continuing ^ EDUCATION

Self-Injury:

TENSION

THE GOAL OF THIS PROGRAM is to give nurses a better understand of and promote effective
assessment and intervention strategies for people who engage in self-injurious behavior. After studying the information
presented here, you will be able to
1. DEFINE "self-injury."

2. PROVIDE three reasons why people

engage in self-injurious behavior.

By Sandy Hannon-Engel, RN, PhD(c), CS

The ED is busy, and you are assigned a 25-year-old

woman who cut herself with a razor blade and needs
sutures. You have heardfrom other nurses that "cutters" just "want attention" and that you shouldn't
"feed into that behavior." You ask the woman why she
cuts herself. She answers, "Because I feel better."
hy do people intentionally injure themselves? It's
a common question from nurses in all specialties
when they care for someone who has inflicted
bodily injury on themselves, such as cutting, scratching
or burning themselves. Often nurses are frustrated and
frightened by this behavior and feel inept in its
treatment.
Self-injurious behavior can have serious consequences
for the individual and elicit feelings of helplessness from
caregivers. Even many psychiatric practitioners refuse to
treat these high-risk patients because of the suspected
poor and chronic prognosis.1

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3. DISCUSS assessment and

intervention strategies.

Numerous stereotypes and misconceptions surround

this behavior, resulting in inadequate treatment by
professionals and social stigmatization. This module will
provide the necessary knowledge to dispel the mystery
and promote effective treatment for people who suffer
from self-injurious behavior.
Nurses must understand their own beliefs about
self-injury and whether these beliefs help or hinder their
ability to provide care. Research suggests that nurses'
knowledge of this topic directly relates to their satisfaction
and perceived effectiveness with this patient population.1
In the case of the young woman in the ED, what would be
your initial thoughts and feelings about her care? Do you
have the skills to assess this patient and implement a plan
of care based on the best available evidence?
Common terms for self-injury include nonsuicidal self
injury, deliberate self-harm, self-mutilation, self-abuse and
self-inflicted violence. The North American Nursing Diagnosis
Association defines self-mutilation as the "deliberate
self-injurious behavior causing tissue damage with the
intent of causing nonfatal injury to attain relief of tension."2
More recently, the term "nonsuicidal self injury" has been
used.

Kdy concepts that help in understanding self-injury

include:
Self-injury is an act done to the self by the self.
It must include some type of physical violence.
It is not undertaken with the intent to kill oneself.
It is most often done with the intention to provide relief.
Generally, the easiest way determine whether an activi
ty is self-abusive is to ask the person directly. If the person
feels that the interviewer (such as a nurse) is empathic,
nonjudgmental and genuinely concerned, the person will
answer honestly. But if the interviewer is clearly repulsed
by the behavior, the person may deny that the behavior
was intentional for fear of negative consequences, and an
opportunity for growth and healing is missed.3
Self-injury crosses all boundaries of race, gender, age,
education, sexual preference, religion and socioeco-nomic
brackets.4 The lifetime prevalence of self-injurious
behavior in a college population was as high as 17% with
the average age of onset between 15 and 16.5 Self-injury
typically begins during adolescence, peaks during the 20s
and declines or may disappear in the 30s.
Many self-injurers have histories of or current
co-morbid mood, anxiety, personality or eating disorders;
substance abuse; and obsessions and compulsions.
People growing up in abusive (e.g., physically, sexually or
emotionally abusive) or invalidating environments 5 may
not learn the basic coping skills necessary to regulate
their emotions. People who self-injure can have a history
of failed psychological treatment. Others may never seek
medical or psychiatric treatment.

Types of Self-Injury
Before the late 1980s, most professionals considered
self-injury a singular, horrific and senseless act linked
with suicidality. But in 1987, Body Under Siege:
Self-Mutilation and Body Modification in Culture and
Psychiatry, by Armando Favazza, MD, helped conceptualize
self-harm.6 He concluded that patients could be divided
into four types: major, stereotypical, compulsive and
impulsive.7
Major self-mutilation includes castration, amputation
and eye enucleation and is most often associated with
psychotic states. Stereotypical self-mutilation is
repetitive and the pattern of acting out can be rhythmic
(e.g., head banging and self-biting) and is most often seen
among people with autism, developmental delay or
psychosis. Compulsive is repetitive and ritualistic injury
that occurs multiple times a day. The most frequent
compulsive injuries are hair pulling, skin picking to
severe excoriation and nail biting. 4 Impulsive methods of
injury are most often cutting, burning and carving.
Impulsive self-injury may be episodic and a symptom (or
an associated feature) of many disorders, such as
depression, anxiety, posttraumatic stress disorder and
personality disorders, especially borderline, histrionic
and antisocial. Self-injurers may engage in this behavior
repetitively, become overwhelmingly preoccupied with

the behavior, identify as being a "cutter" or "burner" and

say they are addicted to their self-injury.8

Why Do They Do It?

The following section outlines the common reasons why
people injure themselves. Some people point to only one
of the reasons and some offer multiple reasons.
Relief from overwhelming emotions or regulation
of emotional states. The most common reason for engaging in self-injurious behavior is to obtain relief from
overwhelming emotions.9 The immense psychological
pressure from overpowering emotions can feel unmanageable, frightening and unsafe. People often express a
temporary inner calm, release and relief after self-injury.
They are "cutting through the tension" because they have
yet to learn how to identify, express or regulate their
emotions effectively.
If this sounds unimaginable, consider whatjou do to
cope with uncomfortable, stressful or intense emotions.
Do you eat an extra piece of chocolate or cake or potato
chips? Do you have a glass of wine or maybe two or
smoke a cigarette? Or you may know someone who is a
substance abuser. Self-injury is on a continuum with other
self-destructive behaviors, serves a similar function and
becomes a powerful coping skill that provides an initial
short-term relief from intolerable pain. As with those extra
pieces of cake, cigarettes and mood-altering substances,
there are untoward long-term effects and consequences.10
Physical expression of emotional pain. When other
communication strategies (e.g., speaking, yelling, crying)
fail, self-injury is a way for people to communicate and
provide evidence of their psychological suffering to
others.11 In addition, self-injurers can view their wounds
and scars to see and externalize the immense pain within
them. Nurses may accuse patients of just trying to get
attention, be advised not to encourage this behavior and
may ignore the patient. But this approach is not effective
or therapeutic. In a desperate attempt to effectively
communicate, this approach may foster an escalation in
behavior. Some patients who self-injure do not have the
interpersonal skills to voice their opinions, ask for help
appropriately or say no to unwanted requests. In addition,
if someone is so desperate and willing to go to such
extremes to communicate, don't you think they may have
something important to say? If they had the skills to communicate effectively and get their needs met, they would
not engage in such troubling behavior.12
A relief of numbness or to feel pain. Before a
self-injurious episode, people may feel numb or detached
or dissociate.13 Most of us have experienced dissociation as
daydreaming. To some degree, everyone can dissociate,
but in severe cases it is a defense mechanism that protects
someone in the face of intolerable emotional pain. When a
person uses this protection to an extreme, an overall
absence of emotion or pain can result. In these situations,
people can self-injure to feel emotion or pain. Under these

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-)
conditions, people may harm themselves more severely
physically care for the psychic turmoil beneath. From a\
than intended with little or no recollection of the incident.
treatment standpoint, regular and purposeful practice *' of
With further investigation, they may report flashbacks of
self-soothing exercises using the six senses (e.g., using
past traumatic events that precipitate a dream-like or
aromatherapy, looking at beautiful scenery, sampling a
detached state before the incident.
ma^~mm-am*m>***=mm^aimmmH* finorite
From a treatment perspective,
BEHAVIORAL CHAIN ANALYSIS tea, taking a warm
patients must commit to the
bath) will reduce the need for the behavior.15'16
regular practice of grounding
Shame: Shame and self-injury are
DESCRI
behavior,
sensory and mindfulness
deeply related, and there appears to
exercises to feel connected.
be a cycle connecting
These coping skills will allow
shame with self-injury.17 Directly before
the person to stay in "this
DESCRIBE the specific precipitating event and soon after the act, individuals
moment," thus preventing
(trigger/antecedent) that started the chain, experience an intense sense of shame.
flashbacks dissociation and
This is generally related to their past
at work or home, reminder of past trauma inability to control this behavior, subseself-harm.12
Self-punishment and
quent consequences within
self-hatred: Victims of abuse
themselves and the disapmay blame themselves for their
pointment
of their caregiv-ers. This
e.g., intense emotions, ne
maltreatment. Many believe
illness, unbalanced eating/sleeping, nonprescribed self-generating cycle also breeds
(and were told by their abusers) mood-altering drugs, no exercise, low self-esteem, secrecy about the behavior. The
that they deserved everything
support person not available, hearing voices.
shame people feel and the fear of
they endured, they "asked
being judged leave them isolated
for it," and they are bad and
and alienated from those who
of events, thoughts
deserve punishment. These
would otherwise be
and feelings that
led to the behavior.
helpful. Secrecy and
beliefs can manifest in repetitive self-injury, pervasive 5.
isolation
perpetuates
the self-harm cycle.10
self-invalidation, guilt and immense
WHAT
exactly
were
the
consequences
As
a
nurse,
you
may
be the first to
shame.11 In extreme cases, people will
in the environment?
discover
that
a
patient
is engaging in
report hearing voices of the abuser or
IMMEDIATE,
self-injurious
behavior.
Even
if
you
have
only a few
others who "command" them to harm

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26

themselves. These entrenched beliefs, DELAYED,

cuts later.
mad. And in myself?
or "cognitive distortions," are difficult
to challenge or mitigate because
IMMEDIATE,
minutes, a nonjudgmental empathic stance
people believe in the veracity of their DELAYED,
., remorse, shame because can help build trust and open the lines of
thoughts. In such cases, psychotropic
communication to enable future encounters
angry and disappointed.
medication can alleviate the auditory halluciwith health professionals.
nations, and a comprehensive
Assessing a history of
treatment program can address WAYS to reduce my vulnerability in the future,
self-injurious behavior includes
the multiple cognitive/ behavioral
the types of behaviors (e.g.,
skill deficits.14
Self-nurturing: While this WAYS to prevent prompting event from happening again, cutting, burning); their date of
onset, frequency and intensity;
may seem to be in conflict
ing and distr
prior care given; and situations
with the act of intentionally
that alleviate or
hurting oneself, self-injury can
WHAT
PLANS
to hari
repair,
exacerbate them.
have a self-nurturing
While the self-injurious behavior
component.11 For some, in the
itself is not an attempt at suicide,
care they give to themselves
always ask the person explicitly
afterward (after making the
if suicidal ideation, plan or intent
internal wounds external) there
is present because self-injurious
is an attempt to heal the self.
behavior and suicidal thinking
At times, this under-the-skin
can occur together.4 In addition,
turmoil may remain hidden and grossly
you should complete a comprehensive risk assessment
unclear. Sometimes, bringing this pain to the surface can
that includes asking the
engender clarity and allow the person to

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CLINICALVIGNETTE

nprcrm lAripf

person whet
medication that may be used in an overdose so that you
or others can intervene or make referrals to the appropriate level of care. If your facility does not have a standard
risk assessment, the Suicide Assessment: Five-Step
Evaluation and Triage (SAFE-T) is suitable. Further assessment or identification of "trigger" events, thoughts
and feelings is essential to delay, avoid and ultimately
prevent self-injurious behavior.18 Triggers may include
easy access to the objects (e.g., razors) the person uses for
self-injury. Easy access can precipitate self-injurious
behavior or be an environmental stimulus. One way to
understand this is by imagining you are on a diet: Isn't it
advisable to rid the refrigerator of items that could "trigger" you to veer off course? We ask substance abusers to
not to associate with their drug dealers, to erase their
phone numbers and not to drive down their street. Those
who self-injure could find something else to injure themselves with just as dieters could go to the store and buy
a cake and substance abusers could find another dealer.
But this often symbolic commitment and lack of easy access to items used for self-injury can make the difference
between success and failure.3

The Chain of Events

Further analysis helps identify and break down the chain
of events, thoughts, feelings and behaviors that directly
precede, occur during and follow the episode of
self-injury (i.e., the antecedents, the behavior itself and
the consequences, or the ABCs of behavioral analysis).
Identifying these elements helps uncover the function of
this aberrant behavior and factors that prompt
reoccurrence.3 For instance, your patient has the
following reoccurring cognition (thought) or belief: "I'm
a bad person and deserve to be punished." Imagine how
you would feel if you believed this about yourself. You
would probably report feeling sad or depressed. If asked
to rate these negative feelings from 0 (none at all) to
100% (the most depressed ever), what would you say?
Most would report 90%.15 From this point we inquire
about the typical behavior of a person at 90% depressed
or sad. For some, this may mean having a piece of cake,
glass of wine or cigarette, or taking a mental health day
from work. For those whose self-destructive actions are
further along the continuum, self-injury may be the
choice.2 Thus, we see how powerful thoughts can translate
into troubling behavior.
Clinicians can use a behavioral chain analysis (see
sidebar) to get a complete picture of a behavior. The worksheet does not require special training to use and yields
factors that promote and maintain the behavior and those
that hinder attempts at abstinence. After your patient fills
out the worksheet, review it, ask questions for clarification and offer suggestions to avoid future incidents.12
While this exercise provides valuable insight, your
patient may be resistant. When a person outlines the
sequence of events that lead to self-harm, he or she sud-

Maria, an 18-year-old university student, is admitted

to your unit after an appendectomy. On exam you
notice severe scaring, excoriation and what look like
four recent cuts on her left forearm. According to
her admission, she has no history of psychiatric
treatment and there is no indication in her chart
that anyone has inquired about the origins of her
wounds. You suspect that she may be injuring
herself. How should you proceed?
1. How should you determine the cause of Maria's
injuries?
a. Consult Maria's family, caregivers and friends.
b. Review the research findings.
c. Interview Maria directly.
d. Depend on your own beliefs about Maria's behavior.
2. What is the most effective nursing intervention?
a. Ask the patient about the circumstances before
the incident.
b. Ask the patient, "Are you trying to get attention?"
c. Call for psychiatric services.
d. Don't ask; it could make the situation worse.
3. Maria says the precipitating event to her latest
self-injurious behavior was her inability to com
plete an overdue assignment: "I couldn't handle
the pressure. I cut, and I felt better." Why did
Maria cut herself?
a. Relief of numbness
b. Relief from overwhelming emotions
c. Self-punishment
d. Self-nurturing
4. What can Maria do to avoid this situation in
the future?
a. Make an inner commitment, practice alternative
coping strategies and implement these strategies
when she feels she is going to injure herself.
b. Plan her time wisely and not be late for assign
ments in the future.
c. Request a tutor.
d. Understand that college is stressful and she may
need to cut occasionally.
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27

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denly realizes the seriousness of the behavior. Ultimately, a

hidden or unexamined area in your patient's life is revealed.
In addition, this exercise exemplifies the difficult but
necessary steps required to accept responsibility, craft an
inner commitment and finally relinquish a self-damaging
activity. Thus, you must be supportive and compassionate
but deliberate in your approach: "I understand, I get it, it
makes sense and it has to stop it's ruining your life."
These seemingly dialectical, or opposing, truths are the
basis of a particularly effective research-driven treatment
called dialectical behavioral therapy.12 This
mindfulness-based cognitive behavioral therapy is
considered the bedrock of treatment strategies for people
who self-injure.

Emotional Dysregulation
Dialectical behavioral therapy posits that people can suffer
from a pervasive inability to regulate their emotions.
Emotional dysregulation is a core factor in self-injurious
behavior, a maladaptive attempt to avoid, change or control painful emotions. In addition, people who do not have
the diagnosis of borderline personality disorder but become emotionally dysregulated and self-injure can benefit
from this comprehensive treatment approach. 20
Dialectical behavioral therapy is believed to work by
reducing a person's vulnerability to the negative emotions
associated with the urge to self-injure.20 Treatment
combines weekly individual therapy, a psychoeducational
skills training group and telephone coaching. The group
teaches emotional regulation, interpersonal effectiveness,
distress tolerance and mindfulness skills. Participants in
outpatient therapy also receive individual therapy focusing
on problem solving, new coping skills and motivational
issues. Therapists are specially trained and meet in a
weekly consultation group that facilitates support and
team cohesiveness and reduces burnout. 20
While the full therapy program requires training of the
professional, even introducing a patient to the idea of
replacing self-injurious behaviors with healthy ones can
help. (See, for example, the Cornell University webpage on
distraction techniques: www.crpsib.com/userfiles/File/
Coping-Alt%20Strat-REV-ENGLISH.pdf.)
In review, self-injurious behavior is a (maladaptive) coping skill that generally functions to provide relief, expression, punishment and nurturance; stop numbness; and
perpetuate shame. When you and your patient begin to
analyze this behavior, it becomes clear how to prioritize
and generate alternative and healthy coping strategies.21
Gannett Education guarantees this educational activity is free
from bias.

Sandy Hannon-Engel, RN, PhD(c), CS, is a psychiatric clinical nurse

specialist at Pembroke Hospital in Massachusetts and a National
Institutes of Health funded researcher.

z
EDITOR'S NOTE: References are available online at http://ce.nurse.com.

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