Common mistakes made when Work with self-harm
Angie was a 17-year-old dancer. Her dance teacher told her she needed help or stop dancing, if Angie was going to keep scratching her arm. When she turned 18, Angie decided to get a particularly painful part of her body pierced. That week in therapy, she finally agreed to talk about the resulting infection and why she was hurting herself.
Belle was a bright, talented, sociable 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 obvious. In a few sessions, Belle pulled up the extra long sleeves to show horizontal cuts along her wrists made with dirty scissors.
None of these teenagers wanted to commit suicide. Neither of them needed hospitalization at that time. They were both trying to avoid hurting themselves further. Both were from upper-middle-class families, in good schools, having academic and social success. Angie and Belle presented an image of perfection to the outside world, including their families; until they couldn’t do it anymore. A common mistake mental health professionals and families make is overreacting and believing that suicide is imminent. Self-harm or self-mutilation is actually a coping mechanism used to avoid committing suicide. “If I let out some of the feelings, I won’t feel so overwhelmed; hurt so bad; I’ll feel so numb; and I 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 17. As she grew up, 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 their mother was only seeking attention.
Daisy was a 23-year-old single woman in a banking career that she hated. She felt lonely but, due to the extreme early abuse, she didn’t trust anyone enough to risk friendships or more intimate relationships. After a period of psychotherapy to learn how her story affected her current social situation, Daisy began a meaningful relationship with a non-threatening man. As that relationship grew, Daisy became scared and began to cut her thighs and wrists. When his fiancée found out, he was enraged by her attention seeking behavior.
Another serious mistake made with self-injurious behavior is thinking that the young person or adult is “just trying to get attention.” In fact, those who self-harm are often masters at hiding their secret (s). They are masters at helping others and portraying their lives as if everything is fine. They are “acting” instead of “acting.” Therefore, a big mistake made in the mental health field is to ignore self-harm as simply a ploy to get attention. Most self-mutilations are done in complete privacy. So when statistics say that 1% of Americans self-harm (mostly women), we can be sure that’s a huge understatement. Cutters, markers, burners, bone breakers, scrapers, and chews all find places on their bodies that no one else sees. Bikini lines will be cut, scored above or below breasts, thighs or cuticles will be scratched, and then gloves will be worn. When the behavior is discovered, there is great shame and guilt; Usually it is not enough to stop the behavior, but self-mutilation can increase or worsen, and even more hidden, if the reaction of a loved one or a mental health professional is one of disgust, anger or helplessness. “I am a horrible being, I need to punish myself even more.”
Evelyn was seeing a Marriage and Family Therapist Intern (MFTI) because of her extreme and regular cuts on her arms and ankles. On supervision, the MFTI was certain that Evelyn had been sexually abused as a youngster due to self-harm. After looking at all the other factors involved in Evelyn’s story and her current life situation, it became clear that no such trauma existed. 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 off the scene and quickly landed in prison for life for murder. Evelyn felt truly abandoned.
Fran was admitted to the hospital for vertical cuts to her arm and inner thighs. Cutters know that horizontal means “help”, while vertical means “I’m serious and can kill myself.” Mental health and social work staff pressured 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 account of early emotional neglect by a workaholic father and an alcoholic mother came to light. Fran believed that she was unlovable and that her body was a place to show her contempt for herself. All the important ones had abandoned her, why not abandon herself?
A third mistake many helping professionals make when working with self-injurious people is believing that the etiology of 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 their 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 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’m numb. I can’t feel anything and wonder if I’m still human. I’ll cut. Ow. I can feel something.”
- “I hate myself. I must be punished.”
All of this stems from a sense of abandonment on the part of the person or people who were supposed to be there when the child needed them. Parents will often swear that they gave their children everything they had to give. From his perspective, the child was “too needy” or “got what all the other kids got.” However, from the child’s perspective, he did not get what he needed, when and how he needed it. Therefore, the inner sense is, “My feelings are too many or too many”, “I need to turn off my feelings to be aware and serve others.” or “I do not deserve love as 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 loving. 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. He started scratching his arm to distract himself. When Gwen started running away from home, doing drugs, and prostituting herself, she found that shards of glass and straight edges would work better; causing more pain, which she was sure she deserved. After several years of working on Gwen’s abandonment and self-blame issues, she was able to stop hurting herself and find other healthier coping methods, such as art, music, being in nature, and occasionally rubbing ice on her arm to feel a little pain. 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 physicians realize that mistakes are routinely made, too many girls and boys, men and women will be misdiagnosed and poorly treated in the medical and mental health systems. The first and perhaps most important thing is not to be upset or angry about self-mutilation. Would a professional show anger at an alcoholic? anorexic? Self-mutilation is just another way to deal with trauma, similar to substance use or eating disorders.
Next, it is important to take an interest in the actual physical injury. Ask what tools they use. It was clean? Was the wound cleaned? Where and when do they get hurt? Each response will provide invaluable information on how the client treats himself, triggers, and response to trauma. Inquiring about the thoughts and feelings that immediately precede the act (s) will also help in looking for ways to change or stop the behavior. Self-awareness is extremely helpful for the self-injurious. Working with the self-harming person to understand why and when they hurt themselves will give them power over powerful stress responses like cutting themselves; If they understand why and when, they have options. Finally, giving them alternative coping mechanisms, so that when activated, they can choose, will go a long way toward reducing or stopping self-harm.
With more self-injurious patients showing up in therapeutic settings, be it hospitals, residential treatments, foster homes, or sometimes schools, helping professionals need to be clear about who, how, when, and why people hurt themselves. Much of the fear that surrounds self-mutilation is due to a lack of awareness 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 what is not attention seeking, what is and what is not related to early sexual abuse will only help with the proper diagnosis and treatment planning by parents. and professionals alike.
(c) Lisa Cohen Bennett, Ph.D.