All forms of self-harm seem, at first glance, the most puzzling and enigmatic of behaviors. Surely we are all driven at a basic level, perhaps even by our genes, to preserve our well being, and avoid obvious harm to ourselves?

Perhaps partly because self-inflicted harm is so apparently baffling, it has a tendency to provoke the most anger in outsiders - and, as a result, victims of self-mutilation often find it extremely hard to receive professional help.

Of all disturbing patient behaviours, self-mutilation is often described as the most difficult for clinicians to understand and treat. Typically staff are left feeling a combination of helpless, horrified, guilty, furious, betrayed, disgusted and sad.

The Paradox of Self-Harm

Obviously, many people indulge in behaviour that is harmful to themselves, like smoking or drinking to excess. But the main difference between these behaviours - and someone who repetitively cuts their own arms - is the damage caused by smoking is not usually the actual reason why someone smokes. Rather, harm is typically an unfortunate side effect, and the aim of smoking is the derivation of pleasure from the sensation of smoking. Yet those who cut themselves appear to intend to directly hurt themselves.

There is also an important distinction between suicidal acts and self-mutilation, though those who do cut themselves often go on to attempt suicide. In the case of attempted suicide (for example, most usually by ingestion of pills), the harm caused is uncertain and basically invisible; while for self-lacerations, the degree of self-harm is clear, predictable and often highly visible.

Doctors and lay people find themselves paralyzed in the face of such perplexing behaviour - and so there are very few units in the health service where staff have the necessary training and experience allowing them to confront and manage such bizarre behaviour. Hence the crisis recovery unit at the Bethlem Royal Hospital is almost unique in the United Kingdom as offering a specialist service for those who suffer from self-injury.

What Is Self-Harm?

The most common form of self-injury is cutting, often of the arms and hands, perhaps of the legs, and less commonly of the face, abdomen, breasts and even genitals. Some burn or scald themselves, others inflict blows on their bodies, or bang themselves against something.

Other ways people injure themselves include scratching, picking, biting, scraping and occasionally inserting sharp objects under the skin or into body orifices. Swallowing sharp objects or harmful substances is well known to doctors. Common forms of self-injury which probably rarely reach medical attention include pulling out one's hair and eye lashes, picking at spots or skin, and scrubbing oneself so hard as to cause abrasion (sometimes using cleaners such as bleach).

Exactly how common or rare self-mutilation is in the general population is difficult to determine because it is such a secretive activity - confidential helplines receive calls from those who have injured themselves for years without telling anyone, due to shame and fear of condemnation. But some studies have found that 11% of students questioned had slashed or cut themselves at some point in their lives.

Theories of Self-Harm

Often people report that their self-injury began in childhood with scratches and bumps being disguised as 'accidents,' progressing to more systematic cutting and burning in adolescence.

A popular theory is that those who self-mutilate do so as a result of suffering sexual abuse in the past, often as young children. The theory contends that because these victims were forbidden to reveal the truth about their abuse in oppressive or neglectful families, self-mutilation or self-cutting is one way of expressing to the outside world the horrors of abuse.

So the self-harm in this context is a form of communication, so that others will notice something is wrong and pay more attention to the victim, without the casualty having ever directly said what really happened - for fear of punishment from those who perpetuated the abuse.

Another possible link with early childhood sexual abuse is that this trauma produces extremely low self-esteem - either because you blame yourself for your abuse or the perpetrator ensures you feel low about yourself as part of their campaign to control you. If very low self-esteem develops, then self-harm as an expression of self-hatred becomes more understandable. Certainly one research finding is that self-harmers often grew up in an 'invalidating environment' - one where the communication of private experiences is met with unreliable, inappropriate or extreme responses. The expression of private experiences as a result is not validated - instead, being trivialised or punished.

The problem with these theories is that (for example, in the case of the sexual abuse hypothesis), not everyone who has been sexually abused starts to self-harm, and also not everyone who self-harms has been sexually abused. A small group of patients claim to be sexually abused - yet the corroborative evidence is non-existent, and their own accounts are inconsistent.

An increasingly popular biological theory for self-cutting is that this action causes the release of the body's own natural opiate-like chemicals, which are always released to reduce pain whenever we are injured. Perhaps self-cutters have become addicted to their own body's heroin-like reaction to cutting, which is why they do it again and again - plus suffer withdrawal if they haven't done if for a while. Drugs used to treat heroin addicts have been found to be helpful with self-cutters, but mostly those who described a definite 'high' following cutting themselves.

Another theory, which in-patient units are often employing consciously or unconsciously, is based on the famous psychological principle that all behaviour would not occur if the consequences were not in some way rewarding. So usually cutting leads to a sequence of behaviour, perhaps including provoking the reaction of others, which may become the rewarding reason for why the behaviour is repeated in the first place. These reactions might involve increased attention, for example.

By being admitted to a specialist unit and therefore being removed from the home or local environment, whatever reactions were provoked in others cannot now occur. (Particularly as staff in specialist units like the Bethlem Royal are specially trained to ensure that no consequences might follow from an episode of cutting that could be rewarding, like increased attention.)

Instead, desisting from cutting is rewarded by increased attention from the experienced staff. Also, a framework is established whereby patients learn to accept responsibility for their self-injurious behaviour. Otherwise, a complicated situation can evolve under inexperienced care where staff come to be blamed for the 'patient not getting better' and so subtly take on responsibility for the self-cutting - therefore releasing the patient from accepting their own role in the cause of their problems.

Self-mutilation: Culture & Future

A key issue in the area of self-harm is the de-stigmatization of this mental health issue...and this can be achieved by realizing exactly how much self-mutilation is in fact a popular part of contemporary culture. For example, we attempt to modify our bodies by cutting, piercing, and forcing in many ways ranging from cosmetic surgery, like breast enhancement and nose jobs, to hair removal, skin bleaching, hair straightening, tattooing, body and ear piercing for the insertion of jewelry and other body adornment.

All this activity bears an important resemblance to clinical self-injury in an important respect - it always contains an underlying assumption that an individual is not good enough without adjustment of their body. Some research has indeed found that criminals who have tattoos - compared to those who didn't - were more likely to also self-mutilate.