There has been a growing awareness and concern about young people who self-harm or injure over the past ten years. While self-injury used to be considered to be pathognomonic of Borderline Personality Disorder, it is so common these days that it is more useful to think of it as way individuals have come to deal with emotional pain and stress. Studies have indicated that over 18 percent of people between the age of sixteen and twenty-four have engaged in self-harm behavior at least once over a one year period. This epidemic gives rise to two important questions: what is causing this increase in self-harm, and what can we do about it?
Self-harm can be related to an individual’s difficulty in emotional pain metabolism. Metabolism in this sense refers to the complex psychological and neurobiological systems that allow emotional pain and stress to feel manageable. One learns emotional pain metabolism and self-soothing from early childhood. The most important factor in one integrating these aspects into one’s basic psychological make-up is the emotional holding and nurturing that is provided to children. Heinz Kohut uses the term “transmuting internalizations” to describe the process of a child first experiencing emotional responsiveness, and then at an age appropriate time, being able to internalize, or gradually take over part of the need for this emotional holding. Without this occurring, the child may experience traumatic internalization in which the child will find some ways of coping with complex emotions, but in a way that does not lead to a solid sense of self, resulting in fragile emotional coping abilities. The ability to deal with one’s emotions within oneself does not negate the lifetime need for an emotionally supportive environment. Throughout life it is the combination of internalized emotional abilities and solid social support relationships that lead to emotional stability.
In an emotionally healthy society, there is an ascending hierarchy of emotional pain metabolism. With maturity and increased power, individuals and communities take on emotional responsibility for those more vulnerable. Thus, parents help children deal with their emotional lives, extended families help parents, and communities, including work places, provide emotional holding for families. In dysfunctional societies there is an inverse hierarchy of emotional pain metabolism. Governments and businesses dump stress on individuals, communities and extended family systems are fractured, and schools are unable to provide calm, nurturing atmospheres for students. In this type of system, parents are often stressed, and this stress gets transferred to children. Children are then left, not only with the task of dealing with their own emotional issues, but bearing the burden of the weight of stress passed down from parents and social structures.
In modern day society, not only are social structures weak and parents stressed, but children’s and adolescents’ relationships with nurturing mentoring figures may be weakened. Humans are social animals, with our brains having evolved to deal with complex social relationships. Modern communication technologies have increased the influence of peer groups, especially in adolescence, at the same time as other possible social affiliations have diminished. Adolescent peer groups usually cannot provide the quality of emotional pain metabolism support that adolescents require. One can postulate that it is the combination of fragile internalized emotional structures, along with inverse societal hierarchy of pain metabolism and the increased power of adolescent peer groups that is leading to the significant increase in self-injury in young people.
There are various forms of therapy that are used to treat emotional regulation dysfunction and self-injury. Dialectic Behaviour Therapy, Mentalization, Intersubjectivity Therapy, and Psychodynamic Psychotherapy, are all successful modes of treatment. These therapies all provide in their original forms a significant degree of emotional holding. All psychotherapy research indicates that the “therapeutic alliance”, which is a measure of emotional connection, is the main factor that is associated with successful outcomes in therapy. No technique isolated from a strong therapeutic alliance has ever been shown to have a strong significant correlation to outcome. In studies of very successful therapists, the so-called super-shrink research, it is these therapists ability to understand and connect with their patients that appears to be most important. However, modern psychiatric systems have repeatedly tried to extract simplistic techniques from complex therapeutic modalities and apply these in short-term models for problems like self-injury. A perfect example is this is the use of Dialectic Behaviour Therapy techniques. As developed and taught by Marsha Linehan, DBT provided a tremendous amount of emotional holding both for the patients and the therapists. If emotional holding is essential to the development of solid emotional pain metabolism, then it makes no sense to try to teach a technique to patients in the absence of the emotional holding. While doing this may show some modest results in research, one may actually be causing re-traumatization by leaving the patient alone to metabolize their emotional pain.
In order to properly address the serious issue of self-harm, we need to provide proper support communities that will be able to help individuals deal with stress and emotional pain. It is essential that schools, including universities provide a safe and emotionally nurturing environment. We need to strengthen children’s and adolescents’ relationships with warm, capable mentoring figures. Peer group relationships need to be balanced, with special attention given to stopping emotional bullying, as well as stopping over-sexualization and emphasis on appearance and competition. Treatment modalities need to be cohesive and allow for the development of proper therapeutic relationships with attention to relieving emotional pain and stress. The increase in self-injury is both concerning in itself, but also is a warning about the type of issues young people are dealing with in our society.