1. Understanding Self-Injury: A Pain Too Deep For Tears
Lynne E. Muller, PhD, NCC, LCPC
Mary Ann Mathews
2008
Into self and Mary Ann
A topic that is sometimes hard for us to understand
How anyone can purposefully cut themselves-I whine when I get a small paper cut!
Some of you are already experts in this field, others are like us, people who have studied this issue, and some of you may not be as well versed in this topic yet.
We are not experts. We are two practitioners who saw a need and sought to address it.

2. Self Injury 1. Who self injures? Why do they do it?
What it is and is not.
How can we help?
Our goals today
From the research and from Mary Ann’s practical experience with kids who cut.

3. “I needed to cut the way your lungs scream for air when you swim the length of the pool underwater in one breath. It was a craving so organic it seemed to have risen from my skin itself.”
Quotes throughout from the children themselves. Asking that one of you read it so we can imagine their voices as we hear their words.
Someone have #1 And willing to read this one for us?
Caroline Kettlewell
Skin Game 1

4. Self Inflicted Violence
Self-Injury Terms
Self Inflicted Violence
Cutting
Self Harm
Many terms for self injury in the literature.
We will probably use self-injury or cutting today but we could be using any of these terms.
Self Mutilation

5. SI Behaviors Cutting Scratching Abrading Burning
Some forms of hair pulling
Biting
Inserting foreign objects into the body
Interference with wound healing
Ingesting toxins
Cutting
Scratching
Abrading
Burning
Some forms of hair pulling
Biting (including nail/cuticle biting)
Inserting foreign objects into the body
Interference with wound healing
Ingesting toxins
Can also be:
Head banging
Hitting and bruising themselves
Scalding showers
Cutting off circulation
A number of self injurers use more than one method.
We will not be discussing more serious injuries that sometimes occur with an autistic, psychotic, or schizophrenic diagnosis.
My role is to talk about three students that I worked with in a support group.
J L B
Male female male
When the group began, about mid-year, their cutting was escalating in severity and frequency. They were pulling away from other relationships in their lives.

6. Warning signs Unexplained frequent cuts or burns
Wearing long sleeves or pants in warm weather
Avoiding swimming pools or the beach
Wearing thick bracelets to cover wrists
Having sharp objects in purse, book bag, or bedroom
Difficulty expressing feelings
Withdrawal from close relationships
What to watch for:
Could be signs of other issues as well
Wearing long sleeves or pants in warm weather (cover the marks)
Avoiding swimming pools or the beach (not bathing suit or exposed skin)
Wearing thick bracelets to cover wrists (cuts, scratches covered)
Having sharp objects in purse, book bag, or bedroom (comfort in having the tools close by-just knowing they are there)
Difficulty expressing feelings (verbally shut down. Very expressive in writing)
Withdrawal from close relationships (afraid someone will find out or they may accidentally tell them)

7. Self injury is the intentional harm of one’s own body without conscious suicidal intent. (Aldeman, 1998, Favazza, 1998, van der Kolk, et al., 1991)
All the experts use this definition in the literature for self injury
Self injury is defined by intention
Intent to harm one’s body
Not intending to suicide

8. What Self Injury is NOT It is not a suicide attempt
(attempting to feel better, not escape all feelings)
It is not usually attention seeking
It is not a danger signal to others
In the early stages, it is a carefully controlled behavior. They are careful to avoid arteries and veins. As the behavior intensifies, some kids begin to lose control and hurt themselves more than they intended.

9. NOT SUICIDAL BEHAVIOR
“…self-mutilation is distinct from suicide…A basic understanding is that a person who truly attempts suicide seeks to end all feelings where as a person who self-mutilates seeks to feel better.” (Favazza, 1998)
Intention-does not intend to die as a result of his/her acts. Intends to live.
Rather than a suicidal gesture cutting is a symbol of the fight to stay alive.
“There is no hazy line. If I am suicidal I want to die, I have lost all hope. When I am self-injuring I want to relieve the emotional pain and keep on living.”
(Lindsay, Age15 in Strong, 1998)

10. Who?
Roughly 2% (1-4%) of the population. In some studies reported as high as 8 million Americans self-mutilate.
30 times the rate of suicide attempts
140 times the rate of completed suicides
May also suffer from eating disorders
90% who cut began as teenagers
Estimated 2 million Americna purposefully cut or burn themselves.
The average person who self-injures starts at age 14 and continues iwht increasing severity into her late 20’s.

11. Who? Typical profile Female Mid 20’s to early 30’s
Began cutting as a teen
Middle to upper class
Intelligent, well educated
Perfectionist
I found these students to be quite indignant about generalizations. Of course, we all want to think of ourselves as unique. We don’t want to think that we are just following a crowd or being influenced by others.
Female – though the guys suggested that perhaps the males just don’t tell us; newest research by Lisa Boesky, a clinical psychologist in the field suggests that it may be closer to 50/50
Mid 20’s to early 30’s
Began cutting as a teen – which is a turbulent time, experiencing lots of change, body image may be poor, worried about fitting in, they may not have developed adequate coping strategies
Middle to upper class
Intelligent, well educated
Perfectionist
The kids in this group were articulate, insightful, intuitive . .
They had a deep sense of social justice.
They were upset when they saw other people being treated badly in the school.
They wanted to talk about existential issues: the meaning of life, the purpose of their own lives . . .
I attended a presentation by Dr. Nadia Webb, a neuro-psychologist who specializes in gifted children and those are characteristics she associated with gifted children (perfectionist), so it started me wondering if in some cases there may be a connection there.
Lisa Boesky – self injurers more or less fall into three categories:
The classic kind of self injurer – high achieving, good looks, popular, lots of parental pressure and responses like “I’m fine” “I can handle it”
Anti-mainstream kids – goth, alternative clothing, piercings, tatoos, friends also self injure; are proud of being different - Self injury websites are dangerous for these kids. They bond with other self injurers. It becomes their identity. They have a shared secret. The websites even show pictures of the injuries and it can become a competition. Stopping means giving up this intriguing secret life.
Copy-cat cutters who do it to fit in, not for emotional reasons

12. Who? Males and females All races and socio-economic levels
Ages 15-50’s
Not easily identifiable
Marilyn Monroe, James Dean, Princess Diana
Best neighborhoods as well as foster homes; private schools as well as prisons.
Cutting has been with us for at least two thousand years-
New Testament Gospel of Mark in which a man living in a graveyard who is believed to be possessed, is described as cutting himself deliberately with stone.
Shamans cut . In many cultures (Aztecs, Olmecs, Maya, Hindus) cutting was done to gain favor with the gods.
Catholic church made saints of several people who mortified their flesh.
Blood is very symbolic-of healing and transformation. It is used in many religious ceremonies to demonstrate suffering and salvation.
Early medicine used bloodletting to get rid of bad blood.
Scars are also richly symbolic. They are a permanent, physical record of pain and injury but also of healing. They signify an ongoing ballet and that all is not lost. Nature triumphs and the skin heals.
Cutting may be a primitive form of self-surgery of cutting out that which is bad and the stage is set for healing. (Favazza in Body Under Siege: Self-Mutilation in Culture and Psychiatry.)

13. Characteristics are often depressed, feel powerless or anxious
have low self esteem /negative body image
have difficulty expressing their emotions verbally
experience difficulty with relationships
aim for perfection
often have negative body image
lack impulse control/suppressed anger
do not have a repertoire of coping skills
may have serotonin dysfunction
possible trauma
Depressed, powerless, anxious – Maybe there is poor communication in the family, maybe there is a lot of anger in the home, maybe a parent has a substance problem, maybe the parent is depressed an not able to be a caretaker, maybe someone in the family is too sick to be a caretaker, maybe the parent is working three jobs and is never home. Lisa Ferentz, a clinical social worker who has researched this topic, believes that major disruptions in parental care, prolonged separations exacerbates cutting. (Made me wonder about hospitalizations, incarceration of a parent, military deployment – may not cause cutting, but could exacerbate the behavior.)
Low self esteem –Negative body image – that’s a whole presentation in itself, we know it is rampant – TRUE IN THIS GROUP!
Difficulty expressing emotions verbally can also result from those environments
Difficulty with relationships –
Aim for perfection – no one can be perfect and trying causes a lot of anxiety
Lack impulse control/Suppressed anger – TRUE FOR “B”, new brain research tells us that the prefrontal cortex, that part of the brain that helps us control impulses and anticipate consequences is not fully developed until we are in our 20’s
Have not developed coping skills –
May be serotonin dysfunction –
Possible trauma -

14. Abuse?
Many who self-injure did not suffer childhood abuse (Zweg-Frank, et.al, 1995, Brodsky, et. al., 1998)
50-60% suffered childhood abuse or trauma. That means that 40-50% did not (Favazza,1998)
No evidence that all cutting is precipitated by childhood physical or sexual abuse. Everyone who self injures has a pain narrative, not necessarily an abuse narrative. It may be about half.
“B” feels that being seduced by an older woman was a trigger for him.
The place on their body where they cut may be significant, especially for those who have experienced trauma. Lisa Ferentz, a clinical social worker who has done a lot of work with self injury, said that she worked with a girl who self injured on her upper arm because that’s where her father had grabbed her. Another girl self injured on her inner thigh because that’s where her abuser had ejaculated. Lisa Boesky told a story about a boy who from his bedroom, overheard mom being beaten to death and his self injury was to his ears. They may not have words to describe their trauma. They may be showing us in other ways.

15. Then Why? Invalidating environments (Lineham, 1993)
Expression of private experiences and feelings are not validated
Feelings are trivialized, punished or ignored
Experience of painful emotions are disregarded.
Child’s interpretation of his or her behavior is dismissed
Child told he or she is wrong in both the description and the analysis of his or her own experiences
His or her experiences are attributed to socially unacceptable characteristics or personality traits
Largest research study 1998 Favazza and Conterio of 240 chronic self-mutilators Many of the people in the research told the researcher that their childhoods were “miserable”.
Ranging from physical and sexual abuse to loss of a significant family member. Vast majority said they grew up in families full of anger and double messages, in which they were told to always be strong but prevented from expressing feelings.
Examples of messages: Constant, repeated messages:
You are just not trying hard enough.” (Nothing I do can ever please them)
You’ll never make a good college with those grades.” (All they care about is the college I go to)
You are too sensitive.” (I am defective)
“Cheer up. Snap out of it. Get over it.” (I shouldn’t feel anything)
“Just look on the bright side and stop being such a pessimist.” (I am wrong in what I think)
You don’t hate her. (I don’t even know what I think)
I’ve sacrificed everything so you can be happy and look at you all you do is whine about how strict I am.(I will never be a good enough child)
Parent may be too busy to even notice that the child is in pain-and the child is really good at hiding it.
Parent may be living their own dreams out through their children and push them too much.
Their voices are silenced. They are forced to find another language-primitive and destructive

16. In their own words . . .
2 & 3
“There are times when I hurt too deep for tears, so I cut and it lets out some of the hurt. It’s like when you see the blood flowing out, the pain and fear are flowing with it.”
“Watching the blood flow out makes me feel clean, purified. It feels like something bad or dirty is leaving with the blood.”

17. In their own words . . . 4
“The stopped voice becomes a hand lifting knife, razor, broken glass to cut, burn, scrape, pop, gouge. The skin erupts in a mouth, tongue less, toothless. A voice drips out, liquid…a voice sears itself for a moment, in the flesh. This is a voice emerging on the skin, a mouth appearing on the skin. The body which could not be air on the larynx becomes the stroke of a razor on the breastbone or of a red-hot-knife-tip upon the wrist…” .
Janice McLane (1996)

18. Why do they harm themselves?
To release intense feelings
The physical pain may be easier to deal with than the emotional pain
To feel real, alive
To exert some control
Acting out self punishment
To release intense feelings – and regain equilibrium
The physical pain may be easier to deal with than the emotional pain – and is evidence of the depth of the pain
To feel real, alive
To exert some control – also true of eating disorders
Acting out self punishment
Validation of being
Helps ground themselves in their bodies
Stopping, inducing or preventing dissociation
Communication
Self-nurturing
Self-punishment
Re-enacting previous abuse
Method of coping
“B” said, “This is one thing I can do better than my brother.”

19. Cycle of Cutting Cutting Disassociation Relief Into the Void Panic
Cutting is often ritualistic in nature. There is usually a specific ceremonial pattern involved, a favorite implement, a specific place (on the bed, on the floor). Sometimes comforting relics are kept-a bloodstained piece of gauze…
Experience an emotion they can’t handle-it may be too strong or too painful or because they have been taught that they are not allowed to feel. Since the mind can’t handle it something like a very strong anxiety attack occurs. The heart beats fast, and they may have trouble catching their breath-feel panicked.
The panic is so frightening and overwhelming that they enter into a dissociated state-the mind goes blank and they feel distant form themselves.
They have figured out that cutting or inflicting pain focuses the mind and brings them back from the dissociation.
After cutting they feel calm, reintegrated, “real’ again and often fall into a restful sleep. They have taken control, are active participants, their strength and courage have been tested and they are, once again survivors.
Shame, guilt-When the peace and euphoria recedes they are filled with shame and regret. They hate that they need to cut so much and that they can’t stop. They know they are addicted to a behavior others would consider crazy and grotesque.
Addiction?
some biological evidence that cutting and burning may release natural opiates and other brain chemicals, creating an addiction and withdraw cycle. Karen Conterio (researcher) labels cutting “addictive-like”. Favazza prefers to call it a habit. Both agree that cutting. Like a true addiction, can be progressive, escalating in frequency and intensity over time.
And may move to new places on the body
Shame, guilt,
remorse, disgust
Panic
Mounting anxiety, anger or self hatred, alienation
Muller 2005

20. In their own words . . .
5 & 6
“It’s like opening up a safety valve or letting steam out of a covered pot.”
“Sometimes I cut just to make myself feel something because I am just totally numb.”
(In Strong, 1998, p.7)

21. Why? 7
“I felt like I was isolated from the world, dead, with no emotions at all. The blood told me I was alive, that I could feel…Also I couldn’t cry, and bleeding was a different form of crying.”
(Lindsay in Strong, p.57)

22. What about the DSM?
Currently listed as a symptom associated with a number of mental health disorders
DSM IV doesn’t list self-injury as it’s own diagnosis at this time.
Some mental health professionals are advocating for self injury to be listed as a separate diagnosis

23. SI is often associated with:
Borderline Personality Disorder
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
Dissociative Identity Disorder
Eating Disorders
Substance Abuse
Depression
No surprise that self injury is associated with these diagnoses

24. DIAGNOSIS (Ferreira de Castro, et.al., 1998)
Self-Injure Suicide Attempt
Major Depression
14%
56%
Alcohol Dependence
16%
26%
Schizophrenia 2% 9%
Dysthymia
12% 7%
Adjustment disorder with depressed mood
24% 6%
Further work has been done to compare diagnostic behaviors of those who self-injure to those who attempt suicide.
More evidence that self injury is not a suicide attempt.
The greater the depression the less self-injury and the greater the suicidal behavior.
The reverse is true for the lesser levels of depression-dsythmia.

25. Therapeutic Goals
Encourage communication about self-injury and relevant aspects of the child’s life.
Improve the quality of client’s life as it relates to self-injury.
Explore themes of guilt and shame.
Diminish use of self-injury as the coping skill when client desires to make changes. (Conners, Rubin, et, al,2002).
There is no single therapeutic approach that works with all SI since the roots of the disorder are so varied.
Acute symptoms need to be brought under control with medication or behavior modification in order for the client to be able to tolerate exploring the deeper issues.
Serotonin based meds seem to help stop the chronic, repetitive cutting. Meds alone not enough.
Safe and trusting relationship with therapist vital to helping child learn to soothe and care for him or herself in a healthy manner.
Trauma-based approach. Help them gain control over dissociative states-taught gounding techniques (look around the room. Feet touch the floor).
Decondition anxiety-relaxation and stress management. Develop a social support network.
Understand the anxiety, anger and pain Conceptualize the child as a trauma, neglect, abuse survivor.
Understand and acknowledge the cutting is the coping mechanism. No attempts to eliminate it since it allows the child to survive.
Healing is a process of increasing the understanding of the impact of the environment.
The client will slowly expand her perspective and options for making choices. She or he must direct his or her own healing process
Takes time and has relapses. Process

26. Helping: What to Do (Alderman, 1997)
Learn about self-injury.
Talk about SI. Ask about it.
Be supportive. Show you care.
Acknowledge the effort to cope with very difficult emotions
Set limits
Be available, but refer when appropriate
Don’t discourage self-injury
Recognize the severity of the distress
Learn about self injury - Read. SI is confusing to the cutter and to the helper. Read so you understand and can help. Know resources to suggest.
Talk- removes the secrecy and reduces the shame. Encourages a connection between you and the injurer. The “teach me” model works well with these kids.
Be supportive – Build rapport, develop relationship, demonstrate compassion, care. Ask directly how you might be helpful. If you have any keep your negative reactions to your self. Be non-judgmental and patient. Most cutting results in healable injuries. Most self injurers know when to end a session-after a certain amount of injury the need is somehow satisfied. Only later with compulsive cutters do we see more serious cuts.
Be available - express your willingness with no restrictions on the discussion
Acknowledge – how difficult it is to continue with daily routine and responsibilities
Limits – In schools, we may have to pre-schedule appointments so they don’t come every day.
Don’t discourage injury - it is their coping mechanism. You can’t take it away until they are ready to replace with something else. Telling them to stop is both aversive and condescending. It is their survival skill-nothing else works for them. Leave it alone. It is essential for the person to have this option. Demanding they stop is not only futile it can set up a power struggle
Recognize the severity of the person’s distress-most don’t self injure because they are curious-they do it because they hurt and because they can’t not do it. Honor the high level of emotional distress and pain.
Refer-local therapists
Be patient-SI are maing their best attempts to manage their stress. This is likely their only means of relief. Honor it and their strength and pain.
Eventually support the development of the child’s ability to develop alternative coping strategies

27. What Not to Do Be afraid to ask the question, “Do you self-injure?”
Make eliminating the behavior the primary goal
Make a safety contract or use contracts as a reward or punishment
Visibly monitor their injuries
Make him or her feel ashamed or guilty about the behavior
We can’t afford to ignore the issue. We need to ask.
We already know that we don’t work on eliminating a behavior until the child has integrated more effective coping behaviors into his or her life. They cut to live-so we really want to make a change in that behavior before we have helped them get better?
Contracts just set it up for the child to lie to us. If he or she could stop they would.
Just like we don’t monitor food intake with eating disorders we don’t focus or monitor the cutting.
They already feel bad or they wouldn’t be cutting.

28. “This is yet another secret I must hold to myself because my therapist has given me an ultimatum, either no more hurting myself or we will have to discontinue our therapy. So a little distance comes between us now, a secret that hold great importance which we could both learn from, if I was able to tell her…JML

29. Interrupting the Cycle
Dispute irrational thoughts, feelings
Triggering event
Unbearable tension, anxiety
Dissociation
Self injury
Relapse
Dispute irrational thoughts, feelings - examine the source of strong emotions, dispute negative cognitions, distorted perceptions, over-generalizations, emotional reasoning; teach thought stopping techniques such as “not now”, reframe, use positive self talk, examine the cost and benefit of holding onto these negative thoughts, feelings; help them learn a broader vocabulary for feelings
Triggering event – identify the triggers, process the event/the environment/the people, give permission to avoid the triggers; help them find distractions that work – journaling, drawing, people
Unbearable tension, anxiety – visualizations, exercise, read positive affirmations, physical relaxation strategies, breathing exercises, use pictures of people or places that are calming; teach containment – think of a shape & color that represents what you are feeling, think about the container you would need to hold it (have given it boundaries, what we can picture, we can control), visualize putting it into the container, Is it safe now?, what else do we need to do for it to stay there until the next session?
Dissociation – Help them learn when they are about to dissociate. Use re-grounding techniques – move, stamp foot, use an ice pack
Self injury – CARESS – “I know you have what it takes to take care of yourself.”
Communicate Alternatively – 10 minutes - journal, draw, collage, clay, poetry, tape recorder
Release Endorphins – 10 minutes – physical activity, hugging themselves, laughter
Self Soothe – 10 minutes – wrap in a blanket, take a warm bath, sing, meditate, massage hands/feet with lotion
Relapse – address issues of shame, guilt, failure, self-hatred, loss of control – recognize the progress, reassure, reinforce – never show disapproval – examine external support

30. Expressive Arts Journals Poetry Music Art
Expressive arts are our good friends when working with kids who self-injure.
Words may have failed them but art, music, writing, and play do not.
You’ve already seen evidence of their eloquence in the quotes we’ve used today.

31. ___Self-injurers are survivors. ___Self-injurers are weak people.
Self-Injury Group
Respond to the following statements by writing “A” for “agree” if you mostly agree with the statement or “D” for “disagree” if you mostly disagree. Be ready to explain your responses.
___Self-injurers are survivors.
___Self-injurers are weak people.
___Self-injurers are harming themselves to get attention.
___Self-injurers are perfectionists.
___Self-injury is a type of suicidal behavior.
___Self-injurers are proud of their scars.
___Self-injury helps people cope.
___Self-injurers are more sensitive than most other people.
Techniques we know-open sentences, true/false will create the interactions necessary to begin the process of healing. In group especially this kind of interaction leads to honest and spontaneous discussions.
Muller 2006

32. Self-Injury
If my wound could talk it would say_______________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
____________________________________________________________________________________________________
Gestalt techniques are also very effective. Giving voice is exactly what these kids need most.
Muller 2006

33. Taking Care of Yourself
Monitor your own horror and confusion
Broaden your perspective past the behavior to the intent behind it
Seek consultation
Get support for yourself
Monitor your reactions – You may hear some pretty sickening descriptions. (“B” inserting needles into his back) If your non-verbal communication is shock, horror, judgment – they won’t come back. They are already moving toward isolation, pulling away from family and friends. They are taking a huge risk sharing this with us and will be quick to shut us out if they feel we are like everyone else.
I never asked to see the injuries, but Lisa Boesky, the clinical psychologist who is an expert in the field, said that if the student offers to show you the injury, seeing them can help you gauge the seriousness of the problem.
Another young woman I worked with, “C”, said:
Don’t be mad or weird about it.
Don’t be grossed out or say, I’m gonna call your mother.
It’s a coping skill.
It’s as normal to me as coffee in the morning.
Broaden your perspective – Like all of the other negative coping skills – this is about thoughts, feelings, expressing ourselves, not about the behavior. Identify and respect the function of the behavior. What purpose does it serve?
Seek consultation
Get support for yourself - Have someone you can talk to about this. It is difficult work to learn about their pain and to walk with them as they talk about it. Take care of yourself. Have your own life and friends.

34. Care and Concern
The capacity to derive comfort from another is the single biggest predictor of whether traumatized patients are able to give up their self-destructive habits. (van der Kolk)
It is always about relationship.

35. Care and Concern
The development of a safe and trusting relationship is vital for the child to learn to sooth and care for him or herself in a healthy manner by internalizing their therapist’s care and concern. (Strong, 1988)
A nurturing, safe and caring environment is vital for our wounded kids so they can begin to heal.
Having an adult who cares allows the child to begin to believe that they are worthy of care.

36. Care and Concern 10
“_____ was the first to acknowledge that maybe I was in pain, as opposed to ‘doing it for attention’ . This affirmation of my inner pain was a healing force. “ Shelley
Just having our understanding can help begin the process of healing.

37. Discussion Why the upsurge in self-injurious behavior?
Students who look for fist fights?
Tattoos and piercing?
Addictive?