2 contact hours Self-Injury Behavior: How Can Nurses HELP? 186 JCN / Volume 25, Number 4 She can see the GAPE of CRIMSON grow larger as it spills over the edges and runs down her hand. She can see the SCARLET DROPS grow larger as they gather at her fingertips and then detach and fall through space. But no sound comes from her lips. To an onlooker this would seem an EERILY QUIET moment, a moment engulfed in deathly silence. But the girl lying in the PUDDLE of BLOOD in the silent war hears the discordant noises . raging and roaring as they grate through her mind, PIERCING REMINDERS of what she’d rather FORGET. (Anonymous, 2001) mily* submitted this poem to DEFINING SELF-INJURY by eher high school creative writing Self-injury behavior (SIB) is a complex group of teacher.She began cutting her upper behaviors involving deliberate destruction or alteration Rhonda arms and thighs with a pocketknife of body tissue without conscious suicidal intent Lynn when she was 15 years old and had (Cerdorian, 2005; Favazza, 1996).The self-injury is hundreds of healed scars and several non-life threatening (Shaw,2002), done to alter a Goodman fresh cuts. In an effort to conceal her perceived intolerable mood state by inflicting physical Lesniak self-inflicted wounds, Emily wore black harm serious enough to cause pain and tissue baggy pants and long-sleeved black damage to the body (Levander, 2005, p. 3). Self-injury is used as a coping jackets. She dyed her hair black, which mechanism to help the individual deal with emotional pain or to break matched her fingernail polish and feelings of numbness by arousing sensation (LifeSigns Self Injury Guidance contrasted sharply with her pale skin. and Network Support, 2005, p. 5).The key components of SIB are listed Emily relayed that cutting provided in Table 1. temporary relief from emotional pain, Although McDonald (2006) referred to this phenomenon as self- anger,anxiety, and feelings of self-worth- mutilation, most authors use the term “self-injury” (i.e.,American Self- lessness. She cut when she felt dead Harm Information Clearinghouse, 2005;Van Sell,et al., 2005). Others inside.When she saw her blood, she was use the terms “self-harm” (Ayton, Rasool, & Cottrell, 2003; Harris, 2000), relieved to realize that she was still alive. “self-wounding” (Sharkey,2003), or “self-inflicted violence”(SIV) (Alderman, Emily stated,“It gave me a sense 1997). Because the term “self-mutilation” evokes grotesque images and that I was taking care of my problems, implies permanent damage or alteration to one’s body (Alderman, 1997), but I knew nothing was getting done. I settled for the quick fix; the problem 1 e would come again and eventually it l b Key Components of Self-Injury Behavior would get to the point where I cut a T myself again” (Lesniak, 2007b, p. 4). • A harmful act done to oneself (self-abuse) • A behavior performed on oneself by oneself I Rhonda Lynn Goodman Lesniak, MA (theology), MS, • An intentional act FNP-BC, is a PhD candidate • Typically performed alone (secretive behavior) at the Florida Atlantic University Christine E. Lynn College of • Includes some type of physical violence (self-injury, pain) Nursing. She is a nationally certified • Not performed with the intent of killing oneself school nurse. Rhonda works as a family nurse practitioner at The • Typically follows a ritualistic pattern (a particular instrument on the same bodily location Little Clinic in Lake Worth, Florida. She is a deacon in a specific environment at a certain time) and faith community nurse at First Presbyterian Church of Boca Raton, Florida. Sources: Alderman, 1998; Clark & Henslin, 2007; Sutton, 2005. *Name has been changed to protect privacy. JCN/October-December 2008 187 a Glance Although suicide can be thought as a form of identification for family @ Self-Injury Behavior (SIB) of as the most grievous form of self- or tribal units, whereas others use self- is inflicting deliberate physical injury,SIB is performed without induced scars as a sign of adulthood, a harm on oneself without suicidal suicidal intent. Indeed, SIB may symbol of beauty,or a rite of passage intent; ~1% of the U.S. population even be a way to prevent suicide (Kehrberg, 1997). and 12% of teens self-injure. because it relieves emotional distress Self-injury behavior first appeared @ SIB temporarily relieves (Cerdorian, 2005; Starr, 2004). in clinical literature in 1913 (Shaw, intolerable emotions, offers control, Certain alterations in appearance 2002). Historically,the significance may release endorphins, and provides (piercing, tattoos) might be consid- of blood as a method of payment for opportunity for self-nurturing after ered self injurious, but these are or forgiveness of wrongdoing (sin) wounding; but increases feelings of performed with the goal of is recorded extensively throughout enhancing the body and generally biblical and extrabiblical literature. shame and guilt. are done by another person.Ritual In the fifth century B.C., Herodotus @ Treatment must include mutilation performed as a rite of in his Book 6 of History described authentic caring and address physical, passage publicly acknowledged and a Spartan leader who cut himself mental, and spiritual healing. offering a sense of belonging and with a knife. Hippocrates in 300 pride (genital mutilation, branding, B.C. developed a theory that people it is particularly annoying to those who scarring, tattooing) is not SIB. could be rebalanced through blood- self-injure (Hoyle, 2003; Levander, 2005; Self-injury is not classified as a letting, blistering, vomiting, and so Sutton, 2005). In contrast, SIB usually disorder or syndrome in the Diagnostic forth to cleanse the body (Clark & is temporary and often unnoticeable and Statistical Manual of Mental Henslin, 2007). or hidden. Disorders (DSM-IV-TR) (American In Scripture, God commanded the What are typical self-injury behaviors? Psychological Association, 2000). Israelites not to cut their bodies ritually The most common are cutting and However, SIB has been classified as the pagan nations around them did burning or branding. Other behaviors into four types. It can be related to (Leviticus 19:28, 21:5; Deuteronomy include stabbing, needle sticking, punch- psychosis, in which hallucinations or 14:1-2).The prophets of Baal attempted, ing oneself, interference with wound delusions prompt a mentally ill person without success, to arouse and appease healing (reopening wounds), excessive to self-injure, to organic physiology from Baal with extensive cutting and blood- scratching (Kehrberg, 1997), hitting or autistic disorders, to developmental or letting (1 Kings 18). In the first century bruising, nail biting, pulling out hair physiologically induced disabilities (lip A.D., Mark recorded in his gospel the (trichotillomania), breaking bones, and biting, head banging to stimulate or story of a man who cut himself with drinking substances not intended for sooth), or to emotional factors. The stones night and day (Mark 5:1-5). human consumption (Alderman, 1997; latter is the most common, typical During the first century A.D., Murray,Warm, & Fox, 2005).The tools SIB (Alderman, 1997). Christian clergy and laity practiced most often used are razors, knives, self-flagellation. Early Church martyrs, lighters, broken glass, matches, sewing CULTURAL ORIGINS OF SIB such as the Desert Fathers, promoted needles, pencils (sharpened lead and Self-injury behavior has been penance through self-flagellation with erasers), and sandpaper. Cerdorian described as a culturally defined small leather whips (Favazza, 1996). In (2005) asserted that SIB often is inflicted phenomenon because different the 13th century, the religious orders repeatedly on the same part of the body. cultures have various definitions and renewed this practice, which spread Contradicting the notion that persons unique expressions of the behavior and continued into the next century, who self-injure are seeking attention, (Favazza, 1996; Kehrberg, 1997).The especially in response to the bubonic most self-injuring adolescents wear perspective of Western cultures is not plague because followers believed the clothing that covers their scars and favorable toward self-injury.However, plague called for penance (Favazza, wounds (Cerdorian, 2005; Hoyle, 2003; the perspective of other cultures 1996; Levenkron, 1998). Favazza reports Shannon, 2005). differs. Some cultures use self-injury that this continues today,“particularly 188 JCN / Volume 25, Number 4 heads, eating spiny cactus, and drinking boiling water. Suffering is a way of penance for these followers and, A Call for HELP according to their beliefs, perhaps even the path to salvation (Favazza, 1996). Some psychological experts have As a high school nurse, I taught classes on first aid and cardiopulmonary suggested that SIB might stem from resuscitation (CPR). Over a period of several weeks with one class, I noticed biblical writings (Ellis, 1988; Favazza, a girl who seemed to be asking for my attention. I would observe her 1996; Freud, 1927). In documented watching me or sitting near my chair. I felt drawn to speak with her, almost instances, isolated followers or peripheral as if I were being pulled in her direction. I recognized this as a call for sects have cut off an offensive body part nursing. I intentionally spoke about school events, class work, and so forth to to appease their consciences (Favazza, build trust. I was responding to the girl’s call for attention, yet I also was calling 1996; Strong, 1998). However, this type to her to trust me and making myself accessible in a nonthreatening manner. of self-injury reflects an interpretation One day the girl informed me that she had a friend who was cutting and of biblical texts (Mark 9:43-48) that asked how this friend could be helped. I sensed that the “friend” and my literally follows the letter of the word student were the same person.