Dr. Jane Chin: What are the biggest misconceptions or “myths” people have about self-injury?
Dr. Deborah Serani: I’d have to say that the biggest misconception about self-injury is that most people think that those who cut or self-injure are suicidal. Though any behavior that puts a person in harm’s way requires clinical evaluation, the basic reason individuals cut or self-harm comes from the wish “to control” or to “numb away feelings.”
Dr. Chin: Why is cutting or self injury such a difficult subject for people to talk about?
Dr. Serani: There is a lot of shame associated with this behavior. Seeing the scars or scabs serves as reminder to the person that they cannot find a better way to move through pent up feelings. They feel like they have failed or are flawed in some way, which exacerbates there negative feelings even more.
Another aspect here is that people who cut tend to have an underdeveloped awareness of feeling states. What I mean by this is that it is hard for them to differentiate feelings and emotions and to put them into words. The clinical term for this is “Alexithymia”. So it literally can be difficult for a person to talk about cutting because he or she may not have the ability to describe emotional experiences well. The goal of therapy addresses not only the cutting behavior, but to help the person learn to identify, experience, and express emotions more fully.
Dr. Chin: What are some of the signs of self-injury that family members or friends can watch for?
Dr. Serani: There are visual cues and behavioral cues. The visual clues vary from subtle to obvious. In the subtle range, family and friends should be aware that the wearing of long sleeves or pants on warm, hot days, wearing excessive bracelets on wrists or bandanas wrapped around body parts are often used by individuals who cut. The more obvious cues are seeing scars or bruises on a loved one.
It is important for family and friends to know that finding blood soaked tissues, blood stains on clothing or bed sheets are also signs of cutting and self-harm. Finding sharp objects like glass, a bottle cap, or cutting instruments in one’s pocket , in the bathroom or on a night table or dresser warrant further exploration. Behavioral cues include the need to be alone for long periods of time in the bathroom or bedroom, as these are the places where cutters often report performing their self-injury. Isolation and irritability are other behavioral cues to look for.
Dr. Chin: How may we best approach someone whom we suspect is a cutter and offer support in a non-threatening, non-judgmental way?
Dr. Serani: The best way to approach someone who is cutting or self-harming is to put judgment on the backburner. Approach this person in a sensitive and non-confrontational manner. Saying something like, “I notice things on your body, and I want to understand your pain.” Most cutters respond to a person who is genuinely interested in understanding their behavior.
Dr. Chin: In your article, Cutting: The Quiet Epidemic, You had said that media has something to do with a rise in cutting- and how those looking for role models sometimes see famous people who do it or even glorify by means of movies or songs. What can parents do to help buffer against these influences without sheltering their children? What can teens and adults do to buffer themselves?
Dr. Serani: The media and the music industry can glamorize cutting and self-harm, making it feel “trendy” and “in style”. That message is toxic for vulnerable individuals and a contagiousness results. This phenomenon of contagion is responsible for the cutting trend. A person sees it glamorized as a way to problem solve, and then decides to try it out. With regard to famous people who cut or self-harm, many will say that they were struggling with feelings and emotions but have found better ways to cope with things than cutting or self-harming.
In fact, Angelina Jolie recently said that she has happily moved on from self-harming behaviors. What parents can do to combat this trend is to point out that the goal to well being is choosing healthy ways to express emotions. Activities like running, exercising, writing or creating are better choices than cutting of harming one’s self through self-injury. Teens can educate themselves about cutting to learn that the behavior is not adaptive or healthy. And when media or the music industry glamorizes the subject, teens and adults can use such moments as a springboard to talk about how “off the mark” it is to heighten the self-injury trend.
Dr. Chin: Thank you, Dr. Serani! To read Dr. Serani’s blog, please visit her website.
RELATED ARTICLE: CUTTING, THE QUIET EPIDEMIC
by Dr. Debora Serani, Psy.D.
Originally published in the 2005 Spring Edition of the Suffolk County Psychological Newsletter, republished here with persmission.
The crimson river flows
and the pain recedes.
Circles, lines and bows
The sweetness of the bleed.
This is a poem written by a teenage girl with whom I have been working. She chose to use the name Anne, after her favorite poet, Anne Sexton. Now, some of you may know that Anne Sexton killed herself, and that my patientâ€™s choice to use her name is somewhat suspect. But this Anne, a sixteen year old girl, has no intention of hurting herself. She is like most people who cut. She is trying to soothe herself, not kill herself.
What is Cutting?
Cutting falls under the umbrella of Self-Injurious Behaviors (SIB). Other forms of SIB include burning, skin-picking, wound-picking, skin puncturing and flaying. This paper, however, will focus specifically on cutting behaviors in individuals who are not psychotic or brain damaged.
Cutting can range from severe tissue damage to minor skin scratches. Cuts can take form in delicate lines, swirls, patterns and initials. â€œLike a tattoo,â€ one patient revealed. Cutting can be smooth from beginning to end, suggesting a slow, steadied hand doing the deed. Cuts can occur in haphazard slashes, revealing a fury in the strokes. Cutting wounds can present in a rippled manner, where blood spills intermittently through the skin, giving the lesion a bumpy, prickly look. Redness can accompany cuts, as can bruising. Cuts can be thick, deep and long, and as one patient discovered, can get infected and require hospital attention. Cutting is usually assigned to hidden places, not readily visible to the casual observer. With regard to moderate and mild cutting, clothing conceals them, bracelets hide them, band-aids cover them. More severe cutting may be noticeable in the way a person carries his/her posture (limping, hobbling or recoiling).
The style of cutting will be as individual as the person. So, too, will be the instrument chosen for accomplishing the act. Tools for cutting can be items specifically designed to cut: scissors, knives, razors. Ordinary items can be employed: pins, paper clips, needles, pen caps, forks, broken glassâ€¦anything that can break the skin.
Translating Cutting in Psychological Terms
The cutting, carving and scratching of skin in is an attempt to control overwhelming emotions, feelings of helplessness, and for some is a way to manage anger or shame. Cutting is a way to manage self-punishment, self-hate or self-nurturance. In its simplest form, cutting is a physical solution to a psychic wound. It is a deliberate, private act that can be habitual or isolated in occurrence. It is not attention seeking behavior, not meant to be manipulative, nor is it a conscious attempt to end oneâ€™s life. (Azar, 1995; Carll, 2003; Froeschle & Moyer, 2004; Kress White, 2003; Levenkron, 1999; Strong 1999).
Symbolically speaking, cutting is viewed psychologically as a method to communicate what cannot be spoken. The skin is the projected canvas, an encasement of sorts, where aspects of the psyche reside. Anzeiuâ€™s (1989) theory of skin-ego best describes this, and is compelling reading for professionals. â€œMutilations of the skin are dramatic attempts to maintain the boundaries of the body and the Ego, and to re-establish a sense of being intact and cohesiveâ€ (Anzeiu, 1989, p.20). It is important for psychologists to understand the skinâ€™s symbolic representation in the act of cutting and the ego organization that is being attempted by the individual. Talk is always preferred over action in therapy. So the goal here is to help the patient translate verbally what is occurring physically.
Who is Cutting?
At present, little is known regarding etiology, course, diagnosis, assessment and appropriate treatment interventions for cutting. The data available focuses on self-injury behaviors as a whole.
Statistically speaking, approximately 4% of the population in the United States uses self-injury as a way of coping (Briere & Gil, 1998). Individuals who self-injure are represented in all SES brackets in the United States (Brier &amp;amp; Gil, 1998; Dieter et. al., 2000). The behavior usually has its origin in adolescence, and has been shown to continue for some into adulthood (Kress White, 2004). Girls and women tend to self-injure more than boys and men, but this maybe represented by the fact that females tend to turn to professional help more than males.
Cutting and the DSM
Cutting is not a separate category in the DSMIV-TR, but researchers in the field are pushing for its inclusion in the DSMV. Pattison & Kahan (1983) have been writing about Deliberate Self-Harm Syndrome for over two decades, urging the recognition of cutting and the other self-injury behaviors as distinct disorders. Favazza & Rosenthal (1993) have supported this as well and have been detailing their research about Repetitive Self-Harm Syndrome for over a decade. For now, cutting can be diagnosed as an Impulse-Control Disorder NOS.
Cutting has been markedly linked to borderline personality disorder (Brodsky, et. al., 1995; Russ et. al., 1995). Akhtar (1995) states that the borderline individual uses cutting as both an attempt at self-delineation and to express a connection (or lack of connection) with others. Cutting has been moderately associated with histrionic and narcissistic personality disorders (Konicki & Schulz, 1989; Kress White, 2003), suggesting that the reactive traits in these disorders raises the likelihood of cutting tendencies. Disorders of the Self have also been companioned with cutting and can be seen in the impairment of a patientâ€™s self-capacity for tolerating strong affect and the maintaining of a sense of self worth (Dieter et.al. 2000). Depression, anxiety, obsessive compulsive disorders and eating disorders have also been associated with cutting as have childhood trauma, sexual abuse, and gender identity, though not statistically linked as previously mentioned.
Research into self injury has revealed that the act can become physiologically and psychologically addictive. Clinical studies to date have attended to the role of endogenous opioids. Endorphins function as natural narcotics or opiates in the body as the self-injury occurs, and an individual learns to associate the act of cutting with the rush from the endorphin release (Azar, 1995; Simeon et al.; 1992; Villalba & Harrington, 2000). This â€œhighâ€ secures the cyclic addiction. Individuals who self injure also report feeling no pain as the cutting occurs. This is similar to “stress-induced analgesia” that wounded soldiers and athletes report experiencing (Hilgard, 1976).
Why is Cutting more Prevalent
Cutting behaviors have been reported for many years and are on the rise, reaching epidemic proportions (Froeshcle & Moyer, 2004), but there is no hard and fast evidence as to why. Concern is at such a fevered pitch that the American Self-Harm Information Clearinghouse named March 1, 2005 as National Self Injury Awareness Day to educate and inform medical and mental health professionals and the general public about the self injury. The United Kingdom and Australia have marked March 1st as National Self-Injury Awareness day in their respective countries as well.
Media contagion seems to be a common theory as to why cutting is on the rise. High profile individuals like Princess Diana, Johnny Depp, Christina Ricci, Fiona Apple, Angelina Jolie, and Courtney Love have revealed that they deliberately cut or self injured. Movies like â€œGirl Interruptedâ€ and â€œThirteenâ€, depict individuals using cutting behaviors as a means to reduce adversity. This gets translated as a possible option for individuals who are grappling with significant emotional turmoil. Peer contagion is also a factor in school and work settings – If she tried it, maybe this can work for me.
Assessment and Interventions
Kress White (2003) tells us that we are still in need of finding better assessment and intervention tools for cutting behaviors. For now, many clinical practitioners and school psychologists use eclectic approaches when dealing with cutting.
The first step in assessment is to determine if cutting is a suicide attempt. Therefore, a standard suicide assessment is paramount. Once ideation, intent, and plan are ruled out, the inquiry should address the patterns of cutting, the conflicts the teen or adult experiences, as well as inspection of said cuts if given permission to see them. Educating the individual about what cutting is in psychological terms will help start the recovery process.
Duty to warn will be a matter of interest. A breach of confidentiality may be appropriate when cutting occurs. Teens and adults who cut do not want to end their life, but cutting can put one at risk for significant injury and infection, tissue or muscle damage and accidental death.
Exploring family dynamics is another area that should receive great coverage. The person who cuts often feels that h/she doesnâ€™t have the right to assert him/herself, doesnâ€™t feel that thoughts and feelings are respected, or gets punished for his/her expression by family members (Levenkron, 1999; Strong, 1999). The exploring of the family dynamics will reveal that the family constellation is in need of help as well. Family therapy is very essential modality for recovery.
For teens that are not comfortable with family therapy, cognitive and behavioral approaches can be pursued to help address the maladaptive coping schemas. Psychodynamic therapy can also be a considered orientation to uncover the unconscious and symbolic aspects of the cutting.
Interventions that have been used with patients with dissociative disorders have been useful with individuals who cut. Visualization can be used to move through painful thoughts or affects, and keeps the person in-the-moment. Sensory Grounding Skills, holding something soft, listening to soothing music, drawing or writing, for example, can interrupt the trance-like state and can shift the person from engaging in the maldaptive cutting. Cognitive Grounding Skills, like â€œWho am I really mad atâ€, â€What is setting me offâ€, â€œI am safe and I am in controlâ€, re-orient a person to the here-and-now, and can keep the impulse to cut from emerging.
If cutting is not addressed, a person will not only suffer scarring on a physical level, but will experience poor self-esteem, an inability to tolerate and master conflicts, and constriction in social and intimate relationships, just to name a few. Trust, expression and connection will likely be tentative and tumultuous at school, work and home as well.
Returning to Anne, she reports less frequency in her cutting, and her urges have lessened in intensity. She and I have come to learn that her personality and behavioral traits are dependent in nature. She sees how her need for attachment and the need to not be alone causes her to cut. She has taken very well to journal writing, giving new meaning to the phrase “the pen is mightier than the sword”.
- http://www.selfinjury.info/ – Based in the United Kingdom, this website is volunteer based that raises awareness about self injury worldwide. Many of the contributors are former self injurers.
- http://www.selfinjury.org/ – The American Self-Harm Information Clearinghouse website offers articles and resources to inform the general public as well as health professionals about the phenomenon of self-harm.
- http://www.selfmutilatorsanonymous.org/ â€“ Using a 12 step program, Self Mutilators Anonymous offers in-person and online fellowships to help in the recovery from self injurious behaviors.
- http://www.sidran.org/ – The Sidran Institute, along with Ruta Mazelis, publish The Cutting Edge Newsletter. Articles are often penned by teens and adults living with self injurious behaviors, and there are empirical articles and clinical papers from professionals in the field who treat patients who engage in SIB as well.
- American Self Injury Clearinghouse – www.selfinjury.org
- Azar, B. (1995). The body can become addicted to self-injury. Supplemental readings from the APA Monitor. Washington, DC: American Psychological Association.
- Akhtar, S. (1995). Losing and fusing. Borderline transitional object and self relations. Psychoanalytic Quarterly, 64:583-588.
- Anzieu, D. (1985). The Skin-Ego. New Haven: Yale University Press.
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- Hilgard, E.R. (1976), Neodissociation theory of multiple cognitive systems. In: Consciousness and Self-Regulation, Schwartz G.E. & Shapiro, D. eds. New York: Plenum Press.
- Konicki, P. E. & Shulz, S. C. (1989). Rationale of clinical trials of opiate antagonists in treating patients with personality disorders and self-injurious behaviour, Psychopharmacology Bulletin, 15: 556-563.
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- Russ, M.J., Clark, W.C., Cross, L.W., Kemperman, I. Kakuma, T. & Harrison, K. (1995). Pain and self injury in borderline patients: Sensory decision theory, coping strategies and locus of control. Psychiatry Residency, 63: 57-65.
- Simeon, D.; Stanley, B.; Frances. (1992).Self-mutilation in personality disorders: psychological and biological correlates. American Journal of Psychiatry, 149(2):221-226.
- Strong, M. (1999). Bright red scream: Self-mutilation and the language of pain.
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