Wednesday, 7 December 2022

Some thoughts on self-harm

 Content/trigger warning: Mental health, depression, anxiety, self-harm

Is there a meaningful distinction to be made between direct physical self-harm such as cutting yourself and more indirect self-harm such as deliberately not looking after yourself (for example, not eating) or putting yourself in danger? Self-harm in general is taboo, but the former is what normally comes to mind when we think of people self-harming. The latter, though, also captures a huge range of damaging behaviours that can have long-term health impacts to at least the same degree as inflicting (direct) physical harm on oneself. And both undeniably amount to self-harm - at the risk of stating the obvious, not eating, exercising excessively or deliberately having unprotected sex with someone you know has an STI poses a great risk of harm and it is something one does to oneself. 

But something feels different, aside from the obvious, between the two. Generally speaking, I think we are less concerned if someone skips breakfast than if someone were to confess they were pinching themselves to cause themselves pain. To be clear, I do not mean to equate the two and suggest that somehow they are equally bad, merely to give one example of each where the magnitude is not widely different. Perhaps we would become more concerned if the confession was that someone skipped breakfast because they felt they did not deserve breakfast or to punish themselves or because they are actively avoiding looking after themselves. Even then, though, I still do not think we view the act in the same way, something intuitively (maybe it is just me!) feels less concerning - though, I am not sure it is. Moreover, our concern is also less with the action per se and more with the motivation, which then demonstrates some deeper underlying issue. We are then concerned about that issue and maybe even concerned because it might lead to what we feel are ‘worse’ forms of self-harm. However, if someone says they pinch themselves, their underlying motivation is less important - it already triggers a response that something is wrong here. 

Maybe not looking after ourselves is all too common, there are, often, a plethora of genuine and understandable reasons that can explain such behaviour. The same is not true of directly physically harming yourself. After all, we would not want to characterise every instance of skipping a meal as ‘self-harm’ even if, in theory, every time you do skip a meal, it is harmful to yourself. But even if we know someone is going through a difficult time, we are probably less likely to intervene if someone tells us they routinely skip meals but alarm bells immediately ring if someone tells us they cut themselves, even if the injury seems or appears trivial. It feels bigger, scarier. 

I am not sure that is right. Aside from the obvious (not looking after yourself is, of course, harmful and should, of course, be concerning), I think it perhaps misses something from our analysis of why people self-harm. I think there’s an ignorance about why people, say, cut themselves and, more specifically, why people who do not but engage in other forms of self-harm have ‘chosen’ (I use ‘chosen’ incredibly loosely here given the multitude of competing factors at play that often leave people feeling they precisely have no choice) not to cut themselves, or similar. To put it bluntly, cutting yourself hurts - obviously. But that is not (always) the aim of self-harm. Moreover, I think there is a misconception that somehow people who self-harm do not feel pain or feel pain less and that is (at least part of) why they are able to hurt themselves. Of course, some people do hurt themselves precisely because they want to feel something, their life has made them numb and where the intent is intense physical pain, not eating might not seem sufficient. However, that is not all cases of self-harm. 

Rather, self-harm has all manner of underlying causes and reasons. Some of the individuals whose self-harm manifests itself in not looking after themselves have tried but failed to, for example, cut themselves because it hurt too much. Because they still feel pain even though they want to hurt themselves. So they find other ways of harming themselves that allows them to avoid that intense, immediate pain. An individual might feel the emotions they are feeling are not adequately expressed by hurting themselves directly. Self-harm is not always about feeling pain. It can be emotional distress that prevents you from eating, for example. Or about punishing yourself and not with pain but by denying yourself food. Or about taking control of something, anything in this life and you cannot cut yourself but you can avoid food. Or maybe you just cannot hide the injuries so you choose to self-harm in a more hidden way. Or maybe you’re scared of yourself, you’re scared that you’re able to cut yourself so you force yourself to stop because it scares you and you fill the void left with something else. 

I guess the point is that the underlying reasons that motivate some to cut themselves, will motivate others to respond completely differently. The underlying reasons, the emotional distress or deeply overwhelming situations will not necessarily differ - our concern, equally, should not just because there aren’t bruises or scars or other injuries.