Step 3: Manage Urges to Self-Harm

Urges are like cravings – the desire to do something. Some people experience strong urges to eat various foods, engage in sexual activities, or to do any of a number of different things. You can think of an urge as a state of desire that can fuel your behaviour. Generally speaking, you’re more likely to do something you feel a strong urge to do.

This brings us to self-harm. It makes a lot of sense that, if you have self-harmed many times in the past, you would get urges to self-harm in certain situations, or if you have gone for a long time without doing it. It can be the same thing with alcohol. If you drink a lot of alcohol regularly or have alcohol problems, and you enter a bar or are around others who are drinking, you’ll probably feel the urge to drink.

For some people, urges to engage in self-harm make it very difficult to avoid self-harming. Some people describe their urges to self-harm as a burning or itching sensation in the area in which they normally self-harm, a feeling of tension or agitation in their body, shakiness or irritability. Generally, people often say that the urges go away during or after self-harm, and in some cases, they stay away for a few hours, a few days, or even for longer.

The problem with urges is that, if you give in to them, you are likely to be stuck with more urges in the future. Urges are a lot like a child having a tantrum in a restaurant or grocery store when you have refused her or his request for dessert; they are your brain’s way of saying, “I want to self-harm; do it now!” What happens, however, if you give the child the dessert when she or he tantrums? Well, the child learns that the tantrum produces results (in psychology, we call this positive reinforcement – you do some kind of behaviour and then get something positive for doing it, and then you’re more likely to continue that behaviour in the future). With urges, if you give in to the urge and self-harm, then the urge/your brain essentially got what it wanted – self-harm – and is more likely to kick up a fuss in the future when you are either in a situation in which you normally self-harm or if you have gone for a while without self-harming. Therefore, if you want to move away from self-harm, it is important to learn how to manage and resist urges to self-harm.

Here are some suggestions for ways to cope with urges:

1. Become aware of your urges and the times, days, and situations in which they are most intense and difficult to manage. In order to do this, keep track of your urges each day and at various points in the day. Just write down how strong your urges were at certain times on a scale from 0 (no urges at all) to 5 (strongest urges possible). Then, look and see if you notice any patterns. For instance, some people we have seen have had their strongest urges around mid afternoon, or in the evening. Once they noticed this, they were more able to change their activities at those times of the day to either reduce their urges or reduce the likelihood of their acting on them.
2. Use distraction to cope with your urges. Particularly when you are first trying to quit or move away from self-harming, distraction can be a very useful way to make it easier to ride out urges. Do activities that get your mind temporarily off your urges or the emotional distress that you are feeling, do things to get your mind busy (e.g., crossword puzzles, reading, Sudoku), get out of your immediate environment and go somewhere stimulating, talk with other people, and so on. The basic idea is to do activities that grab your attention and take it away from your urges and your problems – at least temporarily.
3. Use physical exercise to deal with urges. Do some intense exercise, whether this includes vigorous walking, running jumping jacks, martial arts, cycling, pushups, situps, or other such activities. Many people find vigorous exercise to be a very effective way to manage and reduce urges as well as unpleasant emotions.
4. Notice and ride out your urges like waves on the ocean. This strategy is called “Urge Surfing” and was developed by Dr. Alan Marlatt (at the University of Washington) to help people with alcohol problems. The idea is to imagine that your urges are like waves on the ocean, and that you are surfing on those waves. When they become intense, the waves rise and crest, and when the urges weaken, the waves crash to the shore. Just watch your urges as they come and go, and do not act on them. One major benefit of this strategy is that it allows you to see that urges are temporary, that they come and go, and that you have the freedom to choose not to do what they are telling you to do.

Step 2: Figure out What Self-Harm is Doing For You

In Step 1, you worked out the pros and cons of self-harm and hopefully, found some cons you can latch onto to give yourself motivation to move away from this behaviour. One of the next steps is to figure out what self-harm does for you, or what you get out of it, so that you know what to focus on in your efforts to stop. For example, as we mentioned in previous blogs in April and May, people harm themselves for many different reasons. Common reasons include:

• To escape your emotions, feel better, get relief, release tension or “steam”
• To communicate something to someone, get support, or to get someone to stop treating you in a certain way
• To punish yourself
• To feel something, feel less numb, relieve dissociation, etc.
• Others – here, write other things that self-harm does for you that might not fall in the above categories.

Think about what you seem to get out of self-harm. How does it help you? What were your “pros” that you wrote down for Step 1. That’s a good place to start. Then, maybe look at the reasons above, and rate each one on a scale from 0 (not at all relevant) to 10 (extremely important) in terms of how important they are to you.

Once you have a clearer sense of how self-harm works for you, you can start working on ways to move away from self-harm. For example, if self-harm primarily helps you relieve or escape emotions, then you might focus your efforts on the learning of new or different ways to manage your emotions. If self-harm helps you communicate or get your needs met with other people, you might consider beefing up your interpersonal skills or trying other ways to get your message across or needs met. If self-harm is punishment, then you might decide instead to do the opposite of what your urges to punish yourself tell you to do – Instead, do something kind to yourself, or take care of yourself (we will talk more about the perils of self-punishment in a later blog).

Another step you can take right now is to think about what makes it difficult for you to stop self-harming. Here is a list of things that often make it hard for people to avoid self-harm. Go through these and rate them from 0 to 10 using the scale above. Then, you’ll have a better sense of the barriers or hurdles you need to get through in order to help yourself.

• Self-harm works so well to make me feel better that I’m afraid I won’t find anything else quite as good.
• Self-harm is more satisfying than other ways of coping.
• I have a hard time resisting urges to self-harm.
• I think about self-harm all the time.
• I love to self-harm.
• I look forward to it; it’s a vice that I have that nobody knows about.
• People don’t seem to listen/support me when I’m not doing something like self-harm.
• Others – below, write other things that make it hard for you to stop.

In the next blog, we will talk more specifically about how to manage self-harm urges.

We have noticed a few main patterns of self-harm among the people with whom we have worked. Some people self-harm a couple of times in their youth and then quickly give it up, others harm themselves only when certain types of overwhelming situations or stressors occur (such as a relationship break up or major conflict), and still others can get caught up in an addictive patterns of self-harm, where they hurt themselves repeatedly and have a hard time stopping. We don’t know why some people find it much easier than others to give up self-harm, but we do know that, whatever your pattern, there are effective ways to reduce and give up self-harm.

Step 1: Get Motivated

Perhaps the first step in stopping any behaviour that you want to stop is to get motivated. It can be very hard to give up self-harm, particularly if it works well for you as a coping strategy; thus, it is important for you to have some fuel or motivation behind your efforts to quit. One way to get that motivation is to think through the pros (positives or benefits) and cons (downsides) of self-harm.

1)    Write down a list of the pros of self-harm, including both short-term and long-term pros. For instance, you might write down “helps me release tension, makes me feel calm, makes my pain more tangible,” etc. Then, write down a list of the short- and long-term cons. Some of these might include scarring, problems in relationships, etc.

2)    The next step is to really get those cons of self-harm burned into your brain so that you can remember them when you most need them (i.e., when you feel the urge to harm yourself).

We have done some research on the reasons why people want to quit self-harming, and here are some of the things people have told us. You might also find that you have similar reasons and can borrow or steal these and use them in your efforts to help yourself.

• “Self-injury makes me feel like there’s something wrong with me.”
• “I feel ashamed.”
• “I don’t like the scars.”
• “I don’t want to hurt my friends, family, or other loved ones.”
• “I don’t want to have to worry about hiding the scars.”
• “I don’t want others to think I’m crazy or weird.”

In sum, although people of all walks of life may turn to self-harm to help them cope with difficulties, some factors increase the chances people will use self-harm. Basically, females, especially adolescents and young adults, are at greater risk for self-harm. This is particularly the case for people who have endured stressful situations, such as financial difficulties, or even severe stressors such as childhood trauma. The risk for self-harm is even greater for people who suffer from psychological difficulties, who struggle with problem solving or tolerating their emotions,  Finally, use of drugs or alcohol increase the chances that someone will engage in self-harm.

Alcohol and Substance Use May Increase the Risk for Self-harm

People who self-harm may be more likely to use or abuse drugs and alcohol (e.g., Taylor et al., 1999). In fact, about 25% of people who self-harm report substantial problems related to alcohol use.

Not only do people who self-harm tend to have a history of use or misuse of drugs and alcohol, but substances may also be related to self-harm in the moment. Almost half of people who go to the emergency room for self-harm consumed alcohol prior to the self-harm (Horrocks et al., 2003). This may be more likely to be the case for men than women (Hawton et al., 2003).

Certain Mental Health Difficulties place People at Greater Risk for Self-harm

Almost two-thirds of people who receive hospital treatment for self-harm are depressed (Haw et al., 2001). People with certain kinds of anxiety disorders may also be more likely to harm themselves (Meltzer et al., 2002). Other severe mental health difficulties, such as schizophrenia, are strongly related to self-harm as well. Nearly 80% of people who suffer from borderline personality disorder (some symptoms include difficulties managing emotions, relationship problems, identity disturbance, and feelings of emptiness) also struggle with self-harm.

People who self-harm often share some common characteristics. For example, many people who self-harm struggle with impulsivity and have difficulty with problem solving (Haw et al., 2001). Also, many people who self-harm have difficulty managing or tolerating negative emotions.

Life Stress is Linked with Greater Risk for Self-harm

Although self-harm is a problem for people of all walks of life, certain factors are linked with greater stress, and therefore may increase the chances of self-harm. For instance, people from low-income families, who are divorced, live alone, or who lack social support may be more at risk for self-harm (Meltzer et al., 2002).

Other stressful and traumatic life events may increase the chance that people use self-harm. For example, people who have suffered abuse, especially sexual abuse, may be more likely to self-harm (Hawton et al., 2002). More immediate stressors, such as conflict in relationships, may trigger self-harm as well. Chronic or acute physical illness also appears to increase risk for self-harm (De Leo et al., 1999).

Both Males and Females Self-harm

As noted in previous blogs, although some studies found that females were more likely to self-harm than men (World Health Organization, 1989), more recent estimates suggest that males may be just as likely as females to self-harm (e.g., Gratz, 2001; Gratz & Chapman, 2007; Klonsky, Oltmanns, & Turkheimer, 2003).

Self-harm is More Common in Adolescence to Early Adulthood

Self-harm typically begins in adolescence. Generally, the rates of self-harm are highest between age fourteen to about mid-twenties (Ross & Heath, 2002), although many people who self-harm are much younger or older (Auseinet, 2007; Pierce, 1987). Self-harm is much more rare among people older than 35 years old.

Many People Self-harm

A staggering number of people have used self-harm as a way of coping with pain and distress. For example, between 13% and 20% of high school students reported a history of self-harm (Gratz, Conrad, & Roemer, 2002; Hawton et al., 2002; Paivio & McCulloch, 2004; Zoroglu et al., 2003). In the general public, about 4% of the population self-harm (Briere & Gil, 1998; Klonsky, Oltmanns, & Turkheimer, 2003). Given the widespread nature of self-harm, it’s impossible to say that a particular “type” of person self-harms. There are, however, some experiences or situations which may make people more vulnerable to self-harm.