Common mistakes made when work with self harm
Angie was a 17-year-old dancer. Her dance teacher told her that she needed help or to stop dancing if she was going to keep scratching her arm. When she turned 18, Angie decided to pierce a particularly painful part of her body. That week in therapy, she finally agreed to talk about the resulting infection and why she was hurting herself.
Belle was a bright, talented, and outgoing 14-year-old high school sophomore. Her parents took her to psychotherapy when her grades began to drop and Belle’s isolation from her friends became more apparent. In a few sessions, Belle lifted her extra-long sleeves to reveal horizontal cuts across her wrists made with dirty scissors.
None of these teenagers wanted to commit suicide. None of them required hospitalization at the time. They were both trying to avoid harmonizing further. They were both from upper-middle-class families, in good schools, successful academically and socially. Angie and Belle were presenting an image of perfection to the outside world, including their families; until they couldn’t anymore. A common mistake both mental health professionals and families make is to overreact and believe that suicide is imminent. Self-harm or self-mutilation is actually a coping mechanism used to avoid suicide. “If I let some of my feelings out, I won’t feel as overwhelmed, or hurt as much, or feel as numb, and I’ll be able to go on living.”
Charlene was a 35-year-old mother from New York who had moved to the West Coast to be with her true love at age 17. As she grew older, she had children, was jobless, and found herself controlled by money and the emotional whims of her husband. , Charlene began to move between drinking alcohol, not eating, cutting herself, and fleeing to New York. Her husband called her “crazy” and regularly told her children that her mother was just looking for attention.
Daisy was a 23-year-old single woman in a banking career that she hated. She was lonely but, due to early extreme abuse of her, she didn’t trust anyone enough to risk friendships or more intimate relationships. After a period of psychotherapy to learn how her story impacted her current social situation, Daisy began a meaningful relationship with a man who did not threaten her. As that relationship grew, her Daisy got scared and started cutting her thighs and wrists. When her fiancee found out about it, she was enraged by her attention-seeking behavior.
Another serious mistake made with self-injurious behavior is thinking that the youth or adult is “just trying to get attention.” In fact, those who self-harm are often masters at hiding their secrets. They are masters at helping others and portraying their lives as if everything is fine. They are “acting in” instead of “acting”. Therefore, a big mistake made in the field of mental health is to ignore self-harm as a simple ploy to get attention. Most self-mutilations are done in complete privacy. So when the statistics say that 1% of Americans self-harm (mostly women), we can be sure that this is a gross underestimate. Cutters, markers, burners, bone breakers, scratchers and biters, they find places on their bodies that no one else sees. They cut at the bikini line, mark above or below the breasts, scratch their thighs or nibble at their cuticles, and then wear gloves. When the behavior is discovered, there is great shame and guilt; it is usually not enough to stop the behavior, but the self-mutilation may increase or worsen, and even be more hidden, if the reaction of a loved one or mental health professional is disgust, anger, or helplessness. “I am such a horrible being, I need to punish myself even more.”
Evelyn was seeing a Marriage and Family Therapist Intern (MFTI) due to her extreme and regular cuts on her arms and ankles. On supervision, the MFTI was certain that Evelyn had been sexually abused when she was young due to self-harm. After looking at all the other factors involved in Evelyn’s story and her current life situation, it was clear that there was no such trauma. Rather, Evelyn’s parents had separated when she was young, and her mother had had a long series of male partners who received more attention than her daughter. Evelyn’s father was completely out of the picture and quickly landed in prison for life for murder. Evelyn felt truly abandoned.
Fran was admitted to hospital for vertical cuts to her arm and inner thighs. The cutters know that horizontal means “help”, while vertical means “I’m serious and I can kill myself”. Mental health and social work staff pressed Fran and her family about who, when, and how she was sexually abused. Fran and her family insisted that no one had hurt her. When she entered individual psychotherapy, her narrative of early emotional abandonment by a workaholic father and alcoholic mother emerged. Fran believed that she was worthy of love and that her body was a place to display her self-loathing. All the important ones had abandoned her, why not abandon herself?
A third mistake that many helping professionals make when working with people who self-injure is to believe that the etiology of the self-injurious actions stems from early sexual abuse. In 1998, Steven Levenkron wrote a wonderful, helpful, and honest book called CUTTING: UNDERSTANDING AND OVERCOMING SELF-MUTILATION. He clarified that the key element of self-harm is early abandonment; real or perceived. Since his seminal work, other researchers and clinicians have come to fully agree with the premise that self-mutilation is embedded in one or more of three thought processes, whether conscious or not:
- “I’m overwhelmed by my feelings. I need to distract myself or I’ll explode. I’ll cut. Oh, I can focus on that physical pain, instead of the emotional pain.”
- “I’m numb. I can’t feel anything and I wonder if I’m still human. I’ll cut myself. Ouch. I can feel anything.”
- “I hate myself. I must be punished.”
All of this is rooted in a sense of abandonment by the person or persons who were supposed to be there when the child needed them. Parents will often swear that they gave their child all they had to give. From their perspective, the child was either “too needy” or “got what all the other kids got.” However, from the girl’s perspective, she did not get what she needed, when and how she needed it. Therefore, the inner sense is: “My feelings are too many or too many”, “I need to close my feelings to be aware and serve others.” or “I don’t deserve love as I need it: I’m not worthy.”
Gwen was a 14-year-old girl with a lot of potential. She was smart, pretty, sociable, and loved. Her parents were in an unhappy marriage and spent much of their time in toxic fights, praising Gwen’s younger brother for his successes and demeaning Gwen for starting Gwen. She started scratching her arm to distract herself. When Gwen started running away from home, using drugs, and prostitution, she discovered that glass shards and straight edges would do her job better; causing more pain, which she was sure she deserved. After several years of working through Gwen’s guilt and abandonment issues, she was able to stop hurting herself and find other, healthier methods of coping, such as art, music, being in nature, and occasionally rubbing ice. on the arm to feel some bread. She realized that she didn’t need to abandon herself even though her parents had; she deserved better.
Until mental health professionals, parents, teachers and doctors catch on to these mistakes being made on a regular basis, too many girls and boys, men and women will be misdiagnosed and mistreated in the mental health and medical systems. The first and perhaps most important thing is not to be upset or angry about the self-mutilation. Would a professional show anger with an alcoholic? an anorexic? Self-mutilation is just another way of coping with trauma, similar to substance use or eating disorders.
Next, it is important to take an interest in the actual physical injury. Ask what tool(s) they use. It was clean? Did they clean the wound? Where and when do they get hurt? Each response will provide invaluable insight into how the client treats themselves, triggers, and response to the trauma. Inquiring about the thoughts and feelings that immediately precede the act(s) will also help find ways to change or stop the behavior. Self-awareness is extremely helpful to the self-injurer. Working with the self-injurer to understand why and when they hurt themselves will empower them over the powerful stress response, such as cutting; if they understand why and when, they have options. Finally, giving them alternative coping mechanisms, so that when they are activated, they can choose, will go a long way in slowing or stopping self-harm.
With more patients who self-harm turning up in therapeutic settings, whether hospitals, residential treatment, foster homes, or sometimes schools, helping professionals need to be clear about who, how, when, and why people harm themselves. themselves. Much of the fear surrounding self-mutilation is due to lack of knowledge and the helper’s response to perceived physical pain. Certainly not all mental health professionals should work with this specific population. Just as it is important to know personal limitations with substances, eating disorders, or personality disorders, it is important to know personal/professional limitations with self-harm. At the same time, having a basic understanding of what is and is not suicidal behavior, what is and is not attention-seeking, what is and is not related to early sexual abuse will only help. with proper diagnosis and treatment planning by parents. and professionals alike.
(c) Lisa Cohen Bennett, PhD