Managing Self-Injury
Deliberate self-injury is often misunderstood in the media. All self-harm is complex in nature, and rarely determined by one single factor. The Studio 3 Approach is to view deliberate self-injury as an addictive coping strategy to stress and often complex trauma.
There are two forms of self-injury which we will discuss here in detail: deliberate self-injury, which is most common in young people and often used as a coping mechanism, and self-injurious behaviour, which describes unplanned self-injury inflicted by an individual with learning disabilities, autism, or other conditions.
What is the difference between self-injury and self-injurious behaviour?
Self-harm (we prefer the term self-injury) has been defined as the intentional, controlled and usually pre-mediated, low-lethality bodily harm which often serves as a coping mechanism for an individual who is distressed. This is often seen in young people and adults who are in distress, and includes behaviours such as cutting.
Self-injurious behaviour on the other hand is unplanned and often uncontrollable behaviours which result in physical harm to an individual. Whilst these behaviours can become ritualised and part of an individual’s routine, they are not always within that person’s control. These behaviours include but are not limited to head-banging, biting, hair pulling and slapping. Individuals with learning disabilities, autism, and other conditions are more likely to engage in SIB (McClintock et al., 2003).
Please note that the content of this page refers to self-injury, deliberate self-harm, cutting, and mutilation, and therefore may not be suitable to readers sensitive to these elements.
Self-Injurious Behaviour
Self-injurious behaviour often takes the form in people with learning disabilities and autism and other conditions of behaviour such as head banging, eye poking, skin-picking, biting, scratching or slapping.
Types of SIB:
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Compulsive
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Episodic
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Repetitive
Self-injurious behaviour can vary in intensity, and can be superficial, moderate, or extreme.
Individuals who engage in SIB are not doing so in a controlled manner with the intention of distressing supporters, but often in order to communicate an unmet physical, sensory, or emotional need that they struggle to express. For example, an individual may pick their skin because they are bored and unstimulated, or head bang if they are experiencing pain or discomfort such as toothache or a migraine. It is important to understand that a lot of behaviour is communication – though this does not always apply.
For example, some individuals with ASD or learning difficulties may engage in forms of repetitive movement in order to soothe or calm themselves. Stimming and stereotyped behaviours can be regulating in themselves and can be alternatives to engaging in SIB. It is important to recognise the difference between stimming and SIB, as any attempt to reduce harmless stimming or stereotyped behaviours may result in an increase in SIB and vice versa.
Causes of Self-Injurious Behaviour
There is no one cause of SIB, and it can often be caused by a variety of internal and external factors that differ between individuals. Causes and triggers can be sensory or environmental, and can cause the individual to engage in the behaviour to self-regulate, communicate discomfort or other emotions, provide soothing sensory feedback, or a range of other reasons, including:
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To ease inner tension
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To express/provide a release for difficult emotions e.g. anger, fear, confusion, distress
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To gain interaction/engagement from others
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To avoid/reduce interaction from others (especially in response to demands and requests)
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Reducing arousal (physiological and emotional)
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Relieving
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Addictive behaviours and relief
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Self-punishment due to shame and guilt
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In response to stress
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Due to trauma
Sensory Issues
Sensory factors are often a large component of SIB, and it is important to consider why an individual may need to engage in this behaviour to calm down or soothe themselves. It could be that they are experiencing pain and discomfort, or need to create sensory stimulation to distract themselves from uncomfortable internal bodily events (hunger, dehydration etc) or environmental triggers (bright lights, loud noises etc). At Studio 3, we carry out sensory assessments to identify potential causes of SIB, as well as determine factors that will enable us to think about solutions to sensory discomfort without injury.
It is important to first rule out any medical issues such as constipation, migraines, stomach aches or pain that could be causing the SIB. For example, the site of the self-injury may be important – an individual banging their head could indicate a migraine or toothache. An individual may be trying to communicate discomfort and stress, and struggle to identify what exactly is wrong. This could be related to interoception and difficulty interpreting internal bodily signals (Mahler, 2018).
Working with People Who Engage in Self-Injurious Behaviour
It is important to understand the difference between levels of SIB, and to understand the difference between short-term management of SIB and working towards long-term change, which may be a long process. It is important to understand that all behaviour is communication, and that SIB may have a functional purpose, such as being the only way a person can self-regulate or cope. If we attempt to prevent or force a person to stop engaging in SIB, we may be removing their primary coping strategy, and increase their distress.
Instead, we should focus first of all on what may be causing SIB. Often, it is a sign of increased stress in response to external or internal stimuli. The person may struggle to communicate what is causing them stress, and SIB is their only way of coping with what may be physical pain, emotional distress, or a number of factors in their environment. Reducing the person’s general arousal level by making their environment as individualised, calm and comforting as possible is a good place to start. Reducing physiological arousal can be achieved through physical exercise, relaxation techniques and deep pressure. In some cases, medication may be considered if there are underlying physiological causes for their distress. Sensory distraction should also be considered if pain is involved.
As supporters, we must examine our own feelings and beliefs about SIB, and make sure we have our own support networks in place to cope with the feelings of distress and helplessness that may arise when we are supporting someone who self-injures. Acknowledge your own limitations in terms of what you are able to manage when supporting an individual who self-injures, as doing so may bring up difficult feelings for you.
Control
It is often the case that as supporters we wonder how in control of their behaviour a person is when they engage in SIB. As practitioners of the Low Arousal Approach, we believe that people in extreme distress and discomfort are less likely to be in control of their behaviour. When an individual engages in SIB, they are communicating that distress to us, and it is our job to ask why they are doing this? What are they trying to communicate to us? And how aware and in control are they of their behaviour in this moment? Some people may appear to be in control at times, and lose all control over their behaviour at other times. Viewing distressed behaviour as a result of stress and trauma is key, and the first step in understanding why this person may have to engage in self-injury.
At Studio 3, we believe in managing the behaviour first, and trying to change it second. Telling a person to stop, or physically restraining them does not help them in the moment, whether they are in control or not. Empathising with the individual and why they may need to engage in SIB is crucial to understanding the individual’s world, and ultimately helping them move towards a safer, soothing alternative to SIB.
What To Do 'In the Moment'
Using a Low Arousal Approach, we recommend that supporters keep their responses as low-key as possible to avoid further increasing arousal levels. This means keeping your distance, avoiding direct eye contact, and not placing any more demands on the person. If there are things you can do to reduce the sensory environment, such as removing onlookers or providing pain killers if you know someone is experiencing physical discomfort, do so. Speak calmly and clearly, and keep your movements slow and non-threatening. Visual cues may be more effective if someone is highly distressed.
At Studio 3, we use a holistic and integrated approach to supporting individuals who self-injure. We conduct functional assessments in order to determine the cause of the behaviour, examining sensory factors in the person’s external and internal environment (touch, smell, heat, light, noise and interoceptive factors). Working together with support teams, we develop clear crisis management strategies which involve a focus on reducing stress and anxiety and increasing overall well-being.
This means:
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Reducing demands and requests, both verbal and sensory
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Avoiding power struggles and conflict
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Managing environmental triggers
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Using Low Arousal skills to create calm (e.g. non-verbal communication)
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Co and self-regulation
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Increasing positive sensory experiences
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Early identification of dysregulation and applying de-escalation principles
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Distraction and diversion when a person become distressed (e.g. engaging in flow activities, physical exercise, a favourite item etc)
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Redirecting movements when a person begins to self-injure, to alter the nature of the SIB, reduce its intensity, or change/provide sensory feedback
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Providing alternative behaviours that meet the need of the SIB or provide necessary sensory feedback
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Using barriers or protective equipment where absolutely necessary (this should only be a short-term response, as this can have the negative effect of increasing the intensity of the SIB and is therefore recommended on an individualised basis only)
We do not recommend the following strategies when managing a distressed person who self-injures:
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Telling the person to stop
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Raising your voice
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Increasing demands
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Physical interventions, restraint or seclusion
It is important to maintain a positive therapeutic relationship with the individual, and responding negatively to these behaviours may only serve to make them worse.
Resources for supporters:
Self-Injury
Self-injury can be an issue for a lot of children, young people and adults, and many supporters and family members find it challenging to deal with.
What is Self-Injury?
Self-injury describes a wide range of behaviours that people sometimes use to cope with difficult feelings and distressing life experiences. These behaviours may include cutting, burning, scalding, banging or scratching one’s own body, pulling one's own hair or swallowing poisonous substances or objects. The majority of people who self-injure have no intention of ending their life: most people who self-injure do so to manage their feelings. To help us understand how self-injury works for people, it is useful to view it in a broader context. In the same way that some people may cope with stress and its associated feelings of anger and frustration by having a glass of wine or smoking cigarettes, others may manage similar feelings by cutting or burning themselves. Whilst a taboo subject in society, it is important to view this behaviour in the context of stress and trauma, and try to empathise with why a person may need to engage in this behaviour to cope with difficult thoughts and feelings.
Who self-injures?
It is estimated that one in fifteen young people in the UK have deliberately injured themselves, suggesting that around two people in every secondary school classroom have self-harmed at some time. Self-injure amongst young people is more common between the ages of 11 and 25, although occasionally it can occur in children younger than this. Around four times as many girls as boys self-injure, and it is recognised to be more prevalent in some groups such as people with learning disabilities, LGBTQ+ communities, and individuals living in residential settings.
Why do people self-injure?
The experiences that lead to self-injury can generate many difficult feelings and emotions. Young people who self-injure often carry feelings of shame, guilt, self-hatred, anger, frustration and isolation. However, there is a common belief that young people who self-injure are 'attention-seeking.' In reality, most people who self-injure tend to do so in secret, and labelling someone as attention-seeking only serves to further feelings of shame and guilt, and may exacerbate self-injury.
Self-injury is primarily a way to cope with feelings that are distressing. People have reported that self-harm serves a variety of functions, including to:
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Relieve feelings of distress
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Distract from emotional pain
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Reduce shame and guilt by self-punishing
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Regain control
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Calm down
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Feel present
Self-injury can be triggered by a variety of internal and external life events, including suffering abuse, being bullied, grief, physical illness or pain, stress, trauma, feeling isolated or lacking confidence.
How can we support people who self-injure?
Whatever the reason, thoughts of self-injury in individuals can lead to strong feelings of anxiety, fear and frustration in the people who surround them and in those who are trying to support them. The containment and management of these feelings is an important factor in supporting young people who self-injure. To help you do this, try not to focus too much on the self-harming behaviour; ensure that you engage with the person and the issues underlying the self-injury. It might not seem much, but showing that you want to know and understand what is happening for the person can make a lot of difference.
It is important to empathise with the person and not over-focus on their behaviour. Accepting that self-injury helps them to cope is an important first step, and will make it easier for the person to talk to you about their feelings without fearing judgement.
Avoid over-reacting to self-inflicted wounds. Show compassion and concern if a young person shows you their injury, and treat it as you would an accidental injury. Show them that their body is worth caring about.
Supporters can suggest alternative activities, and also work with the individual they support to talk about the feelings behind the self-injury. Working through these feelings in a positive and understanding way is the most effective means of eliminating self-injury over time. Again, this is a slow process for many, and will not be achieved overnight. It is important to be aware of your own limitations as a supporter and do not offer more than you can cope with. Consult a self-injury specialist for individualised support and advice, such as someone from our experienced team of clinical practitioners here at Studio 3.
Avoid:
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Punishing the person
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Blaming the person
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Assuming why they are self-harming
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Not talking about it
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Forcing them to stop
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Treating them like they are incapable of making their own choices
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Over-reacting or panicking
Reducing Self-Injury
For many people, stopping or reducing their self-injury is a long and slow process. People who self-injure need the opportunity to build up their coping skills gradually, and may go on harming themselves for some time. In the meantime, learning how to cause themselves the least damage possible can be crucial and involves learning alternative ways to deal with difficult feelings. From speaking to young people who have self-injured, some alternative coping strategies have been developed to help minimise self-injury:
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Physical exercise
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Holding ice on skin to cause pain without lasting damage
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Keeping a diary
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Hitting a punch bag or pillows
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‘Symbolic’ cutting with a pen
Some other exercises to try include the five minute rule, which is when the urge to self-injure arises, try waiting at least 5 minutes before you do. Once this 5 minutes is up, try another 5 minutes, and keep going as long as you can. Usually, people find that the urge eventually disappears.
Another useful exercise is the 5-4-3-2-1 game, which provides distraction and can help to ground you in the present moment:
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Name 5 things you can see in the room with you.
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Name 4 things you can feel (“chair on my back” or “feet on floor”)
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Name 3 things you can hear right now (“fingers tapping on keyboard” or “tv”)
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Name 2 things you can smell right now (or, 2 things you like the smell of)
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Name 1 good thing about yourself.
This is also good for people experiencing panic or anxiety.
Resources about managing self-harm for individuals and supporters:
Alex's Story
The short video below tells the story of a young woman who struggles with self-injury in the form of cutting as a way to cope. Alex’s story is portrayed by a young actress and represents a number of many different individuals who have had therapeutic support from Studio 3 clinical services. Whilst some viewers may find this video distressing, Alex’s story explains a lot of the emotions that surround self-injury, and we thought that it was important to show why a young person may start to self-injure in order for supporters to empathise with her experience, and for individuals who are also struggling to know that they are not alone. What is important to note is that Alex’s story is a positive one. Like many individuals who deliberately self-injure, Alex learned to develop alternative coping strategies once she sought help.
Viewer discretion is advised, and we would recommend that viewers turn the video off if they start to experience distress (TW: deliberate self-harm, cutting, fake blood).
If you identify with Alex’s story, there are resources available to help you. We would recommend that you seek advice from your local GP or speak to a healthcare professional. You can also reach out to our team of psychologists here at Studio 3. You are not alone, and talking to someone about what you are experiencing is the first step.