Self-injury taking its toll

Indeed, the prevalence of self-harm is increasingly common in teen populations, says Robert Whittaker, a clinical psychologist at the Akeso psychiatric clinic in Milnerton, Cape Town. Statistical analysis of over 50 empirical studies reporting on the prevalence of Non-Suicidal Self Injury (NSSI) in adolescent across the globe, showed that 18.0% of these adolescents engage in NSSI, he points out.

According to the South African Depression and Anxiety Group (SADAG) non-suicidal self-injury is “more common than people realise. It is the only coping skill some people have when they feel emotionally overwhelmed. Frequently mistaken for a suicidal gesture or failed suicide attempt, it is not intended to kill; it keeps people alive in the face of intolerable mental pain or provides time out from stressful situations.” (http://www.sadag.org/images/pdf/self-injury%20facts.pdf)

Also in the UK “the number of children being admitted to hospitals’ Accident and Emergency departments (A&E) and diagnosed with psychiatric disorders – and had also intentionally harmed themselves – has, between 2011 and 2015  more than doubled. Recently published figures show that self-harm among those with mental health problems under the age of 18 rose from 1,098 in 2010/11 to 2,313 in 2014/15. The figures also come as the number of children diagnosed with mental illnesses has more than doubled in five years, and cases of intentional self-harm have also surged.”  (http://www.huffingtonpost.co.uk/2016/02/10/mental-illness-and-self-harm-admissions-among-children-surge_n_9200354.html).

Emotion regulation

“When an adolescent engages in cutting, it is widely acknowledged that a large proportion of this act is for emotion regulation purposes. Cutting releases various endorphins into system which have a marked effect on the adolescent’s emotional state, with many teens reporting that they feel calm and emotionally regulated during and immediately after cutting,” says Whittaker (Linehan, 2015).

“Emotion regulation difficulties often stem from an environment which may feel unsafe, uncontaining and unpredictable. Adolescents with these issues often have not learnt to experience difficult emotions such as anger, fear, anxiety, sadness etc. When they are in situations which evoke these emotions, they can often react in destructive ways, for example breaking up friendships, being sexually inappropriate, using substances and cutting themselves etc. Therefore, cutting is only one (common) option that the teen uses to feel better. It is important to note that they are doing their best with the resources at their disposal and their brain make-up to cope (Linehan, 2015).

“It must be stressed that although NSSI’s are associated with a greater risk of suicidal self-harm, their function is not one of suicide which involves intent and a direct attempt to take one’s own life, for example by hanging or shooting oneself or overdosing on medication/drugs, Whittaker stresses.

According to SADAG there are many factors that could cause someone to self-injure as a way of coping with the pain they feel on the inside.

“Most people who self mutilate have difficulty expressing their feelings verbally and may have a dislike for themselves and their bodies. Some people self mutilate because of low self-esteem, difficulties with relationships and lack of communication skills coupled with mental health issues that may be related to depression and/or anxiety and stress. It is important to understand that whatever the reason is that you self mutilate, there are other more positive ways to deal with the way you feel inside” (Linehan, 2015).

Over time self-harm may even intensify from mild to severe, says Whittaker.

“If the adolescent’s ability to tolerate emotional stress is very poor and does not improve, he/she may need to cut increasingly to achieve a relatively acceptable sense of regulation over time (Aguirre & Galen, 2013).

Hiding self-harm evidence

“Adolescents mostly hide evidence of their self-harm,” says Whittaker. “They will often choose areas which can be more easily hidden, for example the inner arm and the inner thigh. The urge to feel better and more regulated often outweighs the damage that they do to their bodies. They often feel shame and guilt for their behaviour, but lack the skills to regulate their emotions in a healthier manner.

Having said this, an increasing number of teenagers are not ashamed of their scars and wear them openly, he adds. “This may in part be due to how cutting has become increasingly fashionable in popular media and is no longer seen to be as unacceptable. Although it is sometimes a learnt behaviour, the primary aspect of self-harm is as a form of emotion regulation (Linehan, 2015).

Tell-tale signs

According to Whittaker, there are a number of signs that would indicate that a teenager/young adolescent harms him/herself. Their emotional state could also be an indicator. Look for the following: intense interpersonal relationships, loss of friendships, fluctuating mood, low mood, intense and inappropriate anger and markedly low self-esteem (Aguirre & Galen, 2013).

“It is important that teens who self-harm are not shamed,” he cautions. “This only makes them more anxious and lowers their mood which will inevitably make them want to cut more or use another methods to emotionally regulate.”

According to SADAG young people who self injure, do not need responses like stereotyping, condemnation, judgmental attitudes, assumptions about what their behaviour means, threatening or issuing ultimatums. Instead they need care, concern, compassion, support, understanding, time, space, good listening, assistance to find alternative coping skills, and a gentle encouragement to recognise and put into words their emotions.

Treatment

One of the main treatment techniques used at the Akeso psychiatric clinic group is  Dialectical Behavioral Therapy (DBT). “It was the brainchild of American psychologist Marsha Linehan who set out to create an approach which targeted emotion regulation and interpersonal deficits in people with borderline personality disorder (BPD). Cutting is a common aspect of BPD but not everybody who cuts, has the disorder. DBT is a successful method to treat emotion regulation difficulties which are at the root of self-harming behaviour, explains Whittaker.

“The good news is that teenagers/ young adolescents can and do recover if they can learn ways to deal with their emotions constructively,” he concludes.

References:

• Linehan, M. (2015). DBT Skills Training Manual. Second Edition. New York
• Aguirre, B. & Gillian, G. (2013). Mindfulness for borderline personality disorder – relieve your suffering using the core skill of Dialectical Behavior therapy. Oakland, USA.