Non-suicidal self-injury

I think that one of the most baffling phenomena in the repertory of human behavior, to people outside the mental health field, is self-mutilation. Most of us fear and avoid physical pain and disfigurement, and it’s hard for us to understand why anyone would intentionally hurt themselves of self-mutilate. Over the course of my career as a psychologist, I discovered that there are a variety of motivations and explanations for self-harm.

Some people harm themselves because they are in a psychotic state of mind. It may be that voices nobody else can hear tell people to hurt themselves, or that self-harm is the result of delusional beliefs. I’ve known a man who gnawed off several fingers and another who gouged out his eyes for incomprehensible reasons, while psychotic. Other people injure themselves impulsively, because their distress impairs their judgment and they don’t know what else to do; so they bang their heads against the wall, or punch through a pane of glass.

Yet others learn from experience that cutting, or otherwise hurting, themselves provides immediate relief from overwhelming emotional pain; and it becomes a habit. The brain often responds to pain by releasing endorphins, whose molecules resemble morphine. (I recently learned that one reason some people enjoy eating really hot peppers is that the pain gives them an endorphin high.) This substitution of physical pain for emotional pain is hard for many of us to understand, but it reliably meets a need for some people. It can be viewed as a kind of masochism, with the distinction that it’s not done for pleasure, but rather for relief from pain.

What I would say to a client when I learned that they were self-mutilating was something like, “I believe that if you knew better ways to cope with your emotional distress, you’d use them, instead of hurting yourself. So let’s work on finding better ways.” Non-suicidal self-injury (NSSI) is a pathological behavior for many people diagnosed with Borderline Personality Disorder, and its elimination is one of the first goals of the most effective treatment available for people with that diagnosis – Dialectical Behavior Therapy (DBT).

DBT is the creation of Dr. Marsha Linehan. She designed it to help people who feel like they’re living in Hell, as a way out. Each patient in a DBT program is assigned an individual therapist, and is required to attend skills training groups twice a week. Two of the skills modules that are geared to the elimination of  NSSIs – or parasuicidal behaviors – are distress tolerance and emotion regulation. Borderline traits and symptoms are characterized by emotional imbalance. In learning to tolerate distress and regulate emotions, the clients learn how to achieve emotional balance. They no longer have to rely on the endorphin rush they get from cutting or burning themselves, once they’ve found better ways to cope with emotional distress.

The most extreme instance of self-mutilation I ever encountered in my career, not involving psychosis, was a long-considered and carefully executed self-castration. I speculate that the man’s motivation was related to either or both fear of a strong sex drive and/or disturbing sexual fantasies and urges. A fundamentalist Christian, he believed himself to be tempted by demonic “powers and principalities,” in a battle over his soul. He was quite intelligent and had a rationale for his agenda.

When he’d asked a surgeon to castrate him, he’d been told that no doctor could ethically accommodate his request, as there was no medical reason for the surgery. So he studied books on surgery until he felt confident that he could operate on himself. He decided to castrate himself in two  separate surgeries, coached his wife to serve as his surgical assistant, and set up a surgical suite in their home. The first surgery went off without a hitch. I never would have encountered the man if he hadn’t botched the second surgery. When he and his wife couldn’t stop the bleeding after he’d severed his remaining testicle, they had to call 911.

The local hospital contacted me to evaluate him. He was medically stable and ready for discharge, but his doctor wanted me to make a recommendation regarding any possible suicide risk. The man showed no signs of either depression or psychosis. He was pleasant and cooperative, explaining his rationale for castrating himself and answering all of my questions. He seemed somewhat embarrassed by having been found out, but seemed to have no other regrets about his actions. He persuasively denied any suicidal thinking, and he didn’t meet the criteria for involuntary psychiatric commitment. So I recommended that he be discharged. I gave him my card and told him that I was available if he wanted to follow up, but he never contacted me.

As an adult, I’ve never referred to mentally ill people as “crazy” – only behaviors. This was an example of how a legally sane person can do a carefully-considered, but crazy, thing.