In harm’s way
Why do people engage in self-harming or self-injuring behaviour and what can we do to help? Kate Woods finds out.
QUEENSLAND psychiatrist Professor Graham Martin is a very determined man.
So when he stepped towards the room of an angry, uncommunicative, self-injuring 16-year-old and heard one of the nurses say, “I bet you don’t get anything out of her”, he had all the incentive he needed.
He put his head down and strode forward boldly.
“This young girl looked more like a 13-year-old, not anorexic, but certainly very thin. She had scars all the way down her leg and her arm where she had been cutting herself,” he says.
“For the first 20 minutes or so, I could not get her to recognise my presence or respond to any of my questions. She didn’t even react when I started making provocative statements.
“I could see she was hugging a little teddy bear and a small, soft photo album, so eventually I asked to see the album.
“I watched as she looked down at her hands, then at the photograph album, look back at me and then hand it over.
“It was the first time she actually acknowledged me.”
Inside the album were photos of her mother, who had died of cancer when she was six. Her father blamed her for her mother’s death and had repeatedly abused her both verbally and sexually.
Her older brothers had treated her in a similar way.
“Because she was treated so badly by her family, she had come to truly believe she was to blame for her mother’s death,” explains Professor Martin, the director of child and adolescent psychiatry at the University of Queensland.
“So every time something awful happened in the family, she would cut herself because it was the only thing that brought her relief.”
At 13 and then again at 15, she found herself pregnant after being raped by a number of young men at parties where she had used drugs and too much alcohol. Both pregnancies were terminated.
“Listening to this young woman share her terrible story, knowing she has experienced more emotional pain than many of us could ever imagine, I felt compelled to ask: ‘Why are you still alive? Why would you want to go on living?’
“And very quietly she responded with: ‘My violin’.”
Admitting he found it difficult to believe “this damaged little girl” played the violin, Professor Martin pursued the subject further and soon discovered she had actually passed her grade seven exam.
“For the first time she became really animated and she said to me: ‘I would really, really love to become a violin teacher.’
“So we spent some time exploring how she could achieve that goal, and within just that one session, her whole demeanour, her whole attitude changed, and we decided she wasn’t suicidal.
“Eventually she moved to a group home and she went back to school to finish her education. She still uses self-injury occasionally, but she is living a much better life and she is on track to accomplish her dreams.”
Deliberate self-harm and self-injury are common behaviours in Australia.1
While recent figures from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) show more than 25,000 people in any year are admitted to hospital as a result of self-harm,2 worrying new study results suggest an estimated 200,000 Australians, or 11 per 1000 people per month, self-injure.3
The study also showed the 12-month prevalence of self-injury is 2.6%, corresponding to an estimated 520,000 Australians or a rate of 26 per 1000 people per year.
“This can be compared to recent Australian 12-month prevalence figures for panic disorder, obsessive compulsive disorder, generalised anxiety disorder and agoraphobia,” say the authors of the Australian National Epidemiological Study of Self-Injury (ANESSI).
“Such a high prevalence is reason for us to take self-injury as seriously as we would take other mental health problems.”
Furthermore, the study shows self-injury exists across the age groups, not just in young people, and is just as prevalent in males as in females.
While many worry these figures reflect a significant increase in the number of people self-harming in the community, the University of Sydney’s Professor Philip Boyce says it may be because we are more conscious of it now than and as a result more people are seeking help. Or, says the former chair of the RANZCP Clinical Practice Guidelines Team for Deliberate Self-Harm, it may be that we are classifying self-harming behaviour differently.
Professor Martin, who is lead author of ANESSI and director of the Centre for Suicide Prevention Studies in Young People, agrees a true picture of the prevalence and nature of self-harm and self-injury has been difficult, but he believes rates are rising.
He says international studies of school children show that between 2000 and 2003, rates were about 5-6 per cent. More recent studies show they are now more likely to be 8 per cent.
He attributes the rise to changes in society.
“Generally speaking, we live in a faster, more stressful environment. We are also living in a less kind society,” he says.
Other reasons, he surmises, are bullying and changes in parenting practices.
“Parents have less time, are generally less skilled and the relationships between parents to children are much more problematic and difficult.
“It is also clear that violence in the family is more of an issue.”
While mental health problems are also associated with self-harm – problems including general psychological distress, certain mental health conditions such as anxiety, and psychological issues such as dissociation – none of these factors alone will necessarily predict the presence of self-injury, Professor Martin says.
Furthermore, self-injury can be a major risk factor for suicide, but it is not a suicide attempt.
“There is some international evidence showing the longer people go on, and the less therapy they get in the long term, the more likely they are to get into suicidal behaviours. But in the early stages, it is not about suicide.”
Instead, Professor Martin says people use self-injury for several reasons, including to control or contain emotion; to punish the self; or to cure a feeling of emptiness.
“Somehow seeing the blood on the arm, the leg, the stomach or wherever, allows these people to feel real, to feel that they are human and not so isolated.”
And many, he says, do rely on their GPs for help.
Evidence from Western Australia shows that more than a third of people hospitalised after an episode of deliberate self-harm visited their GP in the previous week, while almost two-thirds visited their GP in the previous month.1
That is why Dr Phill Brock, chair of the RANZCP’s Faculty of Child and Adolescent Psychiatry, reminds GPs with patients that may be self-injuring, to take the time to “do a quick inventory”.
“Ask about school, how they are going with their studies, how things are at home or work, with their friends, how they spend their leisure time and so forth.
“If there is any indication of poor coping in any area, that’s then a time to inquire a little further.”
Dr Brock says it is also useful to remember that only a “very, very small minority” of disturbed patients use self-harm repetitively as a coping strategy.
In these cases, he suggests it may be beneficial to ensure a child is placed in a supportive environment where alternative coping strategies can be taught.
“But for the vast majority of cases, the best help a GP can provide is to listen, be respectful and take the complaint seriously. If there is an indication mental health is being compromised, provide some mental-health first aid or arrange an extended session in the near future.”
So far, it’s believed that dialectical behaviour therapy – a skill-based, cognitive behavioural approach that emphasises acceptance of the person as they are, combined with an expectation that current behaviours need to change – has consistently shown efficacy in self-injuring clients.
“Every single act of self-harm has meaning,” Dr Brock says.
“The job of the doctor is to listen and see if they can help the young person find the meaning and find some alternative coping strategies.”
Deliberate self-harm is defined as the intentional poisoning or injury of one’s self, irrespective of the underlying purpose.4 Self-injury is the deliberate destruction or alteration of body tissue without suicidal intent.3
1. Australian and New Zealand Journal of Psychiatry 2004;38:868-884
2. Australian and New Zealand College of Psychiatrists. “Self-harm. Australian treatment guide for consumers and carers”. August 2009. www.ranzcp.org/images/stories/