Updated: Jul 28, 2021
As many as 42% of autistic people will engage in self-harming behaviors at some point in their life time, this is significantly greater than the prevalence of self-harm in the general population which is approximately 17%. The type of self-harm that is used also differs between the autistic and non-autistic populations with hand hitting being the most common type of self-injurious behavior seen in the autistic community and cutting being the most common in the non-autistic community. There are probably several reasons why self-injurious behavior is more common in the autistic population. Autistic people may be less influenced by social norms and therefore more likely to engage in non-normative behaviors. We also know that autistic people are at a greater risk of suffering from anxiety and depression (some studies suggest as many as 70% of young autistic people suffer from mental heath problems) which may lead to self-injurious behaviors. Self-injurious behaviors can also be a method of communication for people with limited language and can be used for example to attempt to communicate a need or a frustration. In this article we will explore how self-injurious behavior can also be an expression of boundary issues in autistic people and the wider population.
Donald Winnicott was a psychoanalyst and paediatrician who was influential in the world of child development theories. In his view the newborn baby is unable to distinguish himself from the environment and as such is constantly on the brink of ‘unthinkable anxiety’ with the ever present threat of ‘annihilation’, ‘… of going to pieces, falling forever, having no relation to the body, having no orientation in the world and complete isolation.’ He believed that through relationships with others particularly the primary caregivers the infant’s true self will emerge as distinct and contained within the body. Some of the earliest signposts for autism are reduced eye contact (evident from 2-6 months) and sensory sensitivities (evident from 7 months) both these attributes will make relationships with the environment and others more challenging which may lead to the process of individuation being stalled or not happen at all leaving some autistic people with a impaired sense of themselves as distinct and separate from the environment and other people. Winnicott saw the re-emergence of infantile unthinkable anxiety in later life as akin to the anxiety experienced by people with a borderline personality disorder (BPD), common symptoms of which are self-harming behavior in many forms. There is evidence that some autistic people particularly women may be misdiagnosed as having BPD due to an overlap in some of the diagnostic symptoms such as intense emotions and unstable relationships. In addition to difficulties with this stage of development increased sensitivity to sensory stimulation leading to sensory overload may reawaken this feeling of ‘unthinkable anxiety’ due to the disorientating qualities of having too much sensory information to process. When our sense of self is threatened or unclear the boundaries between ourselves and the outside world may become blurred. Hitting, kicking or biting one’s own body may be a maladaptive but effective way of re-establishing a sense of self by bringing attention to the physical boundary between the self and the outside world. Further evidence that self-injurious behavior is linked to boundary issues is that self-injurious behavior is far more common in all people who have suffered a boundary violation, particularly sexual abuse. There is also evidence to suggest a link between dissociation and self- injurious behavior. Dissociation is a state in which a person experiences feeling disconnected from themselves and the environment usually brought on by stress and trauma. There is an increased likelihood of a person who suffers from dissociation or dissociative disorders also self-harming which again may indicate self-injurious behavior as a coping mechanism for people experiencing difficulties with boundaries and a coherent sense of self. Deep pressure may be able to provide the same feedback as self-injurious behavior without causing damage and many individuals with autism have written about the soothing and calming properties of deep pressure. Temple Grandin even created her own ‘squeeze machine’ to meet this need. Activities that promote a sense of the bodily self and awareness of the present moment such as yoga, breathing and mindfulness activities can be grounding and reduce the ‘unthinkable anxiety’ of feeling disembodied or lacking clear boundaries. Below I give some examples of how some common mindfulness activities with some adaptions for those who might need extra support.
To complete a body scan sit or lie in a comfortable position and close your eyes. Start by bringing awareness to your feet. Notice any sensations in this area such as pressure or discomfort. The aim is not to try and change anything but just to give attention. When you are ready start to work your way up your body giving each part of your body attention on this journey. End your journey in your head giving attention in turn to your mouth, forehead and eyes. For those who need extra support you can use massage, deep pressure or body brushes to help bring attention to the different parts of the body.
The 5 senses
For this exercise again sit or lie in a comfortable position and close your eyes. If possible this is a lovely exercise to do outside in nature. Start by paying attention to anything you can feel, this could be the wind on your skin or pressure from clothing. When you are ready start to pay attention to any smells in the environment, before moving on to noticing any tastes in your mouth. Next spend a few minutes listening to any sounds in your environment. Finally open your eyes and really notice what you can see, pay attention to the shapes, colors and movement all around.
For those that need a little help you can provide props to pay attention to at each stage of the journey for example deep pressure or a water spray to bring awareness to touch, essential oils to bring attention to smell, cucumber slices to bring attention to taste, a bell or bird song to bring attention to sound and bubbles to bring attention to sight.