An Overview of Self-Injury and Cutting

A new look at self-injury

An Overview of Self-Injury and Cutting

What makes young people cut, scratch, carve or burn their skin, hit or punch themselves, or even bang their heads against a wall?

For years, psychologists theorized that such self-harming behaviors helped to regulate these sufferers' negative emotions. If a person is feeling bad, angry, upset, anxious or depressed and lacks a better way to express it, self-injury may fill that role.

Also known as non-suicidal self-injury, or NSSI, the condition is classified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (2013) as a «new disorder in need of further study,» as well as a symptom of borderline personality disorder, which is marked by such tendencies as emotional instability, unstable relationships and chronic feelings of emptiness. (See companion article on who is more ly to self-injure.)

For treatment, practitioners often turn to dialectical behavior therapy because of its effectiveness in treating borderline personality disorder in general. But now, two researchers at Harvard University are taking a different tack on this inquiry.

Joseph Franklin, PhD, a postdoctoral fellow in the laboratory of suicide researcher and psychologist Matthew Nock, PhD, wanted to step back from earlier assumptions about self-injury and think more broadly about what might be driving self-harming behavior.

Although researchers generally accepted that NSSI helped people deal with strong negative emotions, Franklin wanted to understand more about why that was the case.

Around the same time, Jill Hooley, DPhil, who heads Harvard's experimental psychopathology and clinical psychology program, was finding that people who engaged in NSSI would endure experimentally induced pain for much longer than control participants, and she wondered why.

What factors kept self-injurers from apparently acting in their best interests and avoiding pain? And could identifying those factors help explain why people were motivated to engage in NSSI in the first place?

«We were both interested in knowing why people hurt themselves,» says Hooley, «but Joe was focused on the possible [emotional] benefits of NSSI and I was looking at the motivations behind it.»

While over time their interests and investigations have converged, when they first discovered each other's work, «we were , ‘Oh, this makes so much sense!'» Hooley adds. «This is how the various findings fit together. It was very exciting.»

Why self-injury?

Franklin started his investigation with one of the central questions in the field: Why would people report feeling better after hurting themselves?

«It seemed very strange to me, and to a lot of other people,» says Franklin. Most studies on the topic had relied on self-reports, «but I wanted to look at this experimentally and biologically to see if it was really true.»

In a 2010 study in the Journal of Abnormal Psychology, Franklin and colleagues used a task that measured people's defensive eye-blink responses before and after they dipped their hands into ice-cold water. The results indicated that self-injurers do in fact feel better afterward, he found.

A second finding was more surprising.

«Everyone else reported feeling better, too,» he says.

That is, healthy controls showed exactly the same degree of physiological defensiveness and subsequent physiological relief as those who engaged in self-injury. In a 2013 paper in Clinical Psychological Science, Franklin's team replicated the finding and also showed that most people had equivalent changes in positive emotions in response to shocking stimuli.

Franklin then turned to the pain literature to see if he could gain more understanding. There, he discovered something described by psychologists 70 years ago: a phenomenon called pain offset relief.

According to this concept, virtually everyone experiences an unpleasant physical reaction to a painful stimulus. Removing the stimulus does not return the individual to their pre-stimulus state, however.

Rather, it leads them into a short but intense state of euphoria.

Using a technique called pain offset relief conditioning, those scientists also found that if you paired the pain with a stimulus, over time, people would react more favorably to the pain because they had learned to associate it with pain relief. For example, when researchers shocked rats and then presented them with a pleasant odor, over time, the rats began seeking out the smell.

Testing this paradigm with various types of shocks and physiological measures, Franklin continued to find powerful pain-offset relief effects in all of his participants, self-injurers and controls a.

People who self-injure may unwittingly be tapping into this mechanism, Franklin surmises. The first time they hurt themselves, they experience unpleasant pain.

But when they keep doing it and experience pain relief, they begin to associate cutting or other forms of self-injury with relief, and they return for more.

«That is contrary to what a lot of people assumed and what a lot of treatments focus on,» Franklin says. «People, including myself, were thinking there was something unique about these folks» — that if they were injuring themselves repeatedly, they must perceive or experience pain differently from others.

«But that doesn't appear to be the case at all,» he says. «It looks it's this natural phenomenon that [people who self-injure] happen to be tapping into.»

Harmonic convergence

The next research question may seem obvious: If anyone can experience pain relief by inflicting pain on themselves, why don't more of us do it? To ask the question a different way, why do self-injurers harm themselves instead of opting for healthier or more pleasant ways of relieving emotional pain, such as watching a movie, meeting a friend or going to a yoga class?

As Franklin was pondering this question in light of possible benefits to the self-injurer, Hooley and her team wondered about psychological explanations.

She already knew that self-injurers would endure physical pain for longer, but why? Was this increased pain endurance linked to some of the psychological factors that are commonly associated with self-injury — depression, hopelessness or dissociation, for instance?

Somewhat surprisingly, her team found no significant associations. So having interviewed all of her self-injuring research participants in detail, she returned to her notes in search of clues.

That's when one factor stood out: How often they spontaneously described themselves as being «bad,» «defective» or «deserving of punishment.»

«It was as if harming themselves or experiencing pain was somehow congruent with their highly negative self-image,» she explains.

To test this possibility, her team developed a measure that specifically assesses self-beliefs about being «bad» and deserving criticism. This time, they found an answer: The higher a person's score on negative self-beliefs, the longer they were willing or able to endure pain.

Given his conversations with Hooley, Franklin was thinking along similar lines. When he asked himself why people would undertake this behavior, he looked at it in context of the fact that most people probably themselves and therefore don't want to hurt themselves.

In ongoing, still unpublished work, he asked participants to rate words «me,» «myself» and «I» on a 10-point scale ranging from most unpleasant to most pleasant. Most people rated themselves between a seven and eight, but self-injurers gave themselves only a two or a three.

wise, Franklin reasoned that most people would not be overly fond of stimuli that depict blood, wounds, knives or equivalent images.

But he surmised that people who self-injure might feel differently, partly because his findings suggested they would associate such images with pain relief.

 A 2014 study in Clinical Psychological Science shows this is the case: People who had engaged in NSSI over the past year or who had 10 or more lifetime episodes of self-cutting were much less ly to report aversion to these kinds of stimuli than non-injuring controls.

Meanwhile, Hooley has recently completed a neuroimaging study looking at how people process such stimuli.

«We're predicting that images of self-injury will activate reward-processing areas in the brains of people who engage in NSSI,» she says, «but not in non-self-injuring controls.»

Treatment targets

Now, some of these findings, the researchers and their colleagues are exploring new ways to treat self-injury.

In keeping with her discovery that self-worth is an important intervention variable, Hooley is taking a cognitive route. Clinicians might be able to lift self-injurers' inclination to do bad things to themselves, she thinks, by helping them change what are often deeply engrained negative self-views.

In a 2014 paper in Clinical Psychological Science, Hooley and then-graduate student Sarah A. St. Germain report on the results of a five-minute intervention they developed that seeks to change beliefs about self-worth, but in ways that are believable, grounded in reality and relatively subtle.

«You can't do this by simply telling people who self-injure that they should think more positively about themselves,» she comments.

The team asked people with NSSI and controls to choose which positive characteristics on a list best described themselves, and then to elaborate on some of those characteristics in detail using examples.

Before and after the intervention, the researchers tested people's pain endurance by recording how long they kept their fingers clamped in a pressure device.

(To control for noncognitive effects of good mood, the researchers also included a «happy music» condition with NSSI and healthy controls.)

After the intervention, self-injurers in the cognitive condition kept their fingers in the device for only about half the time they did initially. And the more their sense of self-worth increased, the less willing they were to stay in the painful situation. Meanwhile, the pain endurance of those in all other conditions remained the same. She has not yet looked at effect duration.

«The natural and adaptive response is to say, ‘I'm done with this.' But people who engage in self-injury don't necessarily see pain as something to escape from,» Hooley explains. Instead, experiencing pain validates their sense of being a bad or damaged person.

Increasing their sense of self-worth may undermine this propensity, she adds.

«The more valuable that people feel, the less willing they are to endure a bad situation,» she says. «Conversely, the worse people feel about themselves, the more inclined they will be to try [painful] methods of mood regulation that most other people would not even consider.

» Franklin, meanwhile, is using his findings to test a behavioral intervention using novel counter-conditioning techniques. The intervention targets self-injurers' propensity to pair pain images with relief, and to harbor negative associations to self-related words.

The study is under review, but preliminary evidence suggests that changing people's feelings about self-related words and NSSI-related images can be effective treatments, Franklin says.

Studies also show that associating pain with relief and negative thoughts with self-related words are good predictors of future self-injury, suggesting such tasks could be used as early screening tools for NSSI, report Franklin and colleagues in a 2014 article in the Journal of Abnormal Psychology.

These efforts are a step toward effectively treating people who self-injure, and Hooley and Franklin hope that psychologists who create and study interventions will add their own insights to the mix.

«We hope that our research is improving our knowledge about how self-injury works and providing novel treatment targets,» Franklin says. «Our goal is for researchers and clinicians to use their creativity to attack these targets in new ways.»


What is self-harm?

An Overview of Self-Injury and Cutting

If you want professional help to manage and recover from self-harm you can make an appointment with your GP. You may find it difficult to ask for help. GP’s are trained to deal with these conversations, and are used to talking about mental health with their patients.

Be honest about why you self-harm. People self-harm for different reasons. This will help professionals to find the right support for you.

Don’t give up if the first treatment option you try doesn’t work. There are different treatment options, so other treatments might be better for you.

The National Institute for Care and Excellence (NICE) produces best practice recommendations for health care providers to follow. The NHS don’t have to follow them, but there should be good reason if they don’t.

The two main ways recommended by NICE to manage self-harm are:

  • Short term management of self-harm, and
  • Long term management of self-harm.

You can access the NICE guidelines by clicking on the following links:

Short term management of self-harm

Your GP can support you in the short-term management of self-harm. They will help you, regardless of whether you have a mental illness. Your GP will listen and discuss with you the best treatment options for you.

What treatment should I be offered?
Your GP may talk through with you ways to manage your self-harm, such as by making lifestyle changes. They may also suggest you join a support group. They can also give you advice and treatment for minor injuries. Your GP might ask you to come back for another appointment to see how you’re doing.

Medication shouldn’t be offered to you to reduce your self-harm. But medication may be offered to you to help with symptoms of other mental health conditions. Doctors will think about risk of overdose when prescribing medication.

Harm Reduction
If you can’t stop self-harming, your GP may talk to you about developing harm reduction techniques, such as:

  • developing new strategies that are different to self-harm, and
  • discussing less harmful methods of self-harm.

There is no safe way to self-poison.

Referral to specialist mental health team
Your GP may think about referring you to a specialist mental health team if:

  • things that the GP has tried doesn’t work for you,
  • your levels of distress are getting worse or are high all the time,
  • you’re experiencing symptoms of a serious mental illness,
  • your self-harm risk is getting worse, or
  • you ask your GP to refer you to one.

Your GP should still monitor your physical health.

Mental health services may become responsible for your mental health treatment and care. They may put you under the ‘Care Programme Approach’ (CPA).

Long-term management of self-harm

If you need long-term management for your self-harm, your GP may offer you an assessment with your local community mental health team (CMHT). This assessment will be done to help you receive specialist support to reduce or stop your self-harm. If the CMHT can offer you help, you may be put under the Care Programme Approach (CPA).

What is the Care Programme Approach (CPA)?
If you’re under the care of specialist mental health service and have ‘complex needs’ you may be put under CPA.

Someone who self-harms a lot might have complex needs. If you’re under CPA you will have a care plan. Your care plan explains what support you need to manage and recover from your self-harm.

This should contain information such as:

  • how to stop your self-harm from getting worse,
  • how to reduce or stop harm caused by your-self harm,
  • how to lessen risky behaviours,
  • how to improve your ability to function, and
  • how to improve your quality of life.

Your care plan should also:

  • identify goals that you would to achieve in life, such as employment goals,
  • identify team members and what they should be doing for you,
  • include a risk management plan,
  • identify short term goals linked to your-self harm, and
  • be shared with your GP.

You should have a say about what is written into your care plan. Your family or carers should also be involved if you agree. Your care plan should be reviewed every year, these meetings are usually called ‘CPA meetings’.

What is a risk management plan?
Risk management should be part of your care plan. It should look at:

  • current risk,
  • long term risk,
  • things that increase your risk of self-harm, and
  • a crisis plan.

A crisis plan gives you steps to take in a crisis such as a number to call or distraction techniques to try. Your crisis plan is tailored to your needs, and what will work best for you if you’re in a crisis. The aim of a crisis plan is to think about what support you need when you are in crisis.

What treatment should I be offered?
Your mental health team should think about giving you 3 – 12 sessions of talking therapy to help you to stop self-harming. These sessions may start by your therapist helping you to find different ways of coping with painful emotions.

Your therapist should work with you to help you find the reasons why you self-harm. Your therapy should be tailored to your needs. There are many different types of therapy. You may be offered:

  • cognitive behavioural therapy,
  • psychodynamic therapy, or
  • problem solving therapy.

Your therapist should help you understand the reasons why you self-harm.

Medication shouldn’t be offered to you to reduce your self-harm. But medication may be offered to you to help with symptoms of other mental health conditions. Doctors will think about risk of overdose when prescribing medication.

You can find more information about ‘Talking therapies’ by clicking here.

Harm Reduction
If you can’t stop self-harming in the short term, you can talk with medical professionals about harm reduction, such as:

  • developing new strategies that are different to self-harm, and
  • discussing less harmful methods of self-harm.

There is no safe way to self-poison.

Ending care with the specialist mental health team When your treatment and care is due to end professionals should:

  • tell you what is ly to happen when your care ends
  • tell you ahead of time so that you can get used to the change
  • give you extra support if you need it,
  • make sure you have a clear crisis plan in place,
  • share your care plan with any other professionals who are taking over your care,
  • give you a copy of your plan and what has been agreed, and
  • give your family or carer a copy of the plan if you agree

You can find more information:

  • Talking Therapies by clicking here.
  • Care Programme Approach by clicking here.
  • Medication – choice and managing problems by clicking here.

What if I am not happy with my treatment?

If you aren’t happy with your treatment you can:

  • talk to your doctor about your treatment options,
  • ask for a second opinion,
  • get an advocate to help you speak to your doctor,
  • contact Patient Advice and Liaison Service (PALS), and see whether they can help, or
  • make a complaint.

There is more information about these options below.

Treatment options

You should first speak to your doctor about your treatment. Explain why you aren’t happy with it, giving specific reasons. You could ask what other treatments you could try.

Tell your doctor if there is a type of treatment that you would to try. Doctors should listen to your preference. If you’re not given this treatment, ask your doctor to explain why they think it’s not suitable for you.

Second opinion

A second opinion means that you would a different doctor to give their opinion about what treatment you should have. You can also ask for a second opinion if you disagree with your diagnosis.

You don’t have a right to a second opinion. But your doctor should listen to your reason for wanting a second opinion.


Advocates help you to deal with and overcome issues that you have. They are independent from the NHS and free to use.

They can be useful if you find it difficult to get your views heard. There are 3 types of advocates that might be able to help if you are unhappy about your treatment.

  • NHS complaints advocates can help if you want to make a complaint to the NHS. These are available in all areas.
  • Community or mental health advocates can support you to get a health professional to listen to your concerns. These are available in some areas only.
  • Independent Mental Health Advocates can help and advise you if you’re detained under the Mental Health Act.

You can find more information about ‘Advocacy’ by clicking here.

The Patient Advice and Liaison Service (PALS)

PALS is part of the NHS. They give information and support to patients and can help you to resolve issues.

You can find your local PALS through this website link:


If you’re not happy about your treatment or support, you can make a complaint. This is where your concerns are investigated in more detail.

You can ask an NHS Complaints Advocate to help you with your complaint. They are free to use and don’t work for the NHS.

You can find out more about:

  • Second opinions by clicking here.
  • Advocacy by clicking here.
  • Complaints about the NHS or social services by clicking here.


Cutting and Self-Harm —

An Overview of Self-Injury and Cutting

Self-harm can be a way of dealing with deep distress and emotional pain. It may help you express feelings you can’t put into words, distract you from your life, or release emotional pain. Afterwards, you probably feel better—at least for a little while. But then the painful feelings return, and you feel the urge to hurt yourself again.

Self-harm includes anything you do to intentionally injure yourself. Some of the more common ways include:

  • Cutting or severely scratching your skin
  • Burning or scalding yourself
  • Hitting yourself or banging your head
  • Punching things or throwing your body against walls and hard objects
  • Sticking objects into your skin
  • Intentionally preventing wounds from healing
  • Swallowing poisonous substances or inappropriate objects

Self-harm can also include less obvious ways of hurting yourself or putting yourself in danger, such as driving recklessly, binge drinking, taking too many drugs, or having unsafe sex.

Why people self-harm

Injuring yourself is often the only way you know how to:

  • Cope with feelings sadness, self-loathing, emptiness, guilt, and rage
  • Express feelings you can’t put into words or release the pain and tension you feel inside
  • Feel in control, relieve guilt, or punish yourself
  • Distract yourself from overwhelming emotions or difficult life circumstances
  • Make you feel alive, or simply feel something, instead of feeling numb

Whatever the reasons for self-harming, it’s important to know that there is help available if you want to stop. You can learn other ways to cope with everything that’s going on inside without having to hurt yourself.

“It puts a punctuation mark on what I’m feeling on the inside!”

“It’s a way to have control over my body because I can’t control anything else in my life.”

“I usually feel I have a black hole in the pit of my stomach, at least if I feel pain it’s better than feeling nothing.”

“I feel relieved and less anxious after I cut. The emotional pain slowly slips away into the physical pain.”

Consequences of cutting and self-harm

The relief that comes from cutting or self-harming is only temporary and creates far more problems than it solves.

Relief from cutting or self-harm is short lived, and is quickly followed by other feelings shame and guilt. Meanwhile, it keeps you from learning more effective strategies for feeling better.

Keeping the secret of self-harm is difficult and lonely. Maybe you feel ashamed or maybe you just think that no one would understand. But hiding who you are and what you feel is a heavy burden. Ultimately, the secrecy and guilt affects your relationships with friends and family members and how you feel about yourself.

You can hurt yourself badly, even if you don’t mean to. It’s easy to end up with an infected wound or misjudge the depth of a cut, especially if you’re also using drugs or alcohol.

You’re at risk for bigger problems down the line. If you don’t learn other ways to deal with emotional pain, you increase your risk of major depression, drug and alcohol addiction, and suicide.

Self-harm can become addictive. It may start off as an impulse or something you do to feel more in control, but soon it feels the cutting or self-harming is controlling you. It often turns into a compulsive behavior that seems impossible to stop.

The bottom line is that cutting and self-harm won’t help you with the issues that made you want to hurt yourself in the first place. No matter how lonely, worthless, or trapped you may be feeling right now, there are many other, more effective ways to overcome the underlying issues that drive your self-harm.

How to stop cutting and self-harm tip 1: Confide in someone

If you’re ready to get help for cutting or self-harm, the first step is to confide in another person. It can be scary to talk about the very thing you have worked so hard to hide, but it can also be a huge relief to finally let go of your secret and share what you’re going through.

Deciding whom you can trust with such personal information can be difficult. Choose someone who isn’t going to gossip or try to take control of your recovery. Ask yourself who in your life makes you feel accepted and supported.

It could be a friend, teacher, religious leader, counselor, or relative. But you don’t necessarily have to choose someone you are close to.

Sometimes it’s easier to start by talking to someone you respect—such as a teacher, religious leader, or counselor—who has a little more distance from the situation and won’t find it as difficult to be objective.

When talking about cutting or self-harming:

Focus on your feelings. Instead of sharing detailed accounts of your self-harm behavior focus on the feelings or situations that lead to it.

This can help the person you’re confiding in better understand where you’re coming from. It also helps to let the person know why you’re telling them.

Do you want help or advice from them? Do you simply want another person to know so you can let go of the secret?

Communicate in whatever way you feel most comfortable.

If you’re too nervous to talk in person, consider starting off the conversation with an email, text, or letter (although it’s important to eventually follow-up with a face-to-face conversation).

Don’t feel pressured into sharing things you’re not ready to talk about. You don’t have to show the person your injuries or answer any questions you don’t feel comfortable answering.

Give the person time to process what you tell them. As difficult as it is for you to open up, it may also be difficult for the person you tell-especially if it’s a close friend or family member.

Sometimes, you may not the way the person reacts. Try to remember that reactions such as shock, anger, and fear come concern for you. It may help to print out this article for the people you choose to tell.

The better they understand cutting and self-harm, the better able they’ll be to support you.

Talking about self-harm can be very stressful and bring up a lot of emotions. Don’t be discouraged if the situation feels worse for a short time right after sharing your secret. It’s uncomfortable to confront and change long-standing habits. But once you get past these initial challenges, you’ll start to feel better.

If you’re not sure where to turn, call the S.A.F.E. Alternatives information line in the U.S. at 1-800-366-8288 for referrals and support for cutting and self-harm. For helplines in other countries, see “Get more help” below.

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