Common Mistakes Made When Working with Self Injury
Angie was a 17 year old ballerina. Her dance teacher told her that she needed to get help or stop dancing, if Angie was going to continue to scratch 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 speak about the resulting infection and why she was harming herself.
Belle was a 14 year old, bright, talented, social, high school sophomore. Her parents brought her in to psychotherapy when her grades began dropping and Belle’s isolation from her friends became more obvious. Within a few sessions, Belle raised her extra long sleeves to show horizontal cuts along her wrists made with dirty scissors.
Neither of these teen girls wanted to kill themselves. Neither of them needed hospitalization at that point in time. Both were trying to keep from harming themselves further. Both were from upper middle class families, in good schools, succeeding academically and socially. Angie and Belle were both presenting a picture of perfection to the outside world, including their families; until they could no longer to do so. A mistake frequently made by mental health professionals and families alike is to overreact and believe that suicide is imminent. Self injury or self mutilation is, in actuality, a coping mechanism used to keep from committing suicide. “If I let some of the feelings out, I won’t be so overwhelmed; hurt so much; feel so numb; and can go on living.”
Charlene was a 35 year old mother of 3 from New York who had moved to the West Coast to be with her true love at age 17. As she grew older, had children, no job and found herself controlled by her husband’s money and emotional whims, Charlene began to move between drinking alcohol, not eating, cutting herself and running away to New York. Her husband called her “crazy” and regularly told her children that their mother was just seeking 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, didn’t trust anyone enough to risk friendships or more intimate relationships. After a period of psychotherapy to learn about how her history impacted her current social situation, Daisy began a meaningful relationship with a non-threatening man. As that relationship grew, Daisy became frightened and began cutting her thighs and wrists. When her fiancée found out, he became enraged about her attention seeking behavior.
Another grave mistake made with self harm behavior, is to think that the youth or adult is “just trying to get attention.” In fact, self injurers are often masters at hiding their secret(s). They are masters at helping others and portraying their lives as if all was well. They are “acting in” rather than “acting out.” Thus, a huge mistake made in the mental health field is to disregard the self injury as simply a ploy at attention getting. Most self mutilation is done in complete privacy. Thus, when the statistics say that 1% of Americans self injure, (mostly females), we can be assured that that is a great under-estimation. Cutters, branders, burners, bone breakers, scratchers and biters, find places on their bodies that no one else sees. They will cut on their bikini lines, brand above or below their breasts, scratch their thighs or bite cuticles then wear gloves. When the behavior is discovered, there is great shame and guilt; typically not enough to stop the behavior, but rather the self mutilation can increase or get worse and even more hidden, if the reaction of a loved one or mental health professional is one of disgust, anger or helplessness. “I am such a hideous being, I need to punish myself even more.”
Evelyn was seeing a Marriage and Family Therapist Intern (MFTI) due to her extreme and regular cutting on her arms and ankles. In supervision, the MFTI was positive that Evelyn had been sexually abused as a youth because of the self injury. After looking at all the other factors involved in Evelyn’s history and current living situation, it became clear that there was no such trauma. Rather, Evelyn’s parents had split when she was young and her mother had had a long string of male partners who received more attention than did her daughter. Evelyn’s father was completely out of the picture and fairly quickly landed in prison for life for murder. Evelyn felt truly abandoned.
Fran was admitted to the hospital for vertical cuts on her arm and inner thighs. Cutters know that horizontal means “help,” while vertical means “I am serious and may suicide.” The mental health and social work staff pressed Fran and her family concerning who, when and how she was sexually abused. Fran and her family insisted that no one had harmed her. When she came into individual psychotherapy, her narrative of early emotional abandonment by a workaholic father and alcoholic mother surfaced. Fran believed she was unworthy of love and that her body was a place to show her self-loathing. Everyone important had abandoned her, why not abandon herself?
A third mistake made by many helping professionals when working with self injurers, is to believe that the etiology of the self injurious actions is from early sexual abuse. In 1998, Steven Levenkron wrote a wonderful, useful and honest book called CUTTING: UNDERSTANDING AND OVERCOMING SELF-MUTILATION. He clarified the key element of self injury as being early abandonment; real or perceived. Since his seminal work, other researchers and clinicians have come to strongly agree with the premise that self mutilation is embedded in one or more of three thinking processes, whether conscious or not:
- “I am overwhelmed by my feelings. I need to distract myself or I will explode. I will cut. Ah, I can focus on that physical pain, rather than the emotional pain.”
- “I am numb. I cannot feel anything and wonder if I am still human. I will cut. Ouch. I can feel something.”
- “I hate myself. I must be punished.”
All of these are rooted in a sense of abandonment by the person or people who were supposed to be there when the child needed them. Often, parents will swear that they gave their child all they had to give. From their perspective, the child was “too needy,” or “got what all the other kids got.” From the child’s perspective, however, she did not get what she needed, when and how she needed it. Thus, the internal sense is, “My feelings are too much or too many,” “I need to shut down my feelings in order to be aware of and serve others.” or “I don’t deserve love the way I need it: I am not worthy.”
Gwen was a 14 year old girl with a lot of potential. She was smart, pretty, sociable and well-liked. Her parents were in an unhappy marriage and spent much of their time in toxic fighting, praising Gwen’s younger brother for his successes and demeaning Gwen for begin Gwen. She began scratching on her arm to distract herself. When Gwen began running away from home, using drugs and prostituting, she found glass shards and straight edges would do the job better; causing more pain, which she was sure that she deserved. After several years of work on Gwen’s abandonment and self-blame issues, she was able to stop harming herself and find other, more healthy methods of coping such as art, music, being in nature and an occasional rubbing of ice on her arm to feel some pain. She realized that she did not need to abandon herself even though her parents had done so; she deserved better.
Until mental health professionals, parents, teachers and doctors realize these regularly made mistakes, too many girls and boys, men and women will go mis-diagnosed and mis-treated in the medical and mental health systems. First and perhaps foremost is to not be disgusted or angry at the self mutilation. Would a professional show anger at an alcoholic? an anorexic? Self mutilation is just another means of coping with trauma, similar to using substances or eating disorders.
Next, taking an interest in the actual, physical wound is important. Ask what tool(s) they use. Was it clean? Did they clean the wound? Where and when do they harm themselves? Each answer will give invaluable information concerning how the client treats themselves, triggers and trauma response. Inquiring about thoughts and feelings immediately preceding the act(s) will also help when looking at ways to change or curb the behavior. Self awareness is extremely useful for the self injurer. Working with the self injurer to understand why and when they harm themselves will give them power over the powerful response to stress such as cutting; if they understand why and when, they have choices. Finally giving them alternative coping mechanisms, so that when they get triggered, they can choose, will go a long way in lessening or stopping self injury.
With more self injuring patients showing up in therapeutic settings, whether they be hospitals, residential treatment, foster homes or sometimes schools, helping professionals need to have clarity about who, how, when and why people harm 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 be working 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 injury. At the same time, having a basic knowledge of what is and is not suicidal behavior, what is and what is not attention-seeking, what is and what is not linked to early sexual abuse will only help with appropriate diagnosis and treatment planning by parents and professionals alike.
(c) Lisa Cohen Bennett, PhD