Why Self-Injury Can Be Hard to Quit

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Self-injury remains a stigmatized topic, even amongst some mental health professionals (e.g., Andersson, 2024). It can be viewed as “manipulative” or simply attention-seeking (Tien Shan, 2024). It can also be seen as repulsive, or just plain vexing to family members or helping professionals not used to encountering it. Chances are, like most stigmatized occurrences, it is the lack of understanding that fuels stereotyping and negative reactions (APA, 2024).

It is not without consequence. People who self-injure and have encountered finger-wagging, accusations of manipulation, or some other form of revolt are less likely to report their self-injuring tendencies. On one end of the consequences, they do not discover more constructive means of managing emotional turmoil, accruing shame over their constantly defaced body parts, yielding more emotional turmoil and more proneness to self-injury. On the other end, while nonsuicidal self-injury (NSSI) is not about death, it is possible someone may go too far.

The roles of self-injury

Anyone who has spent much time working with those who self-injure probably realizes it is no spontaneous development to coax others to give them what they want. Nor is it some foreshadowing of suicide. Most people who self-injure, while some have a suicide attempt history, aren’t injuring in the hopes of demise. As counterintuitive as it may sound, NSSI might thought of as an approach to self-preservation or communication.

Some people self-injure as a last resort. For example, I’ve encountered people who are so depressed they say they’re numb, and self-injury makes them feel something. One man told me when he saw his blood run, it reminded him he was alive. Others who dissociate, such as having out-of-body experiences, flashbacks, or derealized states might injure to ground themselves. Still others, such as those with borderline personality disorder (BPD) might self-injure as a form of self-flagellation. Those with BPD also experience inordinately strong anger and anxiety at times and engage in NSSI to distract from the internal emotional beehive that’s been kicked. Physical pain tends to trump emotional in the moment.

Why self-injury is hard to kick

It's been my experience that people who self-injure often don’t know why they do it, except that “it works,” even if afterward there is shame. The impulse for even ephemeral relief from emotions or dissociation can be irresistible. Consider the person who, after a hard day, runs to make a stiff drink, or a smoker who, upon encountering some stressor, runs outside for a cigarette. If something “works,” it can easily become habit-forming. Sticking with the spirit of habits that “work” because of something chemical that creates a desired effect, it is interesting to learn that NSSI may well be in this category and more complex than distraction or self-punishment.

There is evidence that NSSI could have a component of chemical addiction. Researcher Judith Worley (2020) noted: “An addictive component to self-injury has been identified related to an increase in dopamine levels from the self-injury, which then disrupts normal dopamine production similar to substance use disorders.” Readers interested in further reading about this are invited to review Blasco-Fontecilla et al. (2016). Another article by Gill et al. (2023) gives a synopsis of the endogenous opioid system (EOS) role in NSSI and provides an illustrative case study about a young woman who discovered she was burning herself to get high.

Provided this information, people who regularly engage in NSSI could well begin as a passing distraction, like someone occasionally getting high under stress, only to find they increasingly desire the substance regardless of a present stressor. If neurochemistry is a key player in sustaining the behavior, this could explain why it is such a difficult activity to give up for many.

New directions for NSSI treatment

With this addictive component in mind, one can’t help but wonder if understanding this vexing behavior as such would have an effect on the perception of it as manipulative and grotesque to a more empathic view conducive to constructive conversations by helping professionals and family members. Such an alteration could encourage sufferers to come forward for assistance and avoid the downward spiral of shame about NSSI that only serves to perpetuate it.

When they do come forward, while there are psychotherapeutic interventions that can be successful in reducing/remitting NSSI, one wonders if a change to, or at least augmentation with, an addiction model of treatment could yield more promising results, especially in treatment-refractory cases. The respected NSSI-as-addiction researchers Blasco-Fontecilla et al. (2016) have suggested it could well be promising, but, unfortunately, no studies detailing trials of an addiction model of treatment of NSSI seem to be available yet.

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Constructive conversations about NSSI

In the meantime, remember that it is more productive to not be alarmist about NSSI and to respond thoughtfully; don’t react pedantically to confessions of self-injury.

While it would be erroneous to say self-injury is never about attention seeking, if the phenomenon is only conceptualized through such a reductionistic lens, there’s danger ahead. This is because it can become easy to get dismissive and simply view them as a “manipulator” and try to intervene with confrontation, letting them know you’re onto them and to quit it.

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Instead, it’s amazing what a self-injurer may tell you if you ask, “If those cuts (or burns, bruises, etc.) could talk, what would they tell me?” This opens a dialogue about the experience of self-injury and is much more productive than, “What did you do!?” We could quickly learn that the self-injury is communicating something about a deeper concern for which they injure and direction to appropriate intervention.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the 988 Suicide & Crisis Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual's provider or formal supervision if you're a practitioner or student.