"Cutting herself with a knife hurt. It also made Jill McArdle feel better... Jill had made a galvanizing discovery: cutting herself could temporarily ease her emotional distress." Thus began an article in the July 27, 1997, "New York Times Magazine" entitled "The Thin Red Line" by Jennifer Eagan.

Most people are horrified by the thought of a child or teen deliberately hurting herself or himself. But to a person engaging in self-injurious behavior (SIB), such self-mutilating, self-inflicting or self-abuse brings a kind of "relief" from an immediate crisis situation. SIB may also communicate that something is, otherwise, too painful or overwhelming for the individual to manage alone.

Signs of crisis

At age 14 Celia was attracted to the music of Nirvana and Marilyn Manson as a way of identifying with others who seemed to feel the way she did: depressed and unacceptable. She began to purge her food to lose weight, thinking that if she were thin, she would be more acceptable. She began to cut herself as a self-loathing "technique" to stop the flood of negative feelings about herself. Her parents inadvertently added to her distress by being critical of the way she dressed, wore her hair, and chose her music and friends. They did not realize that these were all self-injurious ways of expressing how Celia was feeling about herself and her world.

SIB can include:

*burning
* cutting
* scratching
* hitting
* restricting or purging food
* pulling out hair
* puncturing the skin with objects
* excessive body piercing or tattooing (as distinguished from the popular fad of body piercing or tattooing, which is not necessarily SIB)
* ingesting cleaning or other substances
abusing drugs and/or alcohol
* sexual acting out
* choosing abusive partners
* engaging in excessively risky behavior

This list is by no means exhaustive. Indeed, there are as many and creative ways of injuring oneself as there are people. For the self-abuser, the process of SIB is quite effective and efficient in warding off numbness, pain or other disturbing feelings.

Relief from emotional pain, numbness
To get an idea of the principle behind this behavior, consider what it's like to scratch a mosquito bite or poison ivy rash. Scratching offers temporary itch "relief": the body's natural painkillers - including endorphins - rush to the infected area in response to the stimulus, thereby resulting in a brief numbing effect. However, it also causes mild damage to the skin and abuses the nerve endings.

Recall this intense urge to scratch a bite or rash. Now, try to imagine surgery without anesthesia - which is how many individuals experience intense emotional pain. In both cases, the victim must deal with an overwhelming compulsion to DO SOMETHING. A SIB reaction can be understood as an individual's urgent need to take action against the pain.

Allison, age 15, was heavily into drug abuse before she was found out by her mother. By that time the teen was even prostituting herself to get the drugs - and affection. Up until then she had been a "straight A" student with high accolades from her teachers. A year after her therapy began, Allison disclosed sexual abuse by a step-brother that had begun when she was age four and continued for several years. The drug abuse was her way of numbing the painful feelings that began to erupt when she hit adolescence. Traumas have a way of resurfacing during the various developmental stages, which continue throughout life.

While the type of scratching described earlier is a normal, acceptable behavior, SIB is never an acceptable option. The comparison of the two is used solely to help explain a phenomenon that is usually very difficult for parents, family and friends of the self-abuser to comprehend.

It is important to be able to make the distinction between SIB and suicidal behavior. Some acting out may be with suicidal intent; most, however, is not. SIB is often an effort to manage or avoid suicidal ideation and may, in fact, be the "lesser of two evils!" Reacting as if it were "suicidal" in nature could actually exacerbate the behavior. The communication of SIB is clearly that something is wrong and needs attention. The underlying pain needs to be addressed.

There are many reasons for SIB. Trauma survivors often say they are so tired of feeling "nothing" that they hurt themselves to feel. They resort to anything that tells them they are "alive."

Survivors of child abuse, especially sexual abuse, often are so chronically numbed because of the resulting posttraumatic stress disorder that they manifest SIB. Or, as in the case of June, they might want to annihilate the "hated" element of themselves through SIB.

June, who presented with scars on both forearms and legs, had been sexually, physically and emotionally abused as a child, removed from her family, then moved to many foster care situations - none of which could address her behavioral and emotional problems. She began to self-injure as a young child by hitting herself with her fists and pulling out her hair in an effort to feel something. She eventually "graduated" to cutting, burning and excessive piercings as a way of expressing her self-hatred and desire to destroy the part of herself she could not accept: the damaged part. In her mind destroying the outside was a way of externalizing how she felt inside. And she expected people to understand her better once they could "see" how she felt.

Other children and adolescents are severely depressed or chronically mildly depressed. They need the stimulation to feel less "low" - a somewhat naturally produced "high." Still others use SIB to punish themselves for real or perceived offenses, or for being, in their own minds, inherently "bad" people.

Twelve-year-old Eddie was taken to outpatient therapy following a history of fighting at school. While in therapy, he acknowledged that he always challenged "the bigger guys" because he knew they would be able to beat him up. He was able to deal with feelings of guilt over the death of his younger brother by getting others to inflict injury upon him - a covert way of self-injury.

A cry for help

Underlying SIB is frequently basic and pervasive self-loathing. The self-abuser uses the body as an external symbol of the desire to destroy the self - a wish which is not necessarily suicidal. We are not talking about a desire to die; rather, a hatred of the self or the way things are.

SIB is always a legitimate cry for help and should be addressed by professionals familiar with the SIB method of communicating. This behavior can be very addictive if not addressed. As in other addictions, greater and greater stimulation is usually needed over time to duplicate the original feeling of "relief."

Lillian was, from a very young age, very compulsive about her appearance, her room, her schoolwork, her belongings and cleanliness around the house. She would bathe several times a day and become irate if anything in her room was moved. She believed that in order for everything to be "perfect," she had to remain completely in control of her environment. This thinking was extended to her emotions, as well.

Lillian learned that she could stop any undesirable feelings - those that made her feel vulnerable - by pinching herself. When she would inevitably fall short of perfect, her efforts would escalate: she would become more and more obsessive about her environment, her person and her feelings. As the pinching became less "effective," Lillian experimented with different methods of self-injury, eventually settling on cutting herself with a razor as the most satisfactory. To avoid being too obvious, the child would cut herself over and over in the same place. And she learned just how deeply to cut to reach the desired effect without requiring stitches.

SIB followed Lillian into adulthood. Though in medical school and on her way to an exciting career, she continued to hurt herself. Her self-injury had become so ritualistic that she developed a schedule of acting on it - certain days and certain times. Increased frustration with the challenges of medical education and conflicts with her "schedule" eventually rendered her techniques ineffective. She then took on other forms of SIB, including restricting food and sleep, and carefully drawing blood with sterile syringes. It was only when confronted by a colleague who had observed some of her behaviors that Lillian decided to get help.

Children as young as three and four have been treated for hurting themselves. They may be unable to cope with the loss of a loved one or their own anger. They may be struggling with a history of, or ongoing, abuse and need to tell someone. What they have in common with older children and adolescents who hurt themselves is an inability to verbally express their feelings and needs.

Children and adolescents of any age engaging in SIB may need help expressing the family's emotional dysfunction. Will, for example, began to scratch his arm absentmindedly while listening to his parents fight yet again. He had no way, at age nine, to express his fear, frustration, sadness and helplessness that escalated every time he heard them verbally assault each other.

What you can do right now

If you observe or hear about someone's self-injuring, please help them get to someone who can help. Guidelines for immediate response:

[ul]* DO respond to the injury medically, not emotionally.
* DO tell the person that you know something is going on and will assist in getting some help.
*DO try to empathize. Look at the situation from the person's perspective instead of your own. This behavior is not horrible to this individual; it is helpful. It is not about you; it is about his or her inability to cope differently.
* DO NOT shame the person. He or she already feels bad enough.
* DO NOT label the person "attention seeking." If the individual knew healthy ways to get help, he or she would.
* DO NOT demand the person stop because it upsets you. He or she is unable to stop until some healthy coping skills are learned.

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SIB Informational Resources

Recommend reading...
Eagan, J., (1997) The Thin Red Line. The New York Times Magazine, (July 27), 21-48.

Miller, D., (1994) Women Who Hurt Themselves: A Book of Hope and Understanding. New York: Harper Collins Publishing, Inc.

Favazza, A.R., (1996) Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry. Baltimore, MD: The Johns Hopkins University Press.

Helpful websites...
http://www.palace.net/~llama/psych/injury.html