The pain inside

“She’s just doing it for attention.” This is a phrase I have often heard from people trying to understand why a patient, a friend or a loved-one has been deliberately hurting themselves. It can seem almost impossible to understand such behaviour for anyone who hasn’t personally experienced the urge to deliberately cut yourself, burn yourself or inflict harm in some other way. It goes against all our natural instincts of survival and self-protection. Unfortunately, though understandably, the assumption often ends up being that a person who does such a thing must be either attention-seeking or “crazy”. But, most often, neither is the case.

Most often, people who deliberately injure themselves do it secretly and go to considerable lengths to hide it. This directly contradicts the idea of such behaviour being a way of seeking attention and sympathy.

In the majority of cases, self-harm is not being done in response to hallucinated voices or delusional beliefs. Most people would be considered “of sound mind” at the times they engage in self harm.

There is no single explanation for why people might feel compelled to injure their own bodies. But there are a few common themes. Understanding these may help us to respond with compassion if we encounter someone struggling with a pattern of self-injury.

Of course, injuring oneself causes physical pain. People who deliberately injure themselves feel that pain – yet that pain is intentionally experienced in preference to something else – something that, for the person who is self-harming, is much worse than the physical pain. If the thought of incising your own flesh with a knife causes you to shudder, try to imagine what suffering a person has to be experiencing internally for such an act to seem like a better option.

Physical pain is being chosen in preference to emotional pain that seems inescapable, overwhelming and intolerable. To an outsider who might know something about the events that led up to this reaction, this often doesn’t make any sense. You could witness someone you care about burning himself after receiving poor marks on an exam – something that you may know would have caused you little concern. A health professional might observe a patient cut herself in reaction to being told she can’t leave the hospital today. From the outside, these reactions may appear to be attention-seeking because the outside observer is asessing them from their own frame of reference. In practice, we can perhaps better understand the person’s distress if we work from the outside in, not from the inside out. That is, we are probably in a better position to empathise with the physical pain caused by the self harm, and to then try to translate from that what their internal, emotional pain might feel like to them for such physical pain to inflicted in an attempt to mask that emotional pain.

It isn’t important what was the cause of a person’s emotional pain. No matter how trivial it’s origin may seem, what is important, in that moment, is that such intense pain is being felt – and the sufferer feels it is impossible to tolerate that pain any longer. If we start by trying to estimate a person’s emotional pain from the circumstances that seemed to trigger it, we underestimate and are then incapable of comprehending the self-injury that followed it.

This seems to be the most common theme I have encountered among those who injure themselves: The pain outside effectively masks the pain inside. The physical pain is more tolerable, and more easily understood, than the internal pain.

There are some other themes that also often emerge when a client explains to me reasons for self-injury. Usually there is a combination of multiple factors that come together:

  • The sight of blood can feel like a release of something “bad” inside
  • There are beliefs such as “I am a bad person; I deserve this” – an attempt to punish oneself
  • The physical pain and outward injury can feel like the only way of expressing or making sense of what is felt inside
  • Self injury may be accompanied by feelings of a rush or a sense of elation (probably caused by endorphins released when the body undergoes physical trauma)
  • The urge to inflict injury may itself seem overwhelming and inescapable – like an addictive urge

Treatment of self injury generally requires a combination of a broad range of strategies, and part of successful treatment means understanding that this behaviour is serving a purpose – it is providing a means of coping with overwhelming feelings. Because of this, stopping self injury necessitates having alternative strategies for coping.

If you know of someone who struggles with self injury, the first step is being able to set aside the difficulty of understanding why and to try to compassionanately empathise; to understand that although you may not be able to identify with how their pain has come about, you can comprehend that we humans sometimes feel internal pain, and that pain can sometimes be overwhelmingly hard to bear.

About Paul McQueen

Dr Paul McQueen is a Clinical Psychologist, holding a Doctorate in Clinical Psychology from the University of Melbourne. He has experience working in both adult and child mental health services in Queensland and Victoria. Dr McQueen is comitted to providing high quality, evidence-based interventions for a range of mental health conditions. He specialises in the treatment of Obsessive Compulsive Disorder, Borderline Personality Disorder and Depression.

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