OACAS Journal: Fall 2008: Why Do the Youth on My Caseload Harm Themselves? Communications As a Possible Factor in Youth Deliberate Self-Harm

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Why Do the Youth on My Caseload Harm Themselves? Communications As a Possible Factor in Youth Deliberate Self-Harm
By Allison M. Cook

It is common knowledge that children who have experienced maltreatment are at additional risk for mental health difficulties throughout their lives. Although currently not considered its own mental health disorder, youth who engage in deliberate self-harm (DSH) behaviour are more likely to have experienced maltreatment in their lives (Zoroglu et al, 2003). It is important for social workers, psychologists and counsellors alike to gain knowledge about this potentially life-threatening behaviour in order to provide effective services to youth who self-harm.

DSH is defined in the literature as “deliberate, direct destruction of body tissue without conscious suicidal intent, but resulting in injury severe enough for tissue damage to occur” (Gratz, 2006, p.1) and can appear in a number of forms including cutting, burning, head banging and suffocation, to name only a few. Other names for DSH exist including self-mutilation and ‘parasuicidal acts’. This type of behaviour has been observed throughout history; however, due to its grisly nature, empirical research concerning why individuals may engage in such behaviour has only begun in the past few decades. DSH has historically been thought to be a symptom of only the most severe psychiatric problems and was not considered to be an issue in the general population. Although DSH is linked to some diagnoses including major depression, borderline personality disorder, eating disorders and posttraumatic stress, recent research has shown an increase in this problem among community samples of people who do not fit the criteria for a mental health disorder. This increase in DSH is particularly apparent among populations of youth studied. World-wide, research has shown that in the general population, the prevalence of self-harm among adolescents is typically much higher than that of adults (Evans, Hawton, Rodham and Deeks, 2005 for adolescent prevalence; Welch, 2001 for adult prevalence).

DSH is very dangerous and it is possible for people to die from it. Accidental death may result when someone underestimates the lethality of their methods or overestimates the likelihood of rescue. This kind of mistake may be particularly common among youth who may lack judgment or have a perception of invincibility common to young people. Those who self-harm as youth are also more likely to commit intentional suicide later in life. There is a need for early intervention to prevent this from happening.

Given that DSH is viewed as distinct from suicidal behaviour, it is very difficult for most people to understand why someone would hurt themselves without the wish to die. The lack of knowledge of the factors contributing to engaging in DSH prevents the development of a gold standard for assessment, prevention and treatment of this behaviour. What we do know is that many youth who hurt themselves have experienced adverse life circumstances such as maltreatment and so Children’s Aid Services workers may find that many of the youth on their caseloads engage in it.

Some researchers have taken the approach that this behaviour would not be done or maintained unless it served some sort of purpose for the person. One of the functions of self-harm supported by adolescents is a social-positive-reinforcement function which refers to youth being able to gain attention from those around them, solicit assistance or increase support in their social networks by self harming. An alternative is that DSH is a maladaptive coping mechanism used to manage negative emotions. This function, known as affect-regulation, has received the strongest support and it has been found that youth experience intense negative
emotions that go away once DSH is done. DSH can also serve a self-punishment function which fits historical reports that say many people engaged in such acts to relieve themselves of their perceived wrong-doings. Functions that receive modest support in the literature are sensation-seeking, to release suicidal thoughts without risking death (antisuicide), to manipulate others (interpersonal influence) and to assert one’s autonomy or affirm the sense of self as different from others (interpersonal boundaries).

It is possible that certain people are naturally placed more at risk for engaging in DSH due to their biological make-up (Joyce et al, 2006). Certain forms of some genes have been found to be more common among people who self-harm and so there may be a biological mechanism that makes it more likely that self-harm will be chosen as a coping mechanism for certain people. There is support for this biological theory of DSH in that many people who do it tend to have higher pain tolerance. Also, when someone is hurt, their body releases endorphins, chemicals that make us feel good. This phenomenon has been referred to as ‘cutters high’ and leads to DSH having an addictive quality, likely to be repeated, increasing in frequency and intensity.

As mentioned previously, the experience of childhood maltreatment is more common among youth who engage in DSH than those who do not. But why is this the case? What is it about childhood maltreatment that makes someone more likely to hurt themselves? Research has only recently been done to answer this question and the results are very specific to the population studied and by type of abuse experienced. One study found that a high level of self-criticism acts as a mediator in the link between maltreatment and self-harm. Children who are emotionally abused become overly critical of themselves and as they grow use self-harm as a way to punish themselves when they perceive that they are not good enough. It has also been suggested that symptoms of post-traumatic stress disorder (PTSD) mediate the relationship between sexual abuse and self-harm. One of the symptoms of PTSD is dissociation or a feeling of being detached from or outside of one’s body. An episode of dissociation often precedes an act of self-harm and people report that feeling pain helps them to feel anchored and reminds them that they are real and alive when they feel disconnected from ‘being’ in the physical sense. Some other reasons survivors of trauma may use DSH include to express trauma-related feelings of rage, frustration, guilt and shame or as a method of re-enacting the trauma that occurred. By engaging in activities that recreate the physical or emotional events that took place at the time of the trauma, the survivor may be attempting to remember an event that was blocked due to its traumatic nature, or to communicate to herself or to others what occurred. Re-enactment may also be an attempt to master a situation that was previously not manageable for the survivor, or an effort to regain a sense of control and power in a situation where they previously felt completely powerless. Being able to harm oneself and then choose when and how to stop the pain allows the survivor to have this sense of control.

Experiencing maltreatment as a child has a number of consequences as an individual grows and any of these could contribute to a youth using DSH. One consequence of maltreatment that has been documented among toddlers is a reduced ability to express oneself. Children who have been maltreated do not have the same communication abilities as their non-maltreated peers and this is particularly true of the toddler describing their own internal states, such as how they are feeling. Although this effect of maltreatment has only been studied in young children, it is possible that the effects remain as they grow. In adolescence, the ability to express ourselves becomes very important, as peer relationships become a priority and romantic relationships begin to form.

When the communication demands of the environment become too great, a youth may use self-harm as a way of expressing themself. A study done with university women supports the idea that a lack of ability to communicate about feelings may contribute to DSH. Specifically, it was found that having experienced maltreatment reliably distinguished the women who self-harmed from those who did not, but the level of what the author calls ‘emotional inexpressivity’ determined the frequency of DSH.

A communication function of DSH has long been documented among people with developmental disabilities as a way to elicit help or attention from their caregivers. Although the stereotypic self-harm among this population is different from that seen among typically-developing youth, there may be similar factors contributing. Many adolescent self-harmers give “to show how desperate I am feeling” or “I wanted to be noticed” as reasons that they self-harm and youth who engage in DSH have been found to have less people they feel they can talk to.

Using data from the Maltreatment and Adolescent Pathways (MAP) project at the Centre for Addiction and Mental Health under the supervision of Dr. Christine Wekerle, a study is currently being done to see if there is an association between a youth’s basic communication abilities and their use of DSH. If this link is supported, it may point to new approaches for prevention and treatment of self-harm and may indicate an importance of workers providing a safe place for youth to express themselves and in teaching them how to do so. It is hoped that a better understanding of deliberate self-harm among youth who have experienced maltreatment will help in the development of effective services for these young people.

About the Author

Allison M. Cook is a Master of Education Student at the University of Western Ontario in the Counselling Program, working on a thesis from the Maltreatment and Adolescent Pathways (MAP) Project dataset, with Dr. Christine Wekerle, Associate Professor, Education, Psychology and Psychiatry, The University of Western Ontario.