Self Injury

SUPPORTING A SELF-INJURER

Someone you care about has honored you by trusting you with information about their self-injury, or maybe you’ve inadvertently discovered it. Regardless of how you found out, you know about it now, and you can’t pretend it away — you have to respond in some way. Here are some guidelines for dealing with SI in a friend or family member.

Don’t take it personally.

Self-injurious behavior is more about the person who does it than about the people around him/her. The person you’re concerned about is not cutting, burning, hitting, or whatever just to make you feel bad or guilty. Even if it feels like a manipulation, it probably isn’t intended as one. People generally do not SI to be dramatic, to annoy others, or to make a point.

Educate yourself.

Get as much information as you can about self-injury in general. This page is a good start; there are also some very informative books out there (in particular, Bodies Under Siege by Favazza, The Scarred Soul by Alderman, and A Bright Red Scream by Strong). The Favazza book is more scholarly in tone, the Alderman book is oriented toward self-help, and Strong’s book presents the voice of self-injurers talking about what they do and why — it lets you inside the mind of people who SI. All contain much valuable information and advice.

Understand your feelings.

Be honest with yourself about how this self-injury makes you feel. Don’t pretend to yourself that it’s okay if it’s not — many people find self-injury repulsive, frightening, or provoking (Favazza, 1996; Alderman, 1997). If you need help dealing with the feelings aroused in you by self-injury, find a good therapist. Be careful, though, that you not try to get “surrogate therapy” for your family member/friend — what goes on in your therapy sessions should remain between you and your therapist. Don’t ask your therapist to try to diagnose or treat the person you’re concerned about, and if the self-injurer seeks treatment, be sure that s/he is seeing a different therapist than you are. Don’t discuss the content of your therapy sessions in any but the most general terms, and never say anything like “My therapist says you should…” Therapy is a tool for self-understanding, not for getting others to change.

Be supportive without reinforcing the behavior.

It’s important that your friend, lover, child, sibling know that you can separate who they are from what they do, and that you love them independently of whether they self-injure. Be available as much as you can be. Set aside your personal feelings of fear or revulsion about the behavior and focus on what’s going on with the person.

Some good ways of showing support include:

• Don’t avoid the subject of self-injury. Let it be known that you’re willing to talk, and then follow the other person’s lead. Tell the person that if you don’t bring the subject up, it’s because you’re respecting their space, not because of aversion.
• Make the initial approach. “I know that sometimes you hurt yourself and I’d like to understand it. People do it for so many reasons; if you could help me understand yours, I’d be grateful.” Don’t push it after that; if the person says they’d rather not talk about it, accept this gracefully and drop the subject, perhaps reminding them that you’re willing to listen if they ever do want to talk about it.
• Be available. You can’t be supportive of someone if you can’t be reached.
• Set reasonable limits. “I cannot handle talking to you while you are actually cutting yourself because I care about you greatly and it hurts too much to see you doing that” is a reasonable statement, for example. “I will stop loving you if you cut yourself” isn’t reasonable if your goal is to keep the relationship intact.
• Make it clear from your behavior that the person doesn’t need to self-injure in order to get displays of love and caring from you.
• Be free with loving, caring gestures, even if they aren’t returned always (or even often). Don’t withdraw your love from the person. The way to avoid reinforcing SIV is to be consistently caring, so that taking care of the person after they injure is nothing special or extraordinary.
• Provide distractions if necessary. Sometimes just being distracted (taken to a movie, on a walk, out for ice cream; talked to about things that have nothing to do with self-injury) can work wonders. If someone you care about is feeling depressed, you can sometimes help by bringing something pleasant and diverting into their lives. This doesn’t mean that you should ignore their feelings; you can acknowledge that they feel lousy and still do something nice and distracting. (This is NOT the same as trying to cajole them out of a mood or telling them to just get over it — it’s an attempt to break a negative cycle by injecting something positive. It could be as simple as bringing the person a flower. Don’t expect your efforts to be a permanent cure, though; this is a simple improve-the-moment technique.)
• If you live apart from the person you’re concerned about, offer physical safe space: “I’m worried about you; would you come sleep over at my house tonight?” Even if the offer is declined, just knowing it’s there can be comforting.
• Don’t ask “Is there anything I can do?” Find things that you can do and ask “Can I ?” People who feel really bad often can’t think of anything that might make them feel better; asking if you can take them to a movie or wash those (month-old) dishes (if done nonjudgmentally) can be really helpful. Spontaneous acts of kindness (“I saw this flower at the store and knew you’d love to have it”) work wonders.

Take care of yourself.

It sounds like hard work, and it is. And if you try to be completely supportive to someone else 24/7, you’re going to burn out (and they won’t have any incentive to change). You have to find ways to be sure your needs are being met.

Take a break from it when you need to. When setting limits, remember that as much as you love someone, sometimes you’re going to need to get away from them for a while. Tell the person that sometimes you need to recharge and that it doesn’t affect your love for him/her. Only break into this personal time in cases of absolute life-or-death crisis.

The balance here is tricky, because if you make yourself more and more distant, you might get a reaction of increasing levels of crisis from the other person. If you let them know that they don’t have to be about to die to get love and attention from you, you can take breaks without freaking the person out. The key is developing trust, a process that will take some time. Once you prove that you are someone who isn’t going to go away at the first sign of trouble, you will be able to go away in non-crisis times without provoking a crisis response.

Ultimatums do NOT work. Ever.

Loving someone who injures him/herself is an exercise in knowing your limitations. No matter how much you care about someone, you cannot force them to behave as you’d prefer them to. In nearly two years of running the bodies under siege mailing list, I have yet to hear of a single case in which an ultimatum worked. Sometimes SI is suppressed for a while, but when it inevitably surfaces it’s often more destructive and intense than it had been before. Sometimes the behavior is just driven underground. One person I know responded to periodic strip searches by simply finding more and more hidden places to cut. Confiscating tools used for SIV is worse than useless — it just encourages the person to be creative in finding implements. People have managed to cut themselves with plastic eating utensils.

Punishments just feed the cycle of self-hatred and unpleasantness that leads to SIV. Guilt-tripping does the same. Both of these are incredibly common and both make things infinitely worse. The major fallacy here is in believing that SIV is about you; it almost invariably isn’t (except in the most casual ways).

Accept your limitations.

Acknowledge the pain of your loved one.

Accepting and acknowledging that someone is in pain doesn’t make the pain go away, but it can make it more bearable. Let them know you understand that SIV isn’t an attempt to be willful or to make life hard for you or to be unpleasant; acknowledge that it’s caused by genuine pain they can find no other way to handle. Be hopeful about the possibility of learning other ways to cope with pain. If they’re open to it, discuss possibilities for treatment with them.

Don’t force things.

If you make overtures and they’re rejected, back off for a few days or weeks. Don’t push it. Some people need time to decide to trust someone else, particularly if they’ve received a lot of negative feedback about their SI before. Be patient.

UNDERSTANDING SELF INJURY

by Stuart Sorensen RMN

The whole idea of self-injury (SI) is, for many people, very difficult to understand. It’s a subject which causes most people to react with very strong emotions and can cause feelings of guilt, anger, depression and for many self-injurers, relief. That’s the bit most people who don’t harm themselves find the hardest to understand.

Many self-injurers find that acts such as cutting, overdosing, burning themselves etc. actually make them feel better – at least in the short term. This is especially true for people with Borderline Personality Disorder (BPD). It’s as though there’s a pressure cooker inside their heads and physical pain or the drama associated with emergency medical care is the only way they know to relieve the distress they feel.

The trouble is that there’s always a price to be paid for self-injury. That price may be physical (scarring, liver damage etc.), social (leading to relationship problems) or psychological (a source of guilt, depression, self-reproach, frustration or anger). The short-term relief is real and it works for a while but self-injury often causes more problems than it solves in the longer term.

This little handout is designed to help self-injurers find alternatives to SI, some of which cause ‘safe’ pain and some which avoid pain or self-injury altogether. The best way to find out which methods work best for you is to try them out – maybe keep a diary of what worked and what didn’t or what reactions you got from others and how that made you feel. Remember that the way you feel about what you do is at least as important as the action itself.

If your self-injuring is mainly to get a dramatic response from others (what some people might call attention seeking) it’s likely that you have a deep emotional need to feel validated. Validation means being valued and treated with respect for your feelings and opinions. You may need to know that others care about you and value your existence. A good way to put this to the test is to do something potentially lethal such as take an overdose and see what response you get. If people worry, make a fuss, rush you to hospital or spend long periods of time ‘supervising’ you that demonstrates the value they place upon you.

It’s not necessarily the attention itself that attracts you to self-injury so much as the validation that the attention demonstrates. People who react dramatically to your threats and suicidal gestures seem to be showing you how much they care and so you continue to feel validated so long as they keep rushing to your aid.

Unfortunately this is a very high risk strategy. And sooner or later it stops working and people begin to think less and less of you – you get to feel less validated instead of more. It’s also worth knowing that people who self-injure have been known to die ‘by accident’ when events don’t turn out the way they’d planned.

Most people who repeatedly injure themselves or make threats of suicide eventually end up alienating the people they love the most – the ones who have to respond when the blood hits the carpet or the pills get misused. Family, friends, partners eventually realise that they can’t cope with this behaviour and simply leave. Self-injury is a way of calling out to others which actually drives most people further and further away.

That’s the bad news – now here’s the good:

There are other ways to get the same amount of validation without resorting to self-injury. If you need to know that you’re wanted and cared for the best way is to get interested in other people. Most people will care about you roughly as much as you care about them. If you make a point of getting interested in someone else’s well-being they will more than likely return the compliment. That’s how friendships are formed – they get worked at.

Another way, when in crisis, is to tell the other person how you feel. Often you’ll get a much better result by sitting and talking honestly instead of expecting them to ‘guess’ how you feel because of what you do. You may be surprised to know that it isn’t always obvious how self-injurers feel.

Many people are confused, frightened and bewildered when faced with suicidal or parasuicidal behaviour. They get ‘sucked in’ by the gravity and drama of the situation but they certainly don’t enjoy it – and after a while they simply get out of the relationship. By expecting people to ‘guess’ how they feel; by ‘acting out’ in such a dramatic way self-harmers actually drive away the very people they’re trying to reach out to.

Other ways to remind yourself that you’re valued by others is to make a list – yes I know it sounds pointless – of all the things you have to be grateful for in relationships. You may have to think long and hard, particularly if you’re in ‘negative thinking mode’ but persevere. Remind yourself of all the times in the past when people have been there for you (even if you set the situation up with SI) and write them down. Some people find that simply reminding themselves of good relationships in this way is enough for them to feel validated once again.

Join a group of other self-injurers or maybe a special interest society. It doesn’t really matter what the group’s about so long as you can meet people and play an active part in it. This helps in two ways:

1 You get to form new relationships with people who may well come to care for you.

2 You develop an interest to take your mind off your own troubles.

For some people, of course, the drama isn’t what it’s all about. These people need to feel the pain of self-injury in order to feel better emotionally. If you’re one of these people you may like to try some other ways of causing yourself pain without actually doing any long term damage. For example:

1. Hold some ice cubes in your closed mouth for as long as you can stand.

2. Wrap a rubber band (loosely) around your wrist and ‘snap’ it against your skin.

3. Squeeze your ear lobe between your finger and thumb.

4. Squeeze the inside of your nose between the two nostrils with your finger and thumb.

5. Hold your arms in front of you for as long as you can bear.

6. Have a cold bath (Not a hot bath as scalding can kill).

7. Squeeze your nipples between your finger and thumb.

If you really feel you must self-injure it’s in your best interests to be honest with the people around you. They’re more likely to stick around if you explain the reasons why. If you ask them to make assumptions or pretend to be suicidal when all you want is an end to the emotional pain you feel family, friends and emergency staff may well grow tired of playing what they may well come to se as a game. As a rule people are much more sympathetic if they get the chance to understand why you’re choosing to self injure.

Everyone knows what emotional pain feels like and most people will relate to that (even if they don’t understand about self-injury itself) if you explain it to them. Most people will also soon come to know the difference between suicidal intention and parasuicidal gestures. If they think you’ve lied to them they may well just turn their backs on you – precisely what you were trying to avoid in the first place.

If all you can manage is honesty – with yourself and with others – that’s a good start. If you must self-injure do it as safely as possible and don’t pretend it’s more than it is to get validation – it’ll only backfire on you.

If you have a problem with self-injury your local library will have lots of useful information about methods of coping as well as local groups and helping organisations. Please have a look at what’s available – it may just save your life.

Here are the six step program recommended to BP’s when they feel like self injuring, feeling down etc. Have a look at these steps as it will help you to understand what they are doing and trying to achieve.

SIX IMPORTANT STEPS

Step 1. Stop

What you are doing and take in six big, deep breathes. Listen to the air as you breath in and out, feel your chest fill and stomach tighten, six times.

Step 2. Sit down, relax and think what the issue/problem is

If you like put your favourite song on in the background. Get your journal and read the promise you made to yourself – ‘I am in control of who I am and how I feel. I have hurt enough over the years and I will no longer hurt myself in any way’ . Now take a few minutes to think then write down what you are currently feeling and what you think the problem/s is.

Step 3. Now review what you are feeling against the issue/problem/s you have

Link your feelings to the problems you have listed and then come up with three (3) things you can do. Some items may be things you can do right now, some may be longer term solutions. Don’t worry about what is what, just list them.

Step 4. Make a positive decision for you

Go back over what you have written and decide what you can do right now.

Step 5. Action time

Whatever positive action you came up with – do it. If you are feeling lonely you may have decided to ring a friend, visit someone, write a letter etc. Do something that is good for you.

Step 6. Things learnt

Review what you wrote in step 2 and make a note of how you feel now, what worked, what didn’t and how it could be improved if there is a next time. Finish with some deep breathing whilst saying to yourself – I am a good.