Approximately two million Americans engage in some form of self-injury (Strong xv; Walters). Defined as an intentional behavior involving damaging or destroying a body part or parts through cutting, scratching, burning, biting, or hitting to produce physical injury regardless of intent to an individual by the individual without the purpose of death, self-injury is also referred to as deliberate self-harm (DSH), parasuicide, self-abuse, self-harm, self-inflicted violence, self-injurious behavior (SIB), self-mutilation, and self-wounding (Strong x; Clarke and Whittaker 4; Zila and Kiselica 3). However, both self-mutilation and "cutters and burners" are offensive and annoying terms to self-injurers (Clarke and Whittaker 2). Though deliberate self-harm is strange and incomprehensible to non-self-injurers ("Emergency" 1), treatment for self-mutilation should not be forced upon practicing self-injurers.

Self-injurious behaviors are broken down into three broad categories. Major self-mutilation results from psychotic illness, severe intoxication, or religious practices and includes extreme but generally uncommon forms of self-injury such as castration, limb amputation, or eye removal. Stereotypic self-injury occurs along with mental retardation, autism, Tourette's syndrome, and other organic diseases as repetitive actions such as head banging, biting, skin scratching, and hair pulling (Clarke and Whittaker 1; Strong 26-27).

Moderate or superficial self-injury is the least understood by both professionals and individuals who do not self-mutilate (Clark and Whittaker 2; Strong 27). Current misunderstandings include a belief that self-injurers, especially teenagers, use deliberate self-harm to cope with seemingly unsolvable problems such as poor body image. Instead, self-injury is a highly effective physical act in response to extreme emotional anxiety for individuals who never learned or had the chance to learn other effective coping mechanisms (Clarke and Whittaker 3; Galley 1; Martinson "Myths").

Moderate self-mutilation most frequently involves cutting of arms, wrists, and forearms with knives, razorblades, needles, safety pins, and fingernails (Clarke and Whittaker 2; Zila and Kiselica 2). Burning is also common. Instruments used include lighters, matches, cigarettes, or heated metal objects such as safety pins. While the arms are the most common harmed body part, injury appears on the face, genitals, thighs, legs, abdomen, and breasts as well. Biting or hitting body parts with other objects or other body parts and interfering with wound healing also classify as self-injurious behaviors with acts limited only to the imagination of the self-injurer (Zila and Kiselica 2).

Another major misunderstanding associated with deliberate self-harm is a false correlation between self-injury and failed suicide attempts, which are two entirely distinct acts (Clarke and Whittaker 4, 6; Strong 18; Zila and Kiselica 3). While suicide is eighteen percent more probable among self-injurers than the rest of the American population, self-injurers distinguish deliberate self-harm from suicide as an attempt to ease emotional tension rather than end life ("Emergency" 1; Zila and Kiselica 3; Crowe and Bunclark 1). As one practicing self-injurer affirms, "The objective wasn't to make myself bleed to death, just to let go of the ugly feelings holding me hostage - feelings that would leave at the sight of blood." (Zila and Kiselica 3)

However, though deliberate self-harm is not practiced with suicidal intent, accident death can result due to unintended excessive self-injury. Since life-threatening episodes are nearly impossible to predict, easily concluded is administering treatment to all self-injurers to maintain their personal safety, regardless of severity (Crowe and Bunclark 1-2). While no single treatment helps every individual, every treatment works for someone. Medications like antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) often reduce self-injurious behaviors (Pies). Outpatient therapy is recommended along with medication. But, if self-injury practices interfere with everyday functioning, partial or inpatient hospitalization is suggested, and restraint may be necessary for seriously life-threatening cases (Lader; Crowe and Bunclark 2). Inpatient units with a typical six-month admission have been established for self-injurious behavior (Crowe and Bunclark 3-4). Many other support services are also available for deliberate self-harm ("Emergency" 1).

Nevertheless, self-injury is anything but a suicide attempt (Clarke and Whittaker 6; Strong 18; Zila and Kiselica 3). Death due to deliberate self-harm occurs by unfortunate accident much like other preventable mishaps such as tripping down a flight of stairs or food poisoning, which sometimes result in bereavement. Individuals with previous self-injury records seeking medical care for self-inflicted wounds should be treated similarly to patients with non-self-inflicted wounds so long as suicidal intent is denied (Martinson "Myths"). As such, self-injurers should not be subjected to unwanted psychological evaluations because their injuries are self-inflicted (Martinson "Rights").

Additionally, all patients have rights in regard to medical care ("Emergency" 1). Providing that human life is not in immediate danger, patients are allowed to participate in decisions about treatment including declining medical attention (Martinson "Rights"). When self-injurers believe medical care for self-inflicted wounds will lead to unsolicited psychological treatment, medical care is unlikely to be sought leaving deliberate self-harmers at a higher risk for infection and other complications (Martinson "Myths").

Patients also have a right to body privacy. Strip-searching self-injurers for further wounds is likely to lead to embarrassment, especially for the physically or sexually abused. Individuals forced to reveal their injuries usually find better ways to conceal cuts, bruises, and scars, sometimes increase self-injurious behaviors to deal with emotions of humiliation, and possibly cease to seek medical attention in the future. Since choosing between coping mechanisms is also a patient right, self-injurers cannot be forced to decide between self-injury and medical care (Martinson "Rights").

Furthermore, patients cannot be denied medical care regardless of the nature of their wounds, self-inflicted or not. Treatment for deliberate self-harm is complicated in both psychological and emergency, where most self-injurers seek medical attention, settings (Crowe and Bunclark 1-2; McAllister, Creedy, Moyle, and Farrugia 3; "Emergency" 1). Due to the self-inflicted quality of their injuries, self-injurers are often not considered deserving of treatment by medical staff (McAllister, Creedy, Moyle, and Farrugia 2). Doctors and nurses feel and regularly express fear, frustration, anger, and lack of empathy toward patients with self-inflicted injuries (Zila and Kiselica 7; McAllister, Creedy, Moyle, and Farrugia 2). However, medical personnel should not base treatment decisions on their own personal views of self-mutilation (Martinson "Myths").

Still, many emergency staff members do have the formal training needed to deal with deliberate self-harm even with the frequency of self-injury and sometimes leave patients waiting for care, which can be further traumatizing ("Emergency" 1; McAllister, Creedy, Moyle, and Farrugia 2). As Dr. Armando Fifatza, professor of psychiatry at the University of Missouri told Tom Jarriel of 20/20 on ABC, "…there are many therapists who, if they encounter these individuals, might not really know what to do." Though, with appropriate care, many self-injurers are able to quit harming their own bodies, suggesting a need to force individuals into treatment, improper care can lead to suicide (Pies; "Emergency" 1).

Necessary for successful treatment is effective communication between the self-injurer and the medical professional but, if the ability to converse is shared unequally, leaving the patient feeling unheard, communication fails (Whotton 3). Although doctors and nurses believe forming a positive relationship with a self-harming patient is problematical, emotional support is needed as well as medical care for proper recovery (McAllister, Creedy, Moyle, and Farrugia 3; Clarke and Whittaker 7). Forcing treatment upon self-injurers eliminates a sense of emotional support.

In contrast, some family members and friends believe forcing treatment can convince self-injurers of their problem and motivate them into therapy (Penzel 40). While self-injurers seem to require protection measurements for themselves from themselves, restraints and other constrictions usually lead to conflict between the patient and the caregiver resulting in unsuccessful treatment and retaliation (Crowe and Bunclark 2; Zila and Kiselica 4). Hospitalized individuals often feel abandoned, rejected, or isolated, which often heightens their problem (Clarke and Whittaker 7).

For self-injurers who are unwilling or unready, unwanted treatment often leads to feelings of resentment towards friends and family members and avoidance of future treatment (Penzel 40). In relation to the patient right of participating in medical care decisions, self-harmers are more likely to seek both physical and psychological care when given choices rather than constraints ("Emergency" 1). Autonomy is crucial for treatment and recovery (Clarke and Whittaker 8).

On the contrary, while the onset of some self-injury arises in adults due to depression or additional problems, self-injurious behavior typically begins around age twelve or thirteen continues into adulthood with approximately four percent of American adolescents self-mutilating (Galley 1-2; Crowe and Bunclark 2). Females account for more self-injurious behavior than males though both sexes practice deliberate self-harm (Galley 2). Self-mutilation among teenagers is also practiced without suicidal intent.

Nonetheless, deliberate self-harm usually spreads among adolescents with a seemingly contagious quality, which is alarming for parents and schools (Galley 1). Medical treatment for self-mutilation includes five percent for youth, and psychological illnesses are found in one out of five of those children and teenagers (Whotton 1). Although patients have the right to participate in decisions concerning care, individuals under the age of eighteen cannot legally nor maturely make medical decisions. A family doctor or school mental health professional should be contacted for medical attention when caregivers or teachers seriously suspect deliberate self-harm in youth even if the child is resistant (Galley 3).

While self-injury is not practiced with suicidal intent, deliberate self-harm is often related to and considered a symptom of specific organic, personality, and psychological disorders, underlying illnesses that need medical treatment (Clarke and Whittaker 6). In fact, of all American psychiatric patients, an estimated three to five percent practice self-harm. Seventy-five percent of patients with borderline personality disorder, the most common personality disorder associated with deliberate self-harm, engage in self-mutilation for reasons such as anxiety relief, self-punishment, and manipulation (Kress 1; Clarke and Whittaker 5; Zila and Kiselica 4). Other personality disorders such as antisocial, dependent, and histrionic also include self-injuring tendencies (Kress 1-2). Dissociative, multiple personality, and posttraumatic stress disorders also commonly coexist with self-injury, especially with dissociative disorder where blood is used as an existential statement, physical proof of being alive (Kress 2; Clarke and Whittaker 5; Zila and Kiselica 4; Strong 56).

Though often linked with personality disorders, which should be medically treated, deliberate self-harm is also present as distinctly repetitive behavior in organic disorders like autism, mental retardation, Lesch-Nyhan syndrome, and Cornelia de Lange syndrome. Fifty-three percent of individuals with Tourette's syndrome exhibit self-injurious behavior as well (Kress 1-2).

Imbalanced neurotransmitter levels, frequently linked with depression, may also play a role in self-injurious behavior (Martinson "Myths"). Psychologist Nancy Meltzer Peterson observes numerous clinically depressed patients who self-injure (Galley 3; Zila and Kiselica 4). Of these individuals, many would prefer to quit cutting but are unsure of where or reluctant to seek help, indicating a need to offer or even force treatment, including medications that balance neurotransmitter levels (Galley 3).

Relating to depression, self-injurers often experience a loss of control of thoughts and emotions, especially negative feelings but even positive emotions associated with intimacy that can lead to an intense fear of abandonment (Strong 41, 55, 101). Often while attempting to create distance from other people and detach from emotions, emotional distress builds to an overwhelmingly and seemingly uncontrollable level resulting in feelings of powerlessness, vulnerability, and frustration. Unable to communicate appropriately, some self-harmers use physical pain to convey emotional pain (Strong 2; Zila and Kiselica 4). Other self-injurers use self-mutilation to manipulate and gain attention from partners, friends, and family members from whom they fear abandonment. Self-injurious behavior is also sometimes used for self-punishment of negative thoughts, emotions, or actions (Zila and Kiselica 4).

Deliberate self-harm also provides tension relief for and control of distressing emotions, one of the most supported explanations for self-injury (Zila and Kiselica 4). Physical changes in the body like wounds alter hormone and neurotransmitter levels, chemicals that control mood and pain relief as well as other functions, and consequently alter emotions. Self-mutilating episodes are typically less severe when individuals self-injure before anxiety becomes overwhelmingly distressing (Clarke and Whittaker 8). Regarding the right to choose which coping mechanisms are used, recommendations for psychological treatments by a professional after caring for wounds is appropriate. But, unwanted evaluations and hospitalizations should not occur, and patients should not be considered dangerous to themselves or others because their injuries are self-inflicted (Lader; Martinson "Myths"; Martinson " Rights").

However, with its repetitive and apparently addictive quality, self-injury is beginning to be thought of predominately as an impulse control disorder (Kress 2; Zila and Kiselica 3; Crowe and Bunclark 2; Clarke and Whittaker 5; Rackl 1). Self-injurious episodes usually occur more than once with medical professionals discovering an average of ninety-three scars from self-inflicted wounds per individual (Zila and Kiselica 3). Other impulse disorders include eating disorders like anorexia nervosa and bulimia, drug addiction, and alcohol abuse to which self-injury is often related, problems that should be treated (Clarke and Whittaker 5; Crowe and Bunclark 2). Moreover, many individuals with eating disorders also self-mutilate (Kress 2; Rackl 1; Zila and Kiselica 5). However, like other addictions that need treated, treatment for self-injury should not be forced.

Still, according to Tracy Alderman, a clinical psychologist working with the Psychiatric Emergency Response Team for the San Diego police, some form of abuse occurred in ninety percent of self-injurious patients, fifty percent happening during childhood (Galley 2; Rackl 1). Emotional, physical, and sexual abuse, all frequently coexisting with self-injury, benefit immensely from counseling (Galley 2; Zila and Kiselica 4-5). Thus, treating self-mutilation is also favorable and possibly should be required.

Nevertheless, not all self-injury is due to psychological or biological problems. Also widely supported is the explanation of ritualistic and symbolic motives exuding religious nuances and symbolism (Zila and Kiselica 4). Cave drawings from more than twenty thousand years ago portray religious customs that include finger amputations indicating self-injury has been culturally important throughout human history (Kress 5). Modern Christian religious self-injury results from Bible influences, identification with Jesus Christ and his crucifixion, sinfulness, demonic forces, and heavenly commands (Zila and Kiselica 4). According to the definition, self-injury is self-injury regardless of intent demonstrating a need to provide or even force medical treatment upon religious self-harmers (Clarke and Whittaker 4). However, spiritual enlightenment through ritualistic self-injurious behavior obviously does not warrant psychological treatment (Martinson "Myths").

For further example, since some subcultures practice self-mutilation, self-injury has become tolerated, though not accepted, in modern American society (Kress 5; Clarke and Whittaker 3). Both facial and body piercing has increased since the punk movement of the 1970's, which used mainly safety pins as well as other metal pieces through the ears, lips, eyebrows, nose, bellybutton, and so forth (Clarke and Whittaker 3). Piercing, and, likewise, tattooing, offer creative expression, a sense of control, and a feeling of belonging and are considered acceptable forms of self-injury (Clarke and Whittaker 2-3; Martinson "Myths").

Another form of self-injury without a psychological or biological cause is for sexual pleasure (Zila and Kiselica 4; Martinson "Myths"). As an intricate part of sadomasochism, self-mutilation as a part of sexual gratification should not be considered dangerous or need treatment (Martinson "Myths"). Motives behind deliberate self-harm should be assessed before even considering forced treatment.

Self-mutilation is dismaying for non-self-injurers especially since many practicing individuals appear intelligent, creative, articulate, and balanced (Strong 18; Crowe and Bunclark 2). If American society offers clean needles to illegal drug users, then offering clean blades and first-aid kits to self-injurers seems logical (Clarke and Whittaker 8). Treatment for self-injurious behavior is complicated due to motive, and, while no treatment works for every individual, every treatment works for some individual (Crowe and Bunclark 2; Pies). Restraints and isolation are ineffective and should therefore not be used in caring for self-injurious behavior (Martinson "Rights"). As psychiatry does not hold all the answers for self-inflicted injury yet (Clarke and Whittaker 8), treatment for deliberate self-harm should not be forced upon practicing self-injurers.

Clarke, Liam and Margaret Whittaker. "Self-Mutilation: Culture, Contexts and Nursing Responses." Journal of Clinical Nursing. Mar. 1998. 1-14. Academic Search Elite. 4 Mar. 2004.

Crowe, Michael and Jane Bunclark. "Repeated Self-Injury and Its Management." International Review of Psychiatry. Feb. 2000. 1-9. Academic Search Elite. 4 Mar. 2004.

"Emergency Staff Need Self-Harm Training." Australian Nursing Journal. Oct. 2001. 1-2. Academic Search Elite. 4 Mar. 2004.

Galley, Michelle. "Student Self-Harm: Silent School Crisis." Education Week. 3 Dec. 2003. 1-6. Academic Search Elite. 4 Mar. 2004.

Jarriel, Tom, Hugh Downs, and Barbara Walters. "The Hurt Inside." Broadcast interview. 20/20. ABC. 9 Feb. 1998.

Kress, Victoria E. White. "Self-Injurious Behaviors: Assessment and Diagnosis." Journal of Counseling and Development. 1 Oct. 2003. 1-8. eLibrary. 5 Mar. 2004.

Lader, Wendy. "SAFE - Help Treat, Prevent & Stop Self-Injury, Self-Abuse & Cutting." 2002. S.A.F.E. Alternatives. 4 Mar. 2004. <http://www.selfinjury.com/sifacts.html>

Martinson, Deb. "Self-Injury: Beyond the Myths." 2001. American Self-Harm Information Clearinghouse. 4 Mar. 2004. <http://www.selfinjury.org/docs/factsht.html>

Martinson, Deb. "Self Injury Rights." 2002. Crimson Tears. 4 Mar. 2004. <http://crimsonwild.tripod.com/crimsontears/id16.html>

McAllister, Margaret, Debra Creedy, Wendy Moyle, and Charles Farrugia. "Nurses' Attitudes towards Clients who Self-Harm." Journal of Advanced Nursing. Dec. 2002. 1-14. Academic Search Elite. 4 Mar. 2004.

Penzel, Fred. Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well. Oxford: Oxford University Press, 2000.

Pies, Ronald. "When One Pain Replaces Another." WebMD. 4 Mar. 2004. <http://my.webmd.com/content/article/41/1674_50289.htm?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348>

Rackl, Lorilyn. "Cutting Through Pain Suburban Hospitals Aim to Help Those Who Deliberately Hurt Themselves." Chicago Daily Herald. 8 Mar. 2004. 1-4. eLibrary. 8 April. 2004.

Strong, Marilee. A Bright Red Scream: Self-Mutilation and the Language of Pain. New York: Penguin Group, 1998.

Whotton, Elaine. "What to Do When an Adolescent Self Harms." Emergency Nurse. Sep. 2002. 1-8. Academic Search Elite. 4 Mar. 2004.

Zila, Laurie MacAniff and Mark S. Kiselica. "Understanding and Counseling Self-Mutilation in Female Adolescents and Young Adults." Journal of Counseling & Development. Winter. 2001. 1-12. Academic Search Elite. 4 Mar. 2004.