Understanding Self-Injury: A Pain Too Deep For Tears

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Understanding Self-Injury A Pain Too Deep For
Tears

• Lynne E. Muller, PhD, NCC, LCPC
• lmuller_at_bcps.org
• Mary Ann Mathews
• mmathews_at_bcps.org
• 2008

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Self Injury

• 1. Who self injures?
• Why do they do it?
• What it is and is not.
• How can we help?

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• I needed to cut the way your lungs scream for
  air when you swim the length of the pool
  underwater in one breath. It was a craving so
  organic it seemed to have risen from my skin
  itself.

Caroline Kettlewell Skin Game
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Self-Injury Terms

• Self Inflicted Violence

• Cutting

• Self Harm

• Self Mutilation

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SI Behaviors

• Cutting
• Scratching
• Abrading
• Burning
• Some forms of hair pulling
• Biting
• Inserting foreign objects into the body
• Interference with wound healing
• Ingesting toxins

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Warning signs

• Unexplained frequent cuts or burns
• Wearing long sleeves or pants in warm weather
• Avoiding swimming pools or the beach
• Wearing thick bracelets to cover wrists
• Having sharp objects in purse, book bag, or
  bedroom
• Difficulty expressing feelings
• Withdrawal from close relationships

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Self injury is the intentional harm of ones own
body without conscious suicidal intent.
(Aldeman, 1998, Favazza, 1998, van der Kolk, et
al., 1991)
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What Self Injury is NOT

• It is not a suicide attempt
• (attempting to feel better, not escape all
  feelings)
• It is not usually attention seeking
• It is not a danger signal to others

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NOT SUICIDAL BEHAVIOR

• self-mutilation is distinct from suicideA
  basic understanding is that a person who truly
  attempts suicide seeks to end all feelings where
  as a person who self-mutilates seeks to feel
  better. (Favazza, 1998)
• Intention-does not intend to die as a result of
  his/her acts. Intends to live.

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Who?

• Roughly 2 (1-4) of the population. In some
  studies reported as high as 8 million Americans
  self-mutilate.
• 30 times the rate of suicide attempts
• 140 times the rate of completed suicides
• May also suffer from eating disorders
• 90 who cut began as teenagers

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Who?

• Typical profile
• Female
• Mid 20s to early 30s
• Began cutting as a teen
• Middle to upper class
• Intelligent, well educated
• Perfectionist

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Who?

• Males and females
• All races and socio-economic levels
• Ages 15-50s
• Not easily identifiable

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Characteristics

• are often depressed, feel powerless or anxious
• have low self esteem /negative body image
• have difficulty expressing their emotions
  verbally
• experience difficulty with relationships
• aim for perfection
• often have negative body image
• lack impulse control/suppressed anger
• do not have a repertoire of coping skills
• may have serotonin dysfunction
• possible trauma

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Abuse?

• Many who self-injure did not suffer childhood
  abuse (Zweg-Frank, et.al, 1995, Brodsky, et. al.,
  1998)
• 50-60 suffered childhood abuse or trauma. That
  means that 40-50 did not (Favazza,1998)

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Then Why?

• Invalidating environments (Lineham, 1993)
• Expression of private experiences and feelings
  are not validated
• Feelings are trivialized, punished or ignored
• Experience of painful emotions are disregarded.
• Childs interpretation of his or her behavior is
  dismissed

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In their own words . . .
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• There are times when I hurt too deep for tears,
  so I cut and it lets out some of the hurt. Its
  like when you see the blood flowing out, the pain
  and fear are flowing with it.
• Watching the blood flow out makes me feel clean,
  purified. It feels like something bad or dirty is
  leaving with the blood.

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In their own words . . .
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• The stopped voice becomes a hand lifting knife,
  razor, broken glass to cut, burn, scrape, pop,
  gouge. The skin erupts in a mouth, tongue less,
  toothless. A voice drips out, liquida voice
  sears itself for a moment, in the flesh. This is
  a voice emerging on the skin, a mouth appearing
  on the skin. The body which could not be air on
  the larynx becomes the stroke of a razor on the
  breastbone or of a red-hot-knife-tip upon the
  wrist .
• Janice McLane (1996)

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Why do they harm themselves?

• To release intense feelings
• The physical pain may be easier to deal with than
  the emotional pain
• To feel real, alive
• To exert some control
• Acting out self punishment

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Cycle of Cutting
Cutting
Disassociation
Relief
Into the Void
Shame, guilt, remorse, disgust
Panic
Mounting anxiety, anger or self hatred, alienation
Muller 2005
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In their own words . . .
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• Its like opening up a safety valve or letting
  steam out of a covered pot.
• Sometimes I cut just to make myself feel
  something because I am just totally numb.
• (In Strong, 1998, p.7)

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Why?
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• I felt like I was isolated from the world, dead,
  with no emotions at all. The blood told me I was
  alive, that I could feelAlso I couldnt cry, and
  bleeding was a different form of crying.
• (Lindsay in Strong, p.57)

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What about the DSM?
Currently listed as a symptom associated with a
number of mental health disorders
Some mental health professionals are advocating
for self injury to be listed as a separate
diagnosis
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SI is often associated with

• Borderline Personality Disorder
• Obsessive-Compulsive Disorder
• Post-Traumatic Stress Disorder
• Dissociative Identity Disorder
• Eating Disorders
• Substance Abuse
• Depression

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DIAGNOSIS (Ferreira de Castro, et.al., 1998)
Self-Injure Suicide Attempt
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Therapeutic Goals

• Encourage communication about self-injury and
  relevant aspects of the childs life.
• Improve the quality of clients life as it
  relates to self-injury.
• Explore themes of guilt and shame.
• Diminish use of self-injury as the coping skill
  when client desires to make changes. (Conners,
  Rubin, et, al,2002).

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Helping What to Do (Alderman, 1997)

• Learn about self-injury.
• Talk about SI. Ask about it.
• Be supportive. Show you care.
• Acknowledge the effort to cope with very
  difficult emotions
• Set limits
• Be available, but refer when appropriate
• Dont discourage self-injury
• Recognize the severity of the distress

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What Not to Do

• Be afraid to ask the question, Do you
  self-injure?
• Make eliminating the behavior the primary goal
• Make a safety contract or use contracts as a
  reward or punishment
• Visibly monitor their injuries
• Make him or her feel ashamed or guilty about the
  behavior

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• This is yet another secret I must hold to myself
  because my therapist has given me an ultimatum,
  either no more hurting myself or we will have to
  discontinue our therapy. So a little distance
  comes between us now, a secret that hold great
  importance which we could both learn from, if I
  was able to tell herJML

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Interrupting the Cycle

• Dispute irrational thoughts, feelings
• Triggering event
• Unbearable tension, anxiety
• Dissociation
• Self injury
• Relapse

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Expressive Arts

• Journals
• Poetry
• Music
• Art

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• Self-Injury Group
• Respond to the following statements by writing
  A for agree if you mostly agree with the
  statement or D for disagree if you mostly
  disagree. Be ready to explain your responses.
• ___Self-injurers are survivors.
• ___Self-injurers are weak people.
• ___Self-injurers are harming themselves to get
  attention.
• ___Self-injurers are perfectionists.
• ___Self-injury is a type of suicidal behavior.
• ___Self-injurers are proud of their scars.
• ___Self-injury helps people cope.
• ___Self-injurers are more sensitive than most
  other people.

Muller 2006
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• Self-Injury
• If my wound could talk it would
  say_______________________________________________
  
• __________________________________________________
  ________________________________________________
• __________________________________________________
  _________________________________________________
• __________________________________________________
  __________________________________________________
  
• __________________________________________________
  __________________________________________________

Muller 2006
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Taking Care of Yourself

• Monitor your own horror and confusion
• Broaden your perspective past the behavior to the
  intent behind it
• Seek consultation
• Get support for yourself

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Care and Concern

• The capacity to derive comfort from another is
  the single biggest predictor of whether
  traumatized patients are able to give up their
  self-destructive habits. (van der Kolk)

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Care and Concern

• The development of a safe and trusting
  relationship is vital for the child to learn to
  sooth and care for him or herself in a healthy
  manner by internalizing their therapists care
  and concern. (Strong, 1988)

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Care and Concern
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• _____ was the first to acknowledge that maybe I
  was in pain, as opposed to doing it for
  attention . This affirmation of my inner pain
  was a healing force. Shelley

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Discussion

• Why the upsurge in self-injurious behavior?
• Students who look for fist fights?
• Tattoos and piercing?
• Addictive?