Self-injury is an expression of acute psychological distress. It is an act done to oneself, by oneself, with the intention of helping oneself rather than killing oneself. Paradoxically, damage is done to the body in an attempt to preserve the integrity of the mind.

Zoe feels depressed, empty, and numb. She lacks the energy to cope with the day ahead of her. The world around her seems fuzzy and unreal, almost as if she is wrapped up in cotton wool, and she cannot think straight. She lights up a cigarette, and starts burning circles on her thigh. When she begins to feel the pain from the burns the haze lifts and she feels different – she can think straight, she feels energised, more alive, more real, and she is ready to face the day.

Arabella is having a flashback. She is seeing vivid images in her mind of traumatic events that she experienced as a young child. She is terrified and feels very small. Her heart is pounding; she is sweating and shaking. She grabs a knife from the kitchen drawer and makes a cut on her left forearm. As soon as she sees her blood flowing, the frightening pictures fade from view. She feels calmer and safe. After carefully dressing her wound and cleaning the knife, she makes herself a hot drink, switches on her favourite record, curls up on the settee and quickly drifts off into a deep and peaceful sleep.

Beyond reason

If read through the eyes of someone who has never self-injured, these fictional scenarios may have caused a furrowed brow of bewilderment. Perhaps the thought of what Zoe and Arabella do to themselves made you flinch, or you found yourself thinking something along the lines of, ‘But I just don’t get it – that’s horrible – how can anyone possibly do that to themselves?’ or ‘It’s beyond reason, it just doesn’t make sense’. Be assured that if your thinking took a similar route, you are certainly not alone. Self-injury frequently stirs up negative emotions in loved ones, caregivers and society in general. Typical reactions include shock, anger, revulsion, fear, and panic.

Self-injury is widely misunderstood. It is an uncomfortable subject to think about, to talk about, a difficult behaviour to accept, and dealing with the issue presents many challenges to caregivers. The motivations that drive self-injury are diverse, and the behaviour can hold a multitude of different meanings. Further, while those of us who don’t self-injure may ponder long and hard trying to make sense of the seemingly senseless, the behaviour usually, though not always, makes perfect sense to those who practise it.

Too familiar

If read through the eyes of someone who self-injures, the scenarios may have felt too close for comfort. Alternatively, you may have felt reassured to know that you are not the only person in the world who self-injures – many think they are. Perhaps you don’t understand what makes you want to hurt yourself and that’s what drew your attention to this book; maybe you feel isolated, desperate, or misunderstood, and are wondering what to do for the best; or perhaps you are seeking ideas on how to stop or reduce the behaviour, or are considering seeking help.

My hope is that this book will bring those of you who self-injure comfort and reassurance that with the right help and support there is a road out of self-injury. Moreover, I remain optimistic that you will acquire some therapeutic tools to help you on your healing pathway. It takes courage and determination to leave self-injury behind, and it would be remiss of me to tell you that letting go of self-injury is an easy process. However, as you will see later in the book people do recover, or they manage to reduce self-injury to a more acceptable level. Often, the hardest step is the first one – admitting to having a problem and reaching out for help.

Choice of terminology

To date, self-injury, which is the primary focus of this book, is not classified as a disorder or syndrome, therefore it does not appear in DSM-IV-TR (APA, 2000), the widely used American Diagnostic and Statistical Manual of Mental Disorders. Further, there is no universally agreed term to describe the behaviour, consequently an array of clinical labels and acronyms are applied throughout the literature. The most common are:

• Self-harm (SH)
• Deliberate self-harm (DSH)
• Self-injury (SI)
• Self-mutilation (SM)
• Self-inflicted violence (SIV)
• Self-injurious behaviours (SIBs).

The terms self-harm and deliberate self-harm are mainly used in the United Kingdom, whereas the terms self-injury, self-mutilation, self-inflicted violence and self-injurious behaviours are more widely used in America. Other terms employed include parasuicide, ‘cutting’, self-cutting, self-wounding, and self-abuse. The downside of using such a large assortment of terms is, (1) it muddies the waters over what behaviours comprise self-injury, and (2) it hinders establishing the prevalence of the problem.

For further discussion on the perennial problem of terminology see Chapter 4.

Why the term self-injury?

In my dilemma over what term to use in Healing the Hurt Within, 2nd edition (Sutton, 2005), the respondents involved with the research for that book were invited to comment on which term they considered most appropriate. The majority regarded ‘self-injury’ or ‘self-injurious behaviours’ as the most fitting terms to describe what they do, hence these will be the principal terms used in this new edition. However, the term ‘self-harm’ will be applied on occasion when material derived from Healing the Hurt Within, 1st edition (Sutton, 1999) is used. The term ‘self-injurer’ will be avoided as this causes offence to some people who use self-injury – the reason being that while self-injury may be one aspect of their behaviour, it does not represent the ‘whole’ of them. In other words, the term self-injurer dehumanises people, strips them of their identity, and labels them by what they do rather than acknowledging them for the unique human beings they are.

Other writers’ work

When referring to other authors’ and researchers’ work, or quoting directly from research respondents’ material, the terms applied will reflect the writer’s choice.

Respondents’ observations on terms

Below are a few of the comments received from respondents concerning terminology, from which you will note that the term ‘self-harm’ is considered too broad, and the terms ‘self-mutilation’ and ‘self-inflicted violence’ (SIV) are considered unacceptable or misleading:

What characterises self-injury?

Although it can be a difficult concept to grasp, self-injury is fundamentally a coping mechanism, frequently born out of trauma or a deep-rooted sense of powerlessness. It could best be described as ‘a pain exchange’ in that overwhelming, invisible, emotional pain is converted into visible, physical wounds which individuals who use the practice find easier to deal with – put simply, what can be seen can be treated. Usually, following an episode of self-injury, people report feeling calmer, more in control, safe from suicide, and more able to cope and function.

A safe haven

In general, individuals that self-injure are emotionally fragile, and highly sensitive to rejection. They take things to heart, and their psychological equilibrium can be easily shaken. Self-injury provides a temporary safe haven from the fear of something devastating happening. Basically, the act serves as an effective strategy for ‘battening down the emotional hatches’ and safeguarding oneself from the likelihood of an overwhelming psychological storm. Albeit unorthodox, self-injury is seen by many as a gift of survival, rather than an act of self-destruction.