Differentiating Self-Injury and Suicide

June 30th, 2012


I’ve been reading an excellent book by Barent W. Walsh called Treating Self-Injury: A Practical Guide. Walsh draws important distinctions between self-injury and suicide, which is useful for both clients and therapists to understand. He deconstructs the stigma and misunderstanding that self-injuring people go through and helps clinicians develop the most relevant ways to think about and help their clients.

Walsh defines self-injury this way: “intentional, self-effected, low-lethality bodily harm of a socially unacceptable nature, performed to reduce psychological distress.” While body modification occurs in cultures throughout the world, the acts of self-injury we are talking about here are not endorsed by the prevailing culture. Walsh says that “among teens there may be considerable social reinforcement for the behavior … however, there are no organized, culturally endorsed rituals that surround it.”

Self-injury tends to be effective in terms of modifying and reducing psychological discomfort. Edwin Shneidman, Ph.D., the founder of the American Association of Suicidology, noted the “unendurable, persistent pain” that drives a suicidal crisis. A suicidal person experiences intolerable psychic pain and wants to find a lasting solution. In contrast, a self-injuring person experiences intense and uncomfortable pain too, but it is temporary — the self-injury itself offers a way to interrupt and reduce the discomfort.

The intent is also different between the two. As Shneidman wrote in Definition of Suicide, the intent of a suicidal person is to “terminate consciousness.” In a self-injuring person, the intent is not to terminate consciousness, but to modify it. Walsh writes, “The overwhelming majority of self-injurers report that they harm themselves in order to relieve painful feelings.” These painful feelings may involve too much emotion (anger, shame, anxiety, sadness) or too little emotion (dissociation, “dead-like” or “zombie-like” experiences).

Walsh identifies a number of other areas of difference between self-injury and suicidal attempts and advocates a thorough assessment so that therapists can better understand the person they are working with and take appropriate therapeutic action. These include:

• Level of Physical Damage and Potential Lethality — suicide methods vs. self-injury methods.

• Frequency of the Behavior — self-injury usually occurs at much higher rates than suicide attempts.

• Multiple methods — self-injury usually involves more than one method over time.

• Constriction of Cognition — suicide viewed as the only way out vs. the perception of options.

• Helplessness and Hopelessness — when these feelings are central vs. some optimism and sense of control that characterizes self-injury.

• Psychological Aftermath of Self-Harm Incident — no immediate improvement after suicide attempt vs. successful “alteration in consciousness” after self-injury.

• The Core Problem — depression and rage over inescapable, unendurable pain vs. body alienation or a combination of intense stress, inadequate self-soothing skills and peer influence.

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