Cutting, burning, scratching or biting the skin as way to regulate negative emotions is on the rise, according to experts, especially among adolescents.
Using physical pain to reduce emotional pain is not a new phenomenon and, with the inclusion of non-suicidal self-injury (NSSI) as a “condition for further study” rather than as only a symptom of other diagnoses in the DSM-5 in 2013, there has been an increase in research on the topic.
The work of Jill M. Hooley, D.Phil., professor of psychology and head of the clinical psychology program and the experimental psychopathology program at Harvard University, has opened new windows on how self-injury is linked with highly negative self-criticism and new tools that may help to reduce self-injurious behaviors.
She spoke with New England Psychologist’s Catherine Robertson Souter about her work with self-injury and how high levels of criticism can wreak havoc on mental health.
Q: You have worked in both depression and in self-injury and found an interesting area where they are linked, in external and internal criticism.
A: The research I have done over time has been looking at depression and schizophrenia and the role of family criticism in relapse. We now understand that criticism is very important in regard to understanding NSSI but instead of family-directed, it is internalized self-criticism.
Q: Why do you think we have seen rates of NSSI rise?
A: To begin to understand that, you need to understand what self-injury does and who is at risk of doing it and then you can start to make sense of why it is happening. With NSSI, with the more unambiguous things like cutting or burning [rather than biting or scratching the skin], you probably see it in one to two percent of adults and around three percent of adolescents.
The reason we should be concerned, beyond the fact that it is in and of itself a dangerous behavior that can cause physical damage, is its association with suicidal behavior. There is a strong association between NSSI and suicide. Most studies find that NSSI is a comparable or stronger predictor of future suicide attempts than are prior suicides.
Q: As you said, we need to understand what it does and who is at risk of doing it. Can you explain?
A: What might surprise people is to learn that self-injury works. It increases positive mood and it decreases negative mood. Contrary to what many people and even many clinicians believe, feeling better after pain is not unique to people who engage in self-injury. It is not that some people are wired differently to get benefits from pain. Self-injury would work to improve mood for everyone.
There is a phenomena called pain offset relief. The act of injury during NSSI is painful but the removal or reduction of the painful stimulus prompts a powerful state of relief. When you remove pain, you feel better. But what is interesting about this is that pain offset relief may occur in part because there is a common neural overlap between physical and emotional pain.
Q: So, you feel better not only from the relief of the pain itself but it elevates your mood from before you self-inflicted the pain?
A: Yes, and because emotional pain is very hard to control but self-induced physical pain is easy to control – just stop what is causing the pain – the pain of self-injury provides a means to get released from the emotional pain.
Which, of course, raises the question, if NSSI works, why don’t we all do it?
Q: Exactly what I was thinking. But then, I don’t want the pain.
A: Right, there are barriers for most people to doing this. Our research now is focused on these barriers. We believe that high self-criticism is a key factor. If you view yourself as toxic or worthless, you are likely to care very little about your body so harming it in an effort to feel better or to atone for being bad becomes a viable and appealing option. And once you try it, you realize that it works.
Then, for people who have these profoundly negative associations with the self or who want to punish themselves for being bad, the fact that it causes pain makes it an appealing behavioral option.
There is a psychological benefit that comes from gratifying a desire for self-punishment. We have data from a recent study that shows that people who are highly self-critical actually feel better psychologically while pain is happening. It is almost as if the experience of pain itself is bringing about an improvement in mood for those people.
So, when you put all of this together, self-injury starts to make sense. You have people who feel profound self-hatred, they will then engage in an act of self-punishment that supports their beliefs that they are a bad person and now they are sort of atoning for that.
They get mood benefits while it is happening and then the pain offset relief that improves mood through another mechanism. Of course, once people start doing this, the mood related benefits start to drive the behavior. It becomes a go-to coping mechanism.
Q: What is the most effective treatment?
A: Well, these ideas are really quite new in terms of why self-injury works and some of the key barriers which, once eroded, pave the way. We are working on new treatment approaches.
We recently conducted a novel intervention to alter associations with NSSI stimuli and the self. This is an online app, a matching game delivered via smart phone. We are trying to condition an aversion to NSSI stimuli by pairing pictures of, say, razor blades with pictures of snakes, for example, and also trying to improve self-image.
In two tests of this intervention, the participants had engaged in self-cutting at least twice the past month and in the third study the participants had made a suicide attempt in the past year.
Across all of the studies, the treatment group showed immediate and substantial reductions of 50-90 percent in self-injury and the treatment effect was associated with both an increased aversion to NSSI stimuli and increased positive associations with the self.
In another study, we did a brief cognitive intervention designed to make people feel better about who they are, as people, and we measured their pain endurance before and after. We found that intervention made the people who engaged in NSSI 50 percent less willing to endure physical pain.
Q: How long before these apps will be available?
A: Both of these studies have been published and we are now working on further refining the mobile app and also looking to see whether we can use these same principals further.
We are in the middle of another treatment study, another online study where we are trying develop new approaches to change how people feel about themselves in a substantial and consistent way. We are looking for things that are scalable that can be done online and might reach more people.
Q: For a psychologist reading this column, what is the most important thing to understand?
A: The bottom line is that criticism is very powerful as a form of social threat and some people are more vulnerable to the consequences of criticism than others, whether it is the external criticism that affects depression or this internal high level of self-criticism.
I think people have often thought that NSSI was a manipulative thing but it is important to understand that it is being driven by profound emotional pain. What therapists should be doing is focusing on developing meaningful change in how people feel about themselves.
By Catherine Robertson Souter