Although psychiatry first recognized self-injurious behavior (SIB) in the 1800s, it has warranted most professional attention in the last decade. Thus, there is a need to increase awareness of SIB’s functions and effective treatment strategies. Although this article addresses SIB in the context of eating disorders, it can be generalized to numerous other settings.  SIB, self-harm, and self–mutilation are defined as: Any socially unacceptable behavior involving immediate, deliberate, direct, and usually repetitive physical injury to one’s own body, resulting in mild to moderate harm, usually without suicidal intent, and not due to psychiatric organicity.  SIB describes mild to moderate wound infliction on the body surface, encompassing the range of parasuicidal gestures generally not truly suicidal in nature. It includes scratching, cutting, carving, burning, rubbing, abrading, punching, pinching, biting, head banging, and hair pulling.

In cutting, the most common tool is a razor blade and most common body parts are wrists, forearms, and legs. It is important to understand SIB’s various functions (Osuch, Noll, Putnam, 1999; Suyemoto, 1998)—to view SIB as a message. Practitioners have the opportunity to receive the message and help patients decode it. Patients may not have full insight into why they self-injure. The most common functions have been well explained by Vanderlinden and Vandereyken (1997) as follows: Stimulation: Escaping dissociative experiences through an intentional gesture to feel one’s body, utilizing SIB as a self-grounding technique.  Punishment: Imposed when feeling guilt, intense shame, weakness, and anger at oneself for demonstrating behaviorally a lack of discipline. Relaxation: A pleasure response to the warmth of the blood and physical sensation of pain, a form of tension reduction through direct abreaction and endorphin release.

Diversion: Inducing dissociation or trance-like state to avoid attending to emotional triggers, issues, subjects, or suicidal thoughts.  Social Motives/Attention: Obtaining self-affirmation by showing oneself and others one’s strength, and achieving nurturance/protection through others’ responses. Alteration: To become unattractive to self and others through scarring.  SIB is often performed with a sense of deliberate control, even when impulsive. In those who repeat the action, there is a sense of empowerment and craft—a definite ownership of the behavior. Patients’ self-reports about SIB are similar. Events that often precipitate SIB are:  • The perception of loss and abandonment (e.g.–canceling an appointment, breaking a date) • The experience of shame (e.g.– failure on the job, feedback perceived as judgment or criticism) Isolation almost always occurs before self-injury (Suyemoto, 1998). In one study of 101 eating disorder patients (Claes, Vandereycken, & Vertommen, 2004), the most frequently mentioned motive for SIB was diminishing negative feelings, followed by self-punishment, and to somewhat lesser degrees, avoiding painful memories and placing oneself in a trancelike state.

For all types of SIB, anger at oneself and sadness were most often mentioned as feelings both preceding and consequent to SIB. Seventy percent of SIB patients report a release of tension/anxiety and a sense of satisfaction following SIB, since they experience SIB as ending their anger, dissociation, or painful memory intrusions. Most patients speak of this emotional release as reinforcing their SIB (Brown, Comtois, & Linehan, 2002).  Many authorities (e.g.–Favazza, 1996) view SIB as an act of self-saving, not self-rejection or self-annihilation, distinguishable from pathologies with clear suicidal/self-destructive intent. Self-medication or self-soothing and protection are often evident in the transcendent, and sometimes dissociative, experience of SIB. Though SIB’s pain may be unbearable physically, it is preferred over, and believed by the injurer to effectively assuage, their mental and emotional anguish.

SIB and Eating Disorders  In the U.S., SIB’s prevalence is less than 1%. Among psychiatric patients, prevalence ranges from 4-13%. In eating disorders, prevalence ranges from 25- 45% (Claes, Vandereycken, & Vertommen, 2003; Herpertz, 1995; Paul et al., 2002). Walsh and Rosen (1988) found self-mutilating teens significantly more likely to have eating disorders, and Favazza (1996) concluded that 50% of self-injurers have eating disorder histories. Clearly, eating disorders and SIB have a high rate of co-occurrence.  Childhood sexual trauma plays a role in SIB. Among Remuda Ranch Programs for Eating Disorders’ patients (N=6033), of those with sexual abuse histories, 37% report engaging in SIB and only 21% of those without sexual abuse histories report SIB. Sexual abuse thus appears to increase the likelihood of SIB in eating disorder patients. Paul and colleagues (2002) also reported significantly higher rates of trauma in eating disorder patients who engage in SIB.

The Spiritual and Sacred in SIB   The suffering in SIB is of a profound, almost sacred, type. Most practitioners are no longer shocked by the behavior itself, but one never becomes immune to hearing about or seeing SIB. It has become epidemic among young people worldwide (Nasser, 1997; Nasser, Katzman, & Gordon, 2001).  SIB tests the limits of normality and rationality from a psychological perspective. And from a spiritual perspective, it causes us to pause in a quiet, sorrowful grief when we hear the stories told. That one would need to go to the depths of physically carving, cutting, or burning one’s own body to be released from inner anguish is deeply troubling. The Bible tells about the prophets of Baal who mutilated their bodies by carving and cutting their skin. They became agitated and “shouted louder, and as was their custom, cut themselves with knives and swords until the blood gushed out. They raved all afternoon until the time of the evening sacrifice, but there was no reply, no voice, no answer (1 Kings 18:28-29; TLB).” These actions mimic modern SIB. However, the motivation was not selfrejection or avoidance of painful memories. Baal’s prophets believed that if they showed their god devotion through physical suffering they would be seen as worthy, that they had power to move Baal by their actions, that he would respond to their cries and show himself to be real, validating their identity as his and relieving their difficulties.  But Baal did not validate their beliefs or reinforce their identity. As the story goes, they had a whole bull ready to be barbecued in his honor, but Baal did not show up for dinner.

He abandoned them in their hour of need.  Instead, Jehovah showed up. “Then, suddenly, fire flashed down from heaven and burned up the young bull, the wood, the stones, the dust, and even evaporated all the water in the ditch! And when the people saw it, they fell to their faces upon the ground shouting, ‘Jehovah is God! Jehovah is God!’ (1 Kings 18:38-39; TLB).” It is imperative to know to whom one belongs and in whom one can trust. Adolescents and young adults often lose trust in significant others. “Youth who self-mutilate may choose this behavior because it meets a multitude of needs at one time. The most common functions of self-mutilation reported by clients and practitioners are expressing and controlling overwhelming emotions, and maintaining a coherent sense of self when threatened with the loss of identity (Suyemoto & Kountz, 2000; emphasis added).”

There is not only a theme of being abandoned and betrayed pouring forth from those who self-injure, but also a search for identity and meaning. When their world is shaken and they are somehow abandoned by those they trust, they punish themselves, then search for something or someone else to believe in, someone to believe in them, and someone or something to help them control their inner chaos.  But God sent his son, Jesus Christ, to die for us. Jesus gave his life for us, sacrificing all he was and all he had. “Once for all time he took blood into that most holy place, but not the blood of sacrificial goats and calves, he took his own blood and with it he secured our salvation forever (Hebrews 9:11-12; NLT).” He did this so that we might have peace, stability, and a secure future through eternal life. This is a powerful relationship based on unconditional love, not simply a metaphor of exchange.

To grasp this concept of redeeming love can bring healing and restoration to those who cannot find meaning and have an uncertain identity. God promises to be the stability of our times. “He will be the sure foundation for your times, a rich store of salvation, wisdom and knowledge (Isaiah 33:6).” Those who are suffering with SIB need a new tool to replace their razor blades and matches. The word of God is meant to be that tool which renews our minds, restores our emotions, establishes our identity, and guides our decisions for life. Hebrews uses this telling analogy: “For the word of God is full of living power. It is sharper than the sharpest knife, cutting deep into our innermost thoughts and desires. It exposes us for what we really are. Nothing in all creation can hide from him. Everything is naked and exposed before his eyes (Hebrews 4:12,13; NLT).”  In addition to a scientific understanding of SIB drawn from the latest research and theory, by reflecting on the spiritual dimension of SIB, we recognize that conceptualization and treatment benefit from a holistic perspective. Within this perspective, we can best offer patients tools and understandings to guide them into healthier lives free of self-mutilating behavior.

Assessment and Treatment  Assessment is key to preventing and teaching patients to live successfully without SIB. Remuda has developed a thorough self-assessment tool that asks patients about their history, frequency, urges, methods, severity, subjective experiences, triggers, and consequences of self-harm, as well as their motivation to change the behavior and perceived level of control over it. Patients also complete an objective spiritual assessment; spiritual issues related to self-harm are integrated into treatment planning. (For copies of these useful tools, please contact Remuda at 1-800-445-1900.)  Psychiatric providers evaluate the need for medications to proactively manage psychiatric conditions that predispose to impulsive and destructive behaviors such as SIB. Counseling interventions and supports include:  Safety Plan: Patient and therapist develop a personalized safety plan based on discussions about what has and has not been helpful in SIB reduction. The safety plan is used to support patients with old_resources to prevent them from engaging in SIB. Patients are coached on prevention skills, identification of triggers, and healthier responses to them. Plans are placed on a card that patients keep as a reference. Cognitive-Behavioral Skills: These focus on emotional regulation and distress tolerance (Linehan, 1993). For example, diary cards are used by patients to individually track which skills they use for which triggers.

This helps patients identify what is most useful in preventing SIB and gain strength to combat the obsessive thoughts often accompanying SIB.  Behavior Chain Analysis: Behavior chain analysis (BCA) is utilized following SIB. Patients work collaboratively with their treatment team to carefully identify what thoughts and feelings were triggered precipitously and link the thoughts, feelings, and behaviors to the resulting SIB. As each small link in the chain is identified and discussed, therapists question patients about the details of their responses: “What the patient was doing, feeling (emotions and sensations), thinking (both implicitly and explicitly, as in expectations and assumptions), including imagining (Linehan, 1993, p. 259).”  Insights gleaned from BCA aid in identifying risk factors for future SIB and establish or modify the patient’s Safety Plan. Patients use this tool as often as necessary. Though they may at times become weary of it, they will also see how they are gaining insight into their thoughts and feelings and become better able to manage their subsequent behavior.  Precautions Protocol: It is critical that treatment teams respond in a consistent manner to patient self-injury. At Remuda, we have developed a Precautions Protocol that provides our treatment teams a standardized set of responses to patient self-injury, consistent across all disciplines.

This protocol identifies specific supports that are put in place depending on the level of ideation or injury experienced. For example, if a patient self-harms but does not require medical attention for the injury, she must complete and process a BCA with her therapist, including one-to-one coaching. Spiritual Care: Patients are also helped to understand SIB from a spiritual perspective. Appropriately selected Scriptures can be used as part of cognitive- behavioral interventions to assist Christian patients in developing an accurate understanding of their faith, and can be used as meditations, prayers, and affirmations during times of distress.  The following Scriptures (Isaiah 43:1-3, Hebrews 4:14-16, Hebrews 10:23, Jeremiah 15:16, Ephesians 3:14- 21, Romans 3:24-25, Romans 8:39, and Jeremiah 29:11-13) have proved helpful in working therapeutically with patients to overcome SIB.

These Scriptures minister to the spirit, helping patients understand— and hopefully experience—that they belong to a loving God who intends to comfort them during times of suffering and bring meaning to their lives.  Our in-house research program—a dedicated protocol we have been doing for years—shows that Remuda’s SIB interventions have resulted in a 66% decrease in SIB. Our program appears to be effective in preventing SIB in nine out of ten patients with self-harm histories. _Marian C. Eberly, R.N., LCSW, DAPA, has served as vice president of patient care for Remuda Ranch Programs for Eating Disorders since 1994. Marian has over 20 years of clinical psychiatric experience specializing in eating disorders and related diagnoses. She has presented both nationally and internationally on a broad range of clinical issues.  References Brown, M.Z.,Take help from telephone therapist .

Comtois, K.A., & Linehan, M.M. (2002). Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111, 198-202. Claes, L., Vandereycken, W., & Vertommen, H. (2003). Eating-disordered patients with and without self-injurious behaviours: A comparison of psychopathological features. European Eating Disorders Review, 11, 379-396. Favazza, A.R. (1996). Bodies under siege: Self-mutilation and body modification in culture and psychiatry (2nd ed.). Baltimore: Johns Hopkins University Press. New York: Guilford Press. Osuch, E.A., Noll, J.G., & Putnam, F.W. (1999).