I recently had the opportunity to ask Dr. Walsh a few questions about self-injury. Dr. Walsh has written extensively and presented internationally on the topic of self-injurious behavior. He is the author of the book, Treating Self-Injury: A Practical Guide published by Guilford Press (2006) and co-author of the book, Self-Mutilation: Theory, Research and Treatment (Guilford Press, New York, 1988).
As the Executive Director of The Bridge of Central Massachusetts, a community non-profit agency, he oversees 40 programs serving children and adolescents with serious emotional, behavioral, and family challenges, as well as adults with mental health, developmental disability, and substance abuse challenges.
What is the difference between self-injury and a suicide attempt?
Acts of suicide and self-injury are different in numerous ways. They are different as to intent, method, frequency, cognition, aftermath and other features. For example, the intent of most people who attempt suicide is to permanently escape misery, intense, persistent psychological pain. The intent for most acts of self-injury is to reduce emotional distress.
The methods most frequently used by people in the U.S. to commit suicide are gunshot, overdose, hanging, ingestion of poison, and jumping from a height. The methods that are common as to SI are cutting, self-hitting, burning, abrading, and picking. Method can tell you a great deal as to whether a behavior is about suicide or self-injury. For a more detailed discussion of these differences see Walsh (2006).
Why is it important to make that distinction?
People who are suicidal require an emergency response and protection. Restriction of means is often very important. Common acts of SI such as cutting, burning, picking can be treated on an outpatient basis and often do not require an emergency response.
Restriction of means is often futile with self-injury. People can always use their hands, finger nails, a staple, a shard of glass, etc. to SI. However, it is important to note that SI is a risk factor for subsequent suicide attempts. It’s important to intervene early with SI so that it doesn’t progress to suicidality.
What causes people to self-injure?
The main reason is its ability to regulate emotional distress. But social contagion factors can also be important.
Who is at risk to self-injure?
People with pervasive emotion dysregulation who lack healthy self-soothing skills. Also, trauma survivors, particularly those who have been sexually abused. The behavior tends to surface in adolescence. And is found in both genders. Since decade 2000 SI has exploded in the general population. The behavior is now common place in middle and high schools, and universities in otherwise high functioning individuals.
Are there signs a parent can identify that a teenager or young adult may be engaging in self-injury?
Unexplained recurrent wounds. Preoccupation with SI books, movies, websites, youtube videos, etc.
What are the most common misunderstandings about self-injury?
That wrist cutting is a suicide attempt. In reality almost no one dies by cutting. It is more risky if someone cuts the neck in the vicinity of major veins or arteries, but this is a very rare behavior.
What is replacement skills training and how is it helpful in the treatment of self-injury?
Replacement skills are crucial in overcoming SI. If people SI to reduce emotional distress, they obviously need to learn healthier ways to regulate emotions, such as mindful breathing, calming visualizations, noncompetitive exercise, journaling, or whatever they find reduces emotional arousal (such skills shouldn’t involve use of chemicals such as alcohol or drugs).
You recommend approaching the topic of self-injury with a dispassionate, low-key style. Why is that?
Because emotionally dysregulated people aren’t helped by more emotion being added to the mix. A low key response avoids inadvertently reinforcing the behavior and also does not punish that which deserves compassion. The strategy is not to be too effusively supportive, but also not to be judgmental or condemning.
What are currently considered the most effective treatments for self-injury?
CBT and DBT. Both teach skills to regulate emotions. DBT seems to have more evidence in support of effectiveness than any other treatment.