Blood is a powerful force. We speak of blood ties and land that has been consecrated by blood. We spill blood to cure disease and to appease gods. Long-standing disputes between groups of people become blood feuds. Blood – and the injuries sustained to obtain it – has long been a symbol of both war and religion. Christians drink wine during Holy Communion that represents the blood of Christ, which was spilt to redeem our sins. Mayan priests opened their own veins for a blood sacrifice for their deities.
Self-mutilation is just as ancient. The historian Herodotus writes of the first King Cleomenes of Sparta, who went insane and was placed in the stocks in the fifth century BCE:
As he was lying there, fast bound, he noticed that all his guards had left him except one. He asked this man, who was a serf, to lend him his knife. At first the fellow refused, but Cleomenes, by threats of what he would do to him when he recovered his liberty, so frightened him that he at last consented. As soon as the knife was in his hands, Cleomenes began to mutilate himself, beginning on his shins. He sliced his flesh into strips, working upwards to his thighs, hips, and sides until he reached his belly, which he chopped into mincemeat.
The first clinical reports of what would now be recognised as self-injury appeared in the late 1800s, in Anomalies and Curiosities of Medicine (1896) by the American physicians George Gould and Walter Pyle. They write of ‘needle girls’, young women who repeatedly injured themselves by inserting sewing needles and pins into their skin, or otherwise cutting themselves. They summarise the case of one 30-year-old woman from New York like this:
On September 25th she cut her left wrist and right hand; in three weeks she became again ‘discouraged’ because she was refused opium, and again cut her arms below the elbows, cleanly severing the skin and fascia, and completely hacking the muscles in every direction. Six weeks later, she repeated the latter feat over the seat of the recently healed cicatrices [cut marks]… Five weeks after convalescence, during which her conduct was exemplary, she again cut her arms in the same place. In the following April, for the merest trifle, she again repeated the mutilation, but this time leaving pieces of glass in the wounds. Six months later she inflicted a wound seven inches in length, in which she inserted 30 pieces of glass, seven long splinters, and five shoe-nails. In June 1877, she cut herself for the last time. The following articles were taken from her arms and preserved: 94 pieces of glass, 34 splinters, two tacks, five shoe-nails, one pin, and one needle, besides other things which were lost – making altogether about 150 articles.
Gould and Pyle classified this ritualistic self-harm as a form of hysteria, and the women who engaged in it as deceitful and attention-seeking. In fact, until the early 2000s, most of the clinical literature classified self-injury with more severe psychiatric disorders such as psychosis and borderline personality disorder, a state of inner chaos and instability, especially where relationships are concerned.
‘Some women who self-injured were hospitalised every time they cut themselves, which could be hundreds of times over their lifetime. They essentially lived in hospitals,’ said Wendy Lader, the clinical director of a US self-abuse programme and one of the first psychologists to treat self-injury. ‘People thought I was crazy when I said that many of these people could be treated as outpatients because they weren’t necessarily suicidal.’
‘These were amazing, bright, intelligent young people that had so much promise, only they were consumed by thoughts of hurting themselves’
Lader first began to study and treat self-injury in the early 1980s after her colleague Karen Conterio began seeing evidence of more and more women self-harming in her outpatient substance-abuse practice. None of these women showed signs of psychosis or personality disorders, nor were they cutting or burning themselves with any intent of suicide. Conterio thought she was seeing just the tip of the iceberg, and so she placed an ad in the Chicago Tribune in 1984 asking to hear from those who regularly hurt themselves without intending to commit suicide. Mail poured in, and people suddenly began talking about self-injury. Its emergence as a pop-culture phenomenon led to an appearance on the Phil Donahue TV show in 1985 with several women who self-harmed.
In 1986, Lader and Conterio founded what would become SAFE (Self-Abuse Finally Ends) Alternatives, the world’s first residential facility specifically to treat women who self-injured, now located outside St Louis. Psychologists generally believed that Lader and Conterio were seeing a rare subset of the population, and that the psyches of these women were as hopelessly scarred as their bodies. Lader wasn’t convinced. ‘These were amazing, bright, intelligent young people that had so much promise, only they were consumed by thoughts of hurting themselves,’ Lader told me.
Though others doubted it, Lader also believed that self-harm was far more common than anyone realised. Proof finally arrived in 2002 from Nancy Heath, a psychologist at McGill University in Canada, and her PhD student Shana Ross. At her placement in a local high school, Ross was regularly talking to teens who expressed concern about their own or a friend’s self-injury. When she discussed making this the focus of her dissertation, Heath tried to talk her out of it.
‘I told her she would never find enough people who self-harmed to get the data for a thesis,’ Heath told me. ‘I finally agreed to let her try.’
Ross’s preliminary results indicated that more than one in five young people had self-injured at least once. This shocked Heath and the rest of the dissertation committee so much that they thought the high-school students had misunderstood the question. So Ross went back to the drawing board, conducting in-depth interviews with those who had reported self-injury and throwing out all the results with even a hint of inconsistency. The percentages dropped, but Ross was still left with a mindbogglingly high number of adolescents reporting self-harm: 13.9 per cent.
Not long after Ross and Heath’s study appeared in the Journal of Youth and Adolescence, Janis Whitlock, a psychologist at Cornell University, published a study of self-injury among 5,000 students at several Ivy League universities. Her results showed similarly high numbers of young people who had harmed themselves: 20 per cent of women and 14 per cent of men said they had self-injured at least once.
‘I was just shocked. Everyone was finding really high rates,’ Whitlock told me. ‘The issue seemed to come out of nowhere.’
What was groundbreaking about these two studies was not just the high rates of self-injury but that these were community populations, and not people hospitalised for psychiatric problems. They were the people you sat next to in class and stood in line with at the grocery store.
All these findings meant that self-injury had to be redefined. By 2006, a small cadre of scientists at the first meeting of the International Society for the Study of Self-Injury (ISSS) did just that. ‘We discussed the definition over dinner and drinks one night,’ Heath told me. ‘It meant the poor waiter had to listen to the most disturbing dinner conversation of his life. We asked each other questions like, “So if removing your own eyeball is self-harm, what about drinking bleach?”’
The definition they developed still stands: non-suicidal self-injury is the deliberate, self-inflicted destruction of body tissue without suicidal intent nor for socially sanctioned purposes such as piercings or tattoos. Epidemiological studies found that, while up to a third of all adolescents had deliberately harmed themselves at least once, fewer than one in 10 adolescents and young adults repeatedly did so. Moreover, although many pop culture accounts report self-injury to be a ‘female’ thing, studies have found that males and females self-injure in roughly equal proportions.
The group is heterogeneous. Many struggle with depression, anxiety, and eating disorders. Some meet criteria for borderline personality disorder. Yet others have autism spectrum disorders or, like me, associated anxiety disorders; this last group spent the most time thinking about self-injury before engaging in self-harm, and had the highest risk of suicide.
In fact, cutting and other forms of bodily self-harm are among the most robust predictors of future suicidal behaviour, says Stephen Lewis, a psychologist at the University of Guelph in Ontario. Lewis and others believe that self-harm signals the inability to cope with emotions at hand. The temporary escape that self-injury provides could be a precursor to the more permanent escape of suicide.
Regardless of the reasons that suicide and self-harm are so strongly linked, researchers still struggled to understand why people would repeatedly (and deliberately) hurt themselves. Matthew Nock, now a professor of psychology at Harvard, tried to figure this out while he was a PhD student at Yale under the psychologist Mitch Prinstein (who is now at the University of North Carolina at Chapel Hill). By delving into the literature on other repetitive behaviours and asking individuals who self-injured to keep diaries, Nock and Prinstein developed the Four Factor Model in 2004.
The model works through positive and negative reinforcement, Prinstein told me. Positive reinforcement is when doing something gives us a reward; negative reinforcement is the removal of something that makes us feel bad. Self-injury offers both positive and negative reinforcement, both for intrapersonal reasons (by altering emotions) and for interpersonal reasons (by altering our relationships with others). Someone who is so numbed by depression that she feels nothing might cut herself to feel something, anything, even if it’s pain – an example of positive reinforcement for intrapersonal reasons. Others might be anxious or enraged and hurt themselves to diminish those feelings, which is a case of intrapersonal negative reinforcement. Still others could injure themselves to demonstrate how distressed they and to get loved ones to react (interpersonal positive reinforcement) or to stop doing something (interpersonal negative reinforcement). A person’s reasons for self-injury can be different each time, and can encompass a variety of motivations, but some are more common than others.
‘By far the most common reason people said they self-injured was to stop feeling so bad,’ Prinstein said.
I could relate to that. Intense, negative emotions I didn’t know how to manage always preceded an episode of self-injury. Sometimes, the goal was to feel better. Other times, the desire to turn down the volume on emotions such as anger or anxiety was tinged with an urge to punish myself. I deserved to hurt, I deserved to feel pain and have scars so that the world would know I was a horrid person. Not everyone, however, reported feeling pain while hurting themselves; a substantial portion of people who self-injure say that their actions don’t result in immediate pain.
those with the greatest difficulties in regulating and responding to emotions were also able to withstand the pain the longest
All this led Joseph Franklin, who received his PhD under Prinstein and is currently a postdoc in Nock’s lab, to ask whether differences in pain perception might contribute to self-injury. He brought 25 individuals who regularly self-harmed into the lab and asked them to place their hands in ice-cold water, a common way to measure pain.
Compared against 47 controls, the individuals who self-harmed were able to leave their hands in the ice-cold water longer, indicating a diminished pain perception. Franklin also found that those with the greatest difficulties in regulating and responding to emotions were also able to withstand the pain the longest. It was as if their emotional pain was distracting them from the physical pain.
A related study by Nock and colleagues at Harvard showed that self-criticism also increased the amount of time for which individuals who self-injured could withstand pain. Franklin believes that people who are overly self-critical might push themselves to endure the pain for longer. These two factors – emotion regulation and self-criticism – seem to be independent, and their appearance together would likely increase any risk of self-injury even further.
This finding hit home with me. Some of my worst periods of cutting occurred after struggles in graduate school, whether it was difficulty completing my thesis, a bad grade on an exam, or just generally feeling not good enough. I wallowed in self-hatred. Experts would likely say that my feeling I deserved the pain, or had somehow earned it through my behaviour, made it easier to tolerate.
One issue bothering Franklin and others involved the barriers to self-harm. ‘If we all feel so much better when pain stops, the question isn’t why so many people self-injure, it’s why so few people do,’ Franklin said.
But recent unpublished experiments reveal that most people have a powerful aversion to mutilating their bodies. When they see pictures of bodily harm, they look away: it’s profoundly unpleasant. That wasn’t the case with those who self-harmed. When these people looked at such images, eye-tracking software revealed that they were drawn to them – probably a significant factor in keeping the disorder in place.
Yet cutters such as me didn’t self-harm to deal with physical pain. We hurt ourselves to cope with emotional pain. Neuroscience is showing how these two factors intertwine. When we get dumped by a romantic partner, we are heartbroken. Anxiety winds us up and leaves us ready to snap. Rage clenches our fists in hate. Emotions are psychological, but they are also physical. When it comes to sensing physical and emotional pain, our brains use the same two areas: the anterior insula, a small patch of neural real estate that’s part of the cerebral cortex behind each ear, and the anterior cingulate cortex, a hook-shaped piece of brain tissue towards the front of the brain. These are the areas in the brain that process pain, regardless of whether we’ve felt the sting of rejection or the sting of a bee.
Pain relievers also act on these two areas, regardless of whether someone is experiencing emotional or physical pain. A 2010 study in Psychological Science revealed that the pain relievers such as Tylenol or paracetamol (acetaminophen) helped to relieve the distress associated with social rejection and also decreased activity in the anterior insula and the anterior cingulate cortex. This doesn’t mean that Tylenol is the next Prozac, but it does show just how intertwined emotional and physical pain are in the brain.
‘If you’re feeling emotionally hurt, those two parts of the brain are aroused,’ Whitlock told me. ‘Among people who self-injure, the experience is very acute. So while rejection might make me feel bad, it makes someone who self-injures feel overwhelmingly bad.’
Far from being the quasi-poetic gestures of a wannabe writer, my self-injury was actually the sign of signal-scrambling in my brain
And the fact that physical and emotional pain perceptions use many of the same neural circuits provides those who self-harm with a curious ‘out’. They’ve learned that, while the pain peaks with self-injury, it then comes down the other side. The physical pain lessens – as does the emotional pain.
It was this link that kept me coming back for more. I didn’t enjoy the pain of cutting but, as the physical pain began to fade, it took some of my emotional distress with it. Far from being the quasi-poetic gestures of a wannabe writer, my self-injury was actually the sign of signal-scrambling between my anterior insula and anterior cingulate cortex. The problem was that the embarrassment of cutting, the knowledge that these marks would become permanently tattooed into my skin, and the fears that someone would discover my secret, meant that any relief was short-lived. All too soon, I was feeling worse than before, leaving me vulnerable to repeat episodes of psychic pain, followed by even more cutting.
So much attention has been paid to young cutters, but what happens to those who self-injure over time? No one really knows. Treatments remain sparse. The most widely used, dialectical behaviour therapy (DBT), encourages people to change their behaviour first, with thought patterns to follow. At the heart of DBT is the Buddhist-like belief that an individual is doing the best that she can and striving to do better, yet clinical trials have shown mixed results. Part of the problem is that borderline personality disorder, the original target for DBT, is generally a more permanent state, where self-injury waxes and wanes, making it harder to determine how well the therapy works.
‘It’s really crazy-making for parents and loved ones because they’ll think a person is out of the woods or has stopped, and then something happens and it starts all over again,’ Whitlock told me.
It has been several years since I last cut myself. Although the urges get easier to resist, when I’m under high stress, thoughts of hurting myself return. I have learned to distance myself from these thoughts, to treat them as comments from the random peanut gallery in my head rather than concrete advice from a reputable source. Similar techniques have been used to treat anxiety disorders such as obsessive-compulsive disorder (with which I have also been diagnosed). In fact, these therapies have helped to shape my brain to work in a healthier pattern. With lots of therapy, I have learned that emotions pass and I can cope with them in ways that don’t leave me embarrassed, ashamed and scarred.
It’s hard not to press the self-destruct button, especially when I know it provides a few moments of blessed relief. It’s hard to live alongside these urges and not give in. But, eventually, self-harm has become just one of a panoply of options at my fingertips. My blood remains inside, my skin intact. My scars have begun to heal.
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is a freelance science writer, whose work has appeared in the Washington Post, Scientific American and Slate, among others. Her latest book is Decoding Anorexia (2012). She lives in Virginia.
In social work, “self-care” is one of those terms that is so overused, it has ceased to mean anything. Typically when self-care is referenced, the speaker is referring to activities and experiences that bring you pleasure. “The work in this field is really tough. You have to practice self-care. Go to a yoga class. Take a walk on a sunny day. Protect your leisure time. Get a mani-pedi. Soak in a bubble bath. Treat yo’self.”
Pleasure is great, and it is important. During seasons when I am depressed, I force myself to indulge in pleasure as though it were a lifeline, because it is. Most likely, there is actual theory and clinical principles behind this, but I’m no clinician, so I can’t speak to that. Here’s my interpretation: feeling bad all day, every day, is exhausting. It’s not good for your body, or your heart, or your psyche. So when I reach day 3 of feeling sad and terrible, I force-feed myself pleasure, even though depression sucks all desire for fun and pleasure out of you. For me it feels similar to the way you might force yourself to eat a salad because you know it’s good for you, even though you may fucking hate eating salads. (I am doing that right now, by the way – eating a fucking salad. It is picture perfect, with local lettuce and beets, tomatoes, dried cranberries, with a lemon-balsamic vinaigrette. I hate it. I’m eating it anyway.)
I thought I was doing this self-care thing the right way until November when it became obvious I was not. Yes, sometimes self-care looks like pleasurable activities, and in such cases, it is not so hard for me to get myself to do it. But if that were all that self-care entailed, I would not have found myself in the place I am in. I’ve been doing that kind of self-care for years with insufficient gains, so this leads me to believe my self-care regimen was incomplete.
What social workers and other people don’t often tell you is that self-care can be completely terrible.Self-care includes a lot of adult-ing, and activities you want to put off indefinitely. Self-care sometimes means making tough decisions which you fear others will judge. Self-care involves asking for help; it involves vulnerability; it involves being painfully honest with yourself and your loved ones about what you need.
I am reconstructing my ideas about what it means to take radically good care of myself. I am making it a priority, to the detriment of other priorities, because I have to come the realization that my life depends on it. I will tell the truth about my present self-care, even though I have zero assurances I am getting it right. Because a) getting it right is not the point (but God, do I love to get things right), and b) the other thing nobody tells you about self-care is that it’s nearly impossible to know if you’re doing it right, until months later when you either find yourself feeling better or shittier. Check in with me in June for an addendum.
TAKE CARE OF YOUR BODY.
Medical self-care is completely unglamorous. Is there anyone on the planet who enjoys going to the dentist? If I go to the dentist once every three years, I’m doing really well. Self-care is paper-gowned, bare-assed vulnerability, as you do the un-fun work of showing up for your Pap smear, mammogram, or enema. Medical self-care is particularly difficult for me when I am depressed and anxious. The depressive part of my brain doesn’t care if I’m sick because it can’t care about anything. The anxious part of my brain doesn’t want to make the doctor’s appointment because what if something is wrong, and what if the nurse is mean, and what if the doctor commits a microaggression, and what if I have to go to doctor’s appointments by myself for the rest of my life because I never find a partner? I’m almost 30, and I can no longer indulge the myth that I am invincible and I will never have physical health issues. Right now, self-care means getting the medical care I need, even if it is difficult and scary for me to accept I am a person who sometimes needs medical care.
In the past year, I have just been quitting shit left and right. Marathons. Jobs. Pet ownership. I hate quitting so much, I can’t even tell you. For a Type-A perfectionist who has always based my self-worth in my accomplishments and being perceived as a capable, self-reliant person, admitting I’m not well enough to do something, like work a full time job, is one of the most painful realities I can imagine. People talk about setting boundaries and avoiding over commitment as though it’s fun. That shit ain’t fun. It is not fun to sit in the office of your work supervisor and explain why you keep calling out sick. It is even less fun to finally suck it up and leave a job because you’re not well enough to work full time, even if you think you ought to be. Even if I have been before, I am not now, and self-care means being honest with myself and other people about that.
The painful self-care I am doing now is coming to terms with the fact that I have built my life around performing only the best parts of myself for other people, or performing for myself to project an image of who I would like to be. And it’s time to quit that shit. I hate it. I feel weak and lazy and dramatic and irresponsible. But I know deep down I am not any of those things, and regardless, it is the self-care I need to do. I can hate it and do it anyway. And maybe tomorrow, I’ll hate it a little bit less. And next week, I’ll hate it less still.
ASK FOR HELP.
In my experience, people talk about reaching out for help as though it is cathartic and will always be well received. The truth is it is scary and uncomfortable, and until you’ve done it, you have no assurance about how people will react. You would think it would be easier if you have strong loving relationships with your friends and family, but I am lucky enough to have all of that, and I still find asking for help completely terrifying and painful and shameful, even though it ought not be any of those things. Having loving parents means I worry about causing alarm. And if the people who love you are empathic people who pour intention into your relationship, it can feel really scary to let them into the dark places of your life, and own up to feelings of deep sadness or suicidal thoughts. For me, a person who is driven to please and to perform, and who has immensely loving friends and family, being honest about my depression causes a unique anxiety – fear that I will say, “I don’t want to live,” and people will hear, “your love is insufficient, and so insignificant to me that I’m willing to leave you.” This line of thinking binds me into a false choice between my pain and someone else’s: if I am honest about my pain, I will cause pain for the people I love; therefore asking for help is a bad choice. No. Reaching out has been necessary, and now that I’m on the other side of it, I’m glad I did, but it took a lot to overcome that line of thinking, and it certainly was not the pleasurable type of self-care.
Also, maybe there are some people in this world who have the ability to ask for help in a graceful and appropriate way. However, I do not possess that trait. My efforts at reaching out and asking for help have fallen in the center of an unattractive Venn diagram, the circles of which include a) clumsiness, b) histrionics, and c) mild disregard for other people’s needs and perspective. Asking for help is difficult on a good day, so when you’ve waited until you are the worst version of yourself before you try to do it, it’s not a pretty picture. You’ve gotta do it anyway, because self-care; it’s totally shitty.
TAKE CARE OF YOUR RELATIONSHIPS.
I believe there’s usually a lot of ugly shit at the root of our depression. Yes, it is a medical and physiological disorder, and I’m trying to unpack the stigma I didn’t know I had toward depression. But mental disorders and illness are never as simple as, “here, you need more of this chemical between your neurons.” Underneath the physiological processes, there is usually a ton of FOO (Family Of Origin) issues, some maladaptive coping, and some cognitive distortions surrounding your identity and your relationship to other people. Recovering from depression means confronting some of that shit and working through some it. (I say some, because baby steps.) Recovery means hard, honest conversations with your loved ones about what you need, and what you don’t need. It also means doing your best to love and support the people who are loving and supporting you, at the very least on your good days. Unfortunately, experiencing a major depressive episode does not suddenly make you the center of everyone’s universe or give you permission to be an asshole. Taking care of your relationships when you’re depressed or anxious can be hard. Not always, but sometimes. I am finding the only way to do this is through open, honest, direct communication. I am stumbling through it, and I am lucky enough to have people who are willing to stumble inelegantly along with me.
TAKE CARE OF YOUR BASIC NEEDS.
Pay your bills. Plain and simple. It’s necessary if one wants to continue living indoors. I can only speak for myself, so I’ll say that financial responsibility is really hard for me when I’m anxious or depressed. I don’t want to log in to my bank account because I’m afraid of judging myself for seeing how much money I’ve spent on eating out because cooking meals at home is too overwhelming a task. I’m forgetful and have trouble focusing, which means utility bills get paid at the last minute, and vehicle oil changes get done 1000 miles too late. Even though these things are hard to do when I’m depressed, I have to find ways to make them happen, even if it means asking for help or reminders.
If you’re doing these un-fun aspects of self-care, I’m proud of you. If you’re doing them, and you are sick, mentally or physically, or if you in a tough spot in whatever way in your life, I’m really, really proud of you because it’s not easy to do. If you’re not doing all of them, or you’re struggling in asking for help, or you’re struggling in quitting something you need to leave behind, I believe in you. It’s not fun or easy, and you can do it anyway.
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