Conflict expresses
As retaliation or revenge after abandonment
Illusion of being able to control a situation of rejection, feeling of omnipotence by means of death
As retroflexed murder
“Acting” of a violent individual that reflects, through suicide and self-punishment, an internal struggle against the desire to kill or attack others
As meeting
After the death of a significant figure from an emotional point of view
As rebirth
As a preliminary step or initiation rite to access a new way of life, in which the failures and frustrations of the previous one are deleted, and an everlasting union with the lost object occurs
As punishment
From the most intense guilt—sometimes delirious—combined with melancholic manifestations.
Psychotic suicide
Typical of melancholic depression with psychotic symptoms, and schizophrenia. Known under the eponym “Cotard’s syndrome.” The patient has the delirious belief of being dead
13.3.4.2 Cognitive Theories
Cognitive theories have concentrated on styles of thinking that lead to an increased risk of self-harm. Cognitive studies have found that people who self-harm have more passive problem-solving styles than others, with solutions being less versatile and less relevant to the problem [71]. Poor problem-solving leads to hopelessness and/or helplessness, which increases the risk of self-harm [72]. Hopelessness and poor problem-solving ability may, however, act independently of each other to increase risk. There is no evidence that any of these cognitive styles is sex-specific.
We could refer here to the term “learned helplessness,” by Seligman, as behavioral conditioning, and associate it with Bourdieu’s “habitus.” The helplessness does not occur immediately, but requires a learning process, in which the information of the relation between a given response and some reinforcement is assimilated. It is based on the consequences of perceiving a lack of correlation between the objectives proposed and the objectives achieved, causing feelings of helplessness and lack of control. The individual adapts his behavior to a situation of non-control, so motivational, cognitive, and emotional deficits are generated in him. For Seligman, a body becomes defenseless before a certain consequence when it occurs independently of all its voluntary responses. Abramson, Seligman, and Teasdaler reformulated the theory in terms of attributional processes. According to them, a negative event by itself is not sufficient to acquire learned helplessness. It would also be necessary for it to be perceived as an uncontrollable, not contingent, event.
In the theory of hope, Abramson argues that there are different attributional styles. Suicidal behavior has been associated with cognitive alterations such as rigidity, defined as difficulty in developing positive alternatives to emotional problems. Aspects such as personality or self-worth could be related to the inferences taking place about the consequences of different events.
13.3.4.3 Social Theories
Durkheim believes that suicide is the result of the influence and control exerted by society. He proposes two variables to consider: a) the degree of social integration of the individual and b) the degree of social regulation of the individual desires (quote).
For Durkheim, suicide, from the cultural point of view, arises from four different categories:
Egoistic suicide: in individuals who, for various reasons, are not steadily and bindingly integrated into a particular social group, and act based on individual and not collective interests (for existentialists, the “earthly meaning”).
Altruistic suicide: opposite of the above, in individuals that are excessively linked to the social group they belong to, with a notable absence of individual criteria (die for the cause, religious faith, politics, etc.).
Anomic suicide: practiced by those who are excluded from the group they belong to, either because they have suffered an economic setback and a loss of status and social recognition, or because they have been deprived of their liberty, or because they have been imprisoned for some type of crime. What brings these people to kill themselves is the feeling of non-acceptance and of irretrievably losing their previous social position.
Fatalistic suicide: occurs in those individuals who do not resist the pressure derived from the strict conditions and regulations to which they are subjected by the social environment in which they live.
“…someone who was banned from another language…” (J. Amery).
Queer 1 researchers claim that heterosexuality is approved in the dominant ideology of the “natural” sexual identity. Kosofsky considers that this belief leads to suicide in people who do not identify with these symbolic forms of expression of personal identity. He argues that queer teenagers are two or three times more likely to attempt suicide and commit it than other young people, and that in the USA, almost 30 % of young people who commit suicide are gay or lesbian [73].
13.3.4.4 Existentialist Theories
“There is but one truly serious philosophical problem and that is suicide” (The Myth of Sisyphus, Camus, 1942).
“Each of us has the plague within him.” (The Plague, Camus, 1947)
The “plague” that Camus suggests is what Kierkegaard called “feeling of anxiety” in 1844, and was later called “existential anxiety” by the humanistic–existential stream, and consists of the fear of death. It is strange then that the suicidal candidate comes to embrace what he fears the most. What happens, therefore? The suicidal individual eliminates the self-preservation instinct conclusively. Suicide affects the two essential dimensions involved in our “being-in-the-world.” The term “being” corresponds to the very existence, and the term “in-the-world” refers to our place, to what happens, to what occurs. Both terms within the expression “being-in-the-world” are fused or homogenized by the problem of meaning. And this is precisely what the suicidal subject eliminates all at once.
Irvin D. Yalom refers to the variety of “suicide as a magical act,” in which there is no thought of death, but rather the contrary, suicide as a means of defeating death by thinking that others will remember him for a long time, the belief in continuing to live if he exists in the consciousness of another person [74].
The “moral or social suicide” [75] is where the person looks for long-term self-destruction, by living a degrading way of life that excludes him from social intercourse.
The “epicurean suicide” is where death is considered rationally and dispassionately, as Lucretius explained: “Where death is, I am not; where I am, death is not,” or in the words of Epicurus: “Death is nothing to us, since when we are, death has not come, and when death has come, we are not.”
13.3.4.5 Classic Theories
The classic theories are summarized in Table 13.2.
Table 13.2
Types of suicide according to Schneider
Characteristics | |
|---|---|
Rational suicide | Derives from an objective and detailed analysis of a limited and insolvable existential situation. The psychotic subject can sometimes face, as a person, psychosis |
Short-circuited suicide | Arises from a primitive impulsive discharge before an acutely stressful situation. It appears as a reflex action that escapes from the psychic processing or mental development. According to the author, it is more common in women |
Theatrical suicide | It comes with an exhibitionist courtship, whose primary objective is to draw the attention of those people close to the patient, rather than cause death itself. It arises from a form of parasuicide or parasuicidal behaviors. However, sometimes we can come across truly committed suicides within this group. In these cases, the lack of impact and consideration generated from their actions, usually repetitive and clearly blackmailing to those who, powerless, face them (family, partner, friends), leads them to force their exhibitionist behavior or to demonstrate their anger and helplessness, increasing the lethality of their actions, with the consequent risk of death |
13.4 Self-Harm and Gender
“The relationship of body and ego is perhaps the most mysterious complex of our lived existence or, if one prefers, of our subjectivity of our being-for-itself. We are not aware of our body during everyday existence. To our being-in-the-world our body is what Sartre called ‘le negligé,’ ‘le passé sous silence,’ neglected, one scarcely speaks of it, doesn’t think of it. We are our body: we do not have it. […] however, we become conscious of it as a foreign body only when we see it with the eyes of the other […] or when it becomes a burden.” (Améry)
“I hurt myself today
To see if I still feel
I focus on the pain
The only thing that’s real.”
(Hurt written by Trent Reznor of Nine Inch Nails, sung by Johnny Cash)
Nonsuicidal self-injurious behaviors refer to deliberate self-injuries without a suicidal intent [76]. Examples of this could be cutting, burning, scratching the skin, hitting or biting oneself.
Conventionally, the term excludes harm resulting from drug or alcohol use or from eating disorders. Self-harm involves either self-poisoning or self-injury. Self-poisoning is synonymous with taking a drug overdose or ingesting substances never designated for human consumption, and self-injury refers to any form of intentional self-inflicted damage including cutting the skin, self-immolation, swallowing objects, hanging or jumping off buildings without (usually) ever compromising the patient’s life.
We want to review now the concepts of “transference” and “acting-out” that we often find in the literature as synonyms, while some authors distinguish between them. Bernard, using the description given by Laplanche and Pontalis, argues that “transference” can take all kinds of forms (sometimes very discreet, he says) with the proviso that it holds that impulsive character, poorly motivated in the eyes of the same individual, but breaking with the usual behavior, even if the action in question is secondarily rationalized. He notes that “transference” can be differentiated from “acting-out” (of the subject has difficulty fantasizing) in that the latter arises in a more or less symbolic form in the course of analytical psychotherapy, in which the subject “leaves” the psychic material of the fantasy and the mental world to perform it before the psychotherapist with an aggressive character of varying severity.
The relationship between body and language is established by the cut, which is what writes, what engraves the writing of suffering on our flesh. It is, like Pane says, what the body will make memory of. The possibility that these cuts might be “read” by others overshadows the pain, time itself can deal with them because the body has the ability to heal. The flesh has the property of self-sealing (healing) and not remaining open. “Physical suffering is not merely a personal problem but also a problem of language. The act of self-inflicting wounds upon myself represents a temporary gesture, a psychovisual gesture that leaves marks” [77].
As Bataille believes, “The urges of the flesh pass all bounds in the absence of controlling will. Flesh is the extravagance within us set up against the law of decency” (Western flesh is Christian, as Michel Onfray argues). “Flesh is the born enemy of people haunted by Christian taboos, but if as I believe an indefinite and general taboo does exist, opposed to sexual liberty in ways depending on the time and the place, the flesh signifies a return to his threatening freedom” [78].
Christian iconography emphasizes the role of flesh and its transgression by marking its limits as the boundary that merges the flesh with the world by means of gashes, sores, cuts, decapitations, etc. This would cause horror in contemporary art, as with the photographs of David Nebreda (a photographer diagnosed with paranoid schizophrenia who uses his own self-portraits. In them, he is subjected to all kinds of lacerations, fasting in the place in which he is confined, because this is his way of expressing the pain). However, indoctrination and repetition for centuries make Christian iconography assume these cuts, wounds, and sores to be nonquestionable beauty since it is transcendent, and is built on beliefs through the centuries, following the direction of Bourdieu’s “habitus.” Thus, the infringed body is promoted by the ecclesiastical power and, far from being repudiated (as with Marina Abramovic’s performances) by some sectors of our society, it is valued for its beauty.
A wounded body is a crossed frontier beyond which we go. Body art represented a barrier that some women artists crossed by using their body as a canvas to denounce their submission, their social under-representation, and their performatively marked sexuality. As Kruger shouts: “My body is a battleground”. Body art is not only practiced by women, but by all those artists who consider it a form of social and gender protest.
The way in which sex and the role of women have been introduced in our society has been denounced by numerous artists, from Frida Kahlo to Louise Bourgeois, one of the first artists who used the female body to denounce the traditional role attributed to women.
Also, the artist Ana Mendieta, through Mutilated Body on Landscape (1973) and Tied-up Woman, where she appears naked, tied and humiliatingly immobilized, denounces the situation of women. Orlan, at the same time, did so through her works, such as Le Baiser de l’Artiste (The Artist’s Kiss, 1977), performance with the slogans “art and prostitution.”
Artists such as Pane, Carole Scheenemann, Kiki Smith, Cindy Sherman, Barbara Kruger or Linda Benglis should be added to this list. The last three highlight the role of the media and Western consumer society on their way to publicizing female imaginary, reporting the imposed media violence and making the imposed sex roles problematic [79].
In Table 13.3, we can see a classification of the different terms used for “nonfatal self-inflicted harms” by Skegg, in 2005 [80].
Table 13.3
Modified table on nonfatal, self-inflicted self-harm terminology. [80]
Terms for nonfatal, self-inflicted harm |
|---|
ATTEMPTED SUICIDE Used widely (especially in North America) for episodes where there was at least some suicidal intent, or sometimes without reference to intent. Repetitive bodily harm may be excluded |
DELIBERATEa SELF-HARM Used in the UK for all episodes survived, regardless of intent North American usage refers to episodes of bodily harm without suicidal intent, especially if repetitive. Usually excludes overdoses and methods of high lethality |
PARASUICIDE Episodes survived, with or without suicidal intent (especially in Europe) or episodes without intent. Repetitive bodily harm may be excluded |
SELF-POISONING OR SELF-INJURY Self-harm by these methods regardless of suicidal intent |
SELF-MUTILATION Serious bodily mutilation (such as enucleation of an eye) without suicidal intent Repetitive superficial bodily harm without suicidal intent (synonymous with the North American term deliberate self-harm). Also known as self-injurious behavior, self-wounding Sometimes the term is used to describe both the above meanings and also stereotypical self-harm in intellectually disabled people |
Casadó Marín [81] classifies self-harm according to the scenario; thus she elaborates this classification by oppositions:
Standardized self-harm/Stigmatized self-harm
Public self-harm/Private self-harm
Standardized self-injuries are those involving body art, body modification processes (diets, aesthetic care/Botox, surgeries, tattoos, piercings, scarifications), self-injuries in the ritual context—flagellations, fasting, crucifixions—also those that take place in penitentiary contexts—hunger strikes—and primarily in religious contexts.
Public self-injuries are those that occur in the ritual context.
Private self-harm occurs in situations of armed conflict (self-injury to avoid the front), in the working environment (in the face of certain working conditions), as a sign of identity among “emos” and “gothic”2 young people, and in situations where self-injuries are interpreted under a diagnostic criterion of mental illness.
Through this classification, the author wants to draw our attention to the fact that self-harming actions must not only be rethought in exclusively pathological terms, but as a practice that can be interpreted and lived in different ways depending on the context, which legitimizes or stigmatizes it. Thus, she brings out the importance of the social aspect when it comes to attributing meaning to the act.
The mortification of the body in relation to the atonement of sins, or the compliance of promises or vows, has to do with the fact that, at the base of Catholicism, the body was a part of the human nature that limited the perfection of the soul, as well as the instrument through which the sin materialized. The disciplines and rules that mortified the body are those that managed to control the sinful nature of men and women and that constantly reminded us of our sinful essence.
13.4.1 Epidemiological Data
Although the estimated prevalence of self-harm varies depending on definitions and methodology, it is clear that it is highest during adolescence [82]. Theoretically, self-injurious behaviors can differ from suicide attempts in three basic aspects: intention, repetition, and lethality [83–87].
Hawton estimates that, during the year after someone inflicts self-harm, the suicide risk is 60 times higher than in the general population [87]. Despite self-harm predicting future suicide attempts, suicide attempts do not predict future self harm.
In the general population, the prevalence of self-harm in adolescents is 5–37 %, compared with 4 % [84] in the adult population [88]. In the clinical population, we found a prevalence of self-harm in adolescence of 61.2 %, with regard to cuts [89, 90]. Most studies report that self-harm is more common in girls than boys, in ratios ranging from 20.3 % vs 8.5 % [91] to 45.2 % vs 38.1 % [92]. However, it seems that the prevalence in children has been increasing in recent years [82].
The greatest risk of hospital presentations in the WHO/EURO Study was in women aged 15–24 years and men aged 25–34 years [93]. Older people are at a much lower risk, and when they do self-harm they are much more likely to commit suicide later [94].
Although being male is an important risk factor for suicide, presentations of self-harm to health agencies are generally more common in women [93].
There are differences in sex distribution between self-cutting and overdose, with intentional overdose presentations involving a preponderance of women and self-cutting presentations displaying a more even gender distribution [95–97].
Past literature has often emphasized self-cutting as the main method of self-harm for women, but more recently research has shown a significantly higher proportion of women self-poisoning compared with men [98, 99]
However, compared with poisonings, cuts (with or without poisonings) are more common in men than in women, mainly in men under the age of 35 years [100]. Some studies [101] show that self-injurious behavior begins in early adolescence, with an increase in frequency and intensity in its evolution, and being more prevalent in women. The underlying factors include being a victim of sexual abuse and alexithymia.
In other research [102], we found significant correlations between self-injurious behaviors or self-mutilation and eating disorders, borderline personality disorder, post-traumatic stress disorder, and dissociative disorders. There is also a relationship between the extremely high rates of self-harm and suicide attempts in girls with ADHD, being associated with inattention, hyperactivity and impulsivity, and a history of trauma in childhood, such as abuse [103].
Between 70 and 80 % of patients who meet the DSM-IV criteria for borderline personality disorder (BPD) do self-inflict injury [104]; the DSM-IV shows that 75 % of BPD is diagnosed in women. Some studies show that between 35–80 % of individuals who self-inflicted injury also suffered from disordered eating behaviors [105]. For them, self-harm and eating disorders should be considered the desire to end with the body.
Recent studies suggest that there are different patterns in terms of self-directed violence in men and women [106], and that women with antisocial traits have a higher prevalence of self-harm and of being diagnosed with BPD than men with antisocial traits [107, 108]. However, it seems that the repetition of self-harm, when there is a history of such behavior, is almost equal in men and women [109].
Some authors say that men and women with gay, lesbian or bisexual orientation are more likely to self-harm than are heterosexuals [110, 111], although there have been conflicting results for teenage girls [112]. High risks have been identified in men who described their orientation as bisexual or who had experienced only minor same-sex attraction [110, 111]. The risk in gay, lesbian or bisexual youth could not be attributed to exposure to some risk factors, including depressed mood, substance abuse, pubertal timing, in fact, most self-harm occurred after or around the time that participants realized that they were not exclusively heterosexual [112]; thus, we can deduce that the social impact (acceptance) has a great influence on these behaviors.
13.4.2 Self-Injuries as a Separate Category
In the DSM-IV, nonsuicidal self-injuries were only mentioned as a diagnostic criterion for BPD, and described as suicidal behaviors, gestures, threats or self-mutilating behaviors [113], in autism, mental retardation, and factitious disorders. In the DSM-IV, self-injury is not considered a disorder in itself.
In the DSM-5, the nonsuicidal self-injury (NSSI) disorder as diagnostic entity was proposed as “conditions for further study.” They insist on differentiating it from BPD, although they recognize the high existing comorbidity with both the said disorder and the eating disorders or the use of substances. They report that, although both diagnoses (along with BPD) are frequently associated, BPD does not invariably appear in all self-injurers. The difference between the two entities is that BPD often shows hostile and aggressive behaviors, while NSSI disorder is associated with situations of closeness, intimacy, collaborative behaviors, and positive social relationships. They also allege differences in the neurotransmitter systems.
The first case of self-harm without suicidal intent was described by L. Eugene Emerson in the Psychoanalytic Review, published in 1913. He talked about the case of Miss A3 and proposed the challenge to understand why a person like her could come to self-inflicting injury when “this patient was not insane.” It was a 23-year-old woman who had self-inflicted injuries in different parts of her body, one of them a “w” on her calf. Throughout therapy, Miss A relates that she was sexually abused in childhood by her uncle and subsequently her father. The particularity of Emerson consisted in investigating the experience of the symptoms, considering that the classification was less important than the causation and its manifestation through the body. For Emerson, there was a relationship between abuse and self-harm, highlighting the sexual nature of the act [114].
Other authors have called a combination of behaviors, including self-mutilation, substance abuse, and abnormal eating, often with a history of childhood sexual abuse, “trauma re-enactment syndrome,” with women seen to be doing to their bodies something that represents what was done to them in childhood [115].
Miller described four common characteristics in these women: the feeling of struggling with their own body (the body as an enemy), the excessive discretion as a principle of life, the inability to protect themselves, and a certain dissociation of consciousness, where thoughts take three roles: the bully, the victim, and the witness who does not protect.
Pattison and Kahan supported the idea of a deliberate self-harm syndrome and described establishment in late adolescence, the episodes being recurrent and multiple, the low-lethality, the production of deliberate injuries to the body, and the tendency toward chronicity being major characteristics.
13.4.3 “The Portrait of the Typical Self-Injurer”
Favazza argued that self-injury affects 1 % of US population, and that 97 % of these are women [116]. This author defined “The portrait of the typical self-injurer” as a “white woman, in her late twenties, who began hurting herself at the age of fourteen. She had injured herself at least 50 times, usually by cutting but also by other methods, including burning or self-hitting.”
Galley [117] defines self-injurers as: “Bright, sensitive, helpful to others, caretakers of their friends and family, good listeners, above average students, and invisible. They are very creative, artists and neat kids, but ones who do not make their needs well known.”
Craigen [118] considers self-harm to be the “new anorexia” affecting young women.
Froeschle and Moyer consider that there are gender differences in terms of self-harm. For men, self-injury is a rite of passage, while for women, the actions are more private and emotionally charged [119], which confirms Bourdieu’s model of “masculine domination.” It is also necessary to note that, in the case of men who self-harm, we find a double stigma, since they perform an action that is considered “feminine,” which jeopardizes their masculine identity, and that, as a practice, it is considered a diverted behavior, which often leads them to remain in anonymity.
13.4.4 Comprehensive Approach of the Motivations for Developing Self-Injurious Behaviors
Klonsky summarizes the main biopsychosocial models proposed by other authors [120]. These functions are not mutually exclusive; thus, it is common for several of them take place at once.
1.
Affect regulation model
It is suggested that self-injury might be a strategy to alleviate acute and intense negative affects [121, 122]. From the systemic and cognitive perspective, it is postulated that early disabling environments hinder the development of appropriate strategies for coping with emotional stress. The individuals that have grown up in these environments and are vulnerable to emotional instability, can find useful means in self-injurious behaviors to regulate and express (to others and oneself, as it brings emotional distress to consciousness itself) intolerable negative affects. Sometimes, people who self-injure state that self-injury is a way of expressing the pain that they cannot put into words. They refer to emotions that combine pain, sadness, anger, and emotional numbing with feelings of guilt, desires for abstraction, self-punishment, loneliness and emptiness. Injuries become the text that gives us access to the emotional universe, the universe of experience through carnal registration. The body is the vehicle for what. The body is the vehicle for what we cannot put into words. As Nietzsche, in Thus Spoke Zarathustra, wrote: “Of all that is written, I love only what a person hath written with his blood. Write with blood, and thou wilt find that blood is spirit.”
2.
Anti–dissociation model
This includes self-harm as a response to states of dissociation, depersonalization, and/or derealization. Gunderson proposes that some temperamentally vulnerable subjects may be precipitated in states of dissociation when they are far from a loved object. This unpleasant state can trigger injurious behavior with the aim of reconnecting with the sense of “ownliness” and body property through the pain, allowing them to feel real and revitalized. This model is more frequently seen in women [101].
The dissociation model can be linked with the affect regulation model. Some people who self-harm report feelings of dissociation from their environment; a feeling of separateness or a lack of self. The function of self-harm is often to end that dissociation [109]. Other authors suggest that self-harm can also function as a means of becoming dissociated, so as to escape overpowering emotion [123]. What the authors believe with this is that, in an episode of dissociation, the cuts allow a reconnection with the world through the pain (seen and interpreted pain that returns to reality), while in the episode of depersonalization, the blood pouring from the wound would be what allows reconnection with the body.
3.
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