Getting a Handle on Self-Harm

Cutting and other forms of self-injury are on the rise among adolescents. Researchers are beginning to understand the phenomenon, and how to treat it.

Keith Negley

The sensations surged up from somewhere inside, like poison through a syringe: a mix of sadness, anxiety, and shame that would overwhelm anyone, especially a teenager.

“I had this Popsicle stick and carved it into sharp point and scratched myself,” Joan, a high school student in New York City said recently; she asked that her last name be omitted for privacy. “I’m not even sure where the idea came from. I just knew it was something people did. I remember crying a lot and thinking, Why did I just do that? I was kind of scared of myself.”

She felt relief as the swarm of distress dissolved, and she began to cut herself regularly, at first with a knife, then razor blades, cutting her wrists, forearms and eventually much of her body. “I would do it for five to 15 minutes, and afterward I didn’t have that terrible feeling. I could go on with my day.”

Self-injury, particularly among adolescent girls, has become so prevalent so quickly that scientists and therapists are struggling to catch up. About 1 in 5 adolescents report having harmed themselves to soothe emotional pain at least once, according to a review of three dozen surveys in nearly a dozen countries, including the United States, Canada and Britain. Habitual self harm, over time, is a predictor for higher suicide risk in many individuals, studies suggest.

But there are very few dedicated research centers for self-harm, and even fewer clinics specializing in treatment. When youngsters who injure themselves seek help, they are often met with alarm, misunderstanding and overreaction. The apparent epidemic levels of the behavior have exposed a structural weakness of psychiatric care: Because self-injury is considered a “symptom,” and not a stand-alone diagnosis like depression, the testing of treatments has been haphazard and therapists have little evidence to draw on.

In the past few years, psychiatric researchers have begun to knit together the motives, underlying biology and social triggers of self-harm. The story thus far gives parents — tens of million worldwide — some insight into what is at work when they see a child with scars or burns. And it allows for the evaluation of tailored treatments: In one newly published trial, researchers in New York found that self-injury can be reduced with a specialized form of talk therapy that was invented to treat what’s known as borderline personality disorder.

“It used to be that this kind of behavior was confined to the very severely impaired, people with histories of sexual abuse, with major body alienation,” said Barent Walsh, a psychologist who was one of the first therapists to focus on treating self-injury, at The Bridge program in Marlborough, Mass., now a part of Open Sky Community Services. “Then, suddenly, it morphed into the general population, to the point where it was affecting successful kids with money. That’s when the research funding started to flow, and we’ve gotten a better handle on what’s happening.”

Joan was 13 when the cutting began. Now 16, she had greatly curtailed this routine in the past few months, she said: “But I still do it, like, every week or so.”

The most common misperception about self-injury is that it is a suicide attempt: A parent walks in on an adolescent cutting herself or himself, and the sight of blood is blinding. “A lot of people think that, but in reality, you cut for different reasons,” said Blue, 16, another high school student in the New York area, who asked that her last name be omitted. “Like, it’s the only way you know to deal with intense insecurities, or anger at yourself. Or you’re so numb as a result of depression, you can’t feel anything — and this is one thing you can feel.”

Whether this method of self-soothing is an epidemic of the social media age is still a matter of scientific debate. No surveys asking about self-harm were conducted before the mid-1980s, in part because few researchers thought to ask.

“It’s not about suicide,” said Dr. Barent Walsh, one of the first psychologists to focus on treating self-injury. “It’s something very different, a way of regulating emotion, of reducing emotional pain.”Credit...Kayana Szymczak for The New York Times

In the 1990s, the idea of self-injury and its underlying psychic misery began to enter popular culture. Princess Diana talked about it, in an interview; so did actors Johnny Depp and Angelina Jolie. A popular 2010 music video by Pink contained vivid scenes of cutting. By then, dozens of online forums were providing community, support and understanding to those who self-injured — and also, some experts say, often reinforcing the behavior, as a badge of membership in a special club.

“Nowadays a lot of younger girls especially are influenced by various media, where this whole self-harm thing is glamorized,” said Blue, who quit harming herself earlier this year. “I was hospitalized, and it was strange: A lot of other girls were impressed by my scars, like, ‘How did you get those? I’m jealous.’ It’s disturbing, this gratification — like, people who I guess feel good or happy when they do it.”

Among current American college students, a privileged group by definition, about 1 in 5 reports having inflicted self-harm on purpose to ease emotional pain at least once, according to surveys done at 10 universities by Janis Whitlock, director of the Cornell Research Program for Self-Injury and Recovery. The first episode occurs around age 15, on average, Dr. Whitlock said, but a large number of people who self-harm started later, at age 17 or 18.

Few people who self-harm once stop there, said Dr. Whitlock, an author of “Healing Self-Injury: A Guide for Parents.” “About 3 in 4 continue, and the frequency tends to go up and down, as people go in and out of various stages,” she said. “It’s absolutely crazy-making for parents, because it’s hard to know what’s happening.”

This on-again, off-again pattern becomes, for about 20 percent of people who engage in it, a full-blown addiction, as powerful as an opiate habit. “Something about it was so grounding, and it was always there for me,” said Nancy Dupill, 32, who cut herself regularly for more than a decade before winding down the habit, in therapy; she now works as a peer specialist for adolescents in central Massachusetts. “I got to the point where I cut myself a lot, and when I came out of it, I couldn’t remember things that happened, like what set it off in the first place.”

People who become dependent on self-harm often come to treasure it as their one reliable comfort, therapists say. Images of blood, burns, cuts and scarring may become, paradoxically, consoling. In isolation, amid emotional turbulence, self-injury is a secret friend, one that can be summoned anytime, without permission or payment. “Unlike emotional or social pain, it’s possible to control physical pain” and its soothing effect, said Joseph Franklin, a psychologist at Florida State University.

Dr. Franklin argues that the brain circuits registering physical and mental pain, while distinct, likely have some overlap. The burn of humiliation feels very different from the burn of fire, of course, but there is some evidence that the relief from yanking a hand away from the flame can activate neural circuits that register psychological relief, although this system is far from worked out. In the research literatures, the sensation of release from either physical or social pain is called “pain-offset relief,” and by most accounts from those who self-harm, the use of one to blunt the other can become addictive.

“As a weird quirk of this effect, people who think the relief of psychological pain is worth the physical pain may reason that self-injury is a good idea,” Dr. Franklin said.

In psychiatry, self-injury is considered a symptom, not a stand-alone disorder. As a result, people who habitually injure themselves often receive an underlying diagnosis, like depression, attention-deficit disorder, post-traumatic stress, borderline personality, bipolar or some combination, which may change from doctor to doctor.

“I was diagnosed with bipolar, borderline, depression,” Ms. Dupill said. She didn’t think any of the labels fit her very well, and “some of the drugs they put me on caused me to panic and harm myself badly.” She considered the surges of anxiety and distress she felt, and sometimes still feels, as a post-traumatic reaction to a chaotic childhood.

If a diagnosis does fit, experts say, treatment should integrate it. In a paper that appeared this summer, a team led by Theodore Beauchaine of Ohio State University argued that preadolescent girls with a history of family trauma and attention-deficit disorder are at extremely high risk for later self-injury, and treating the A.D.H.D. as well as the traumatic stress would be a powerful prevention strategy, and could reduce later suicide risk.

The one treatment that appears to be most effective for breaking the habit of self-harm is a specialized talk therapy, originally invented for people with a diagnosis of borderline personality disorder, who are highly suicidal. Habitual self-injury is a risk factor for later suicide, and those who engage in it, like people diagnosed with borderline, endure gusts of dark emotion.

Through one-on-one and group therapy sessions, at least once a week for two months or more, people who injure themselves learn a series of coping skills to weather troughs of misery. These skills include mindfulness techniques and opposite action, in which patients act opposite to the way they feel in order to alter the underlying distress. The therapy is called dialectical behavior therapy, or D.B.T., and was developed by Marsha Linehan, a psychologist at the University of Washington.

In a study of 800 adolescent inpatients at Zucker Hillside Hospital, in Glen Oaks, N.Y., a team of doctors found that those who received D.B.T. had far fewer incidents of self-injury, spent less time on suicide watch and had shorter hospital stays, by two weeks on average, compared to adolescents who had been treated before D.B.T. was standard. Another kind of standardized talk therapy, called cognitive behavior therapy, or C.B.T., can also be adapted to help people who habitually self-harm. Both strategies are more likely to be helpful when driven by guided or driven by the person in pain, a recent review found.

“There is real hope,” Ms. Dupill said, “if you let the person going through this have some control, if you listen to them, if you’re curious about their behavior and not afraid of it.”