Living with self-harm
[CW: This newsletter contains descriptions of self-harm. Please skip this edition if it will be triggering or detrimental to your mental health.]
It feels like a roar of energy that starts at my gut and spreads outward. My shoulders lock and my arms shake. I ball my hands into fists until my nails dig into my palms and keep my arms aloft. I curl my head into my chest. My entire body jerks and writhes from the discomfort. The adrenaline escapes in a guttural scream.
This is what it looks like when I fight the urge to self-harm. It’s estimated that 65 to 80 per cent of individuals with borderline personality disorder (BPD) engage in some form of self-harm unrelated to suicide attempts, also known as non-suicidal self-injury (NSSI). Approximately 50 per cent of people with PTSD report they’ve harmed themselves at some point, and four to six per cent of the general population engages in NSSI. The function of self-harm varies but includes providing relief from negative mood states, reducing stress, serving as a form of personal punishment, and expressing emotions in a visceral fashion to receive care.
I’ve written and rewritten versions of this edition nearly a dozen times. Of all my mental health symptoms, NSSI is the most shameful to me. It’s visible evidence of my “craziness;” a dark mark that indicates to the world that I’m impulsive. That I’m sick. It’s my vulnerability on display. The freshest scars and bruises scream with the emotions and circumstances that caused them, though as they fade so too will the memories associated with them.
I started self-harming in my early teens. According to Freedom from Self-Harm: Overcoming Self-Injury with Skills from DBT and Other Treatments by Kim L. Gratz and Alexander L. Chapman, most people who engage in NSSI start the behaviour at 13 or 14. At the time, I knew what I was doing was unhealthy, but I assumed it was just a teenage phase I would grow out of. I was wrong though.
Just as, with practice, I’ve become a more skilled writer, I also became more skilled at self-injuring. My scars grew more noticeable. As I became more desperate for the release that comes with self-injury whenever I found myself in emotionally fraught situations, I used whatever was around me to hurt myself—my fists, the walls, the floor, my nails, my palms. The NSSI had diminishing returns though. I needed more and more of it, and immediately, to escape my emotional pain.
My worst incident of NSSI came in 2018. All the ingredients for peak emotional turmoil were there: interpersonal conflict, being too overwhelmed to express myself, and abandonment. I took the bannister in my stairway in both hands and banged my head against it, over and over, as hard as I could. I was so dissociated in the moment that I didn’t feel a thing—until warm blood started streaming down my face. I screamed for my partner to call an ambulance.
I took a picture of myself that day, the damage I did, to serve as a reminder of what happens when I’m too effective at unhealthy coping mechanisms. Once my scalp was glued back together, I knew I never wanted to feel so helpless that such an extreme level of violence seemed like my only option, so I began looking into tools for coping with my self-harm urges.
Myths About Self-Harm
Before I delve into coping with self-harm, I think it’s important to address a few myths about NSSI since it is so stigmatized and misunderstood.
Self-harm is manipulative: This is probably one of the most damaging myths to people who self-harm. In their book, Gratz and Chapman chock this up to the idea that, because self-harm is so serious, loved ones want to intervene quickly, and when they have to do that time and time again, it can feel as though they’re being manipulated. As Gratz’s and Chapman’s research has found, for most people who engage in NSSI, influencing others isn’t the primary reason they hurt themselves.
Self-harm is a gendered problem: Another particularly devastating myth is the belief that only those who identify as girls or women harm themselves. In their research, Gratz and Chapman found those who identify as men self-harm just as much as women do, and seem to do so for the same reasons. Though women are more likely to get help for NSSI, men are just as likely to experience it.
Self-harm is crazy and irrational: Self-harm is a coping mechanism some people use to meet basic human needs like releasing emotional pain. I’ve even engaged in NSSI to snap myself out of particularly bad dissociative episodes. Of course, there are much less dangerous ways to cope with pain or dissociation; however, many people who self-harm don’t yet have the tools required to cope in a different manner.
The only way to stop self-harming is by resolving underlying issues: This is a myth I once believed myself. While I absolutely needed to resolve my underlying issues, that was likely to be a long-term task, and I was quickly becoming more of a danger to myself in the meantime. If I had waited to address my NSSI, I could have ended up injuring myself severely. Even if I had resolved all my underlying issues first, there’s no guarantee I would have stopped self-harming. NSSI is addictive. Confronting all my past traumas wouldn’t necessarily make my urges disappear in highly-charged situations.
Functions of Self-Harm
Self-harm has very real functions. NSSI is ultimately a coping mechanism, albeit one that can be difficult to understand to those who don’t engage in the behaviour. Common functions of self-harm include:
Feeling better: Many people engage in NSSI because it is very effective at relieving emotional pain and tension immediately. Unfortunately, the relief is often short-term followed by shame around engaging in the behaviour in the first place.
Distraction: When I was still living at home, I coped with emotional abuse by cutting. The insults directed at me were so painful that the only way I could handle them was to give myself a physical distraction to focus on.
Express feelings: For so long, I had trouble accurately expressing my emotions in words. Creating a physical version of my emotional pain was my only path to expression before I developed healthier coping strategies. It turned my nebulous emotions into something concrete and tangible. Plus, it was much easier to treat a flesh wound than my trauma.
Self-punishment: When I was a child, many of the interpersonal confrontations I endured ended in violence. In a sick sense, I started to expect physical abuse and got used to the experience of all my failings being punished in an instant. Once I left home, interpersonal confrontations still happened, but there was no one to physically punish me for my failings. So, I punished myself.
Ending dissociation: Like self-harm, dissociation is a coping mechanism that can often take on a life of its own. It can be very difficult to end episodes of dissociation without intense physical stimulation, which can easily come through pain.
Self-harm is addictive: When injured, the body releases a rush of endorphins, a pain-relieving chemical that can result in a natural high. These highs can be addictive, making people more likely to repeat the behaviour that caused the endorphin rush.
Dialectical Behaviour Therapy (DBT)
I didn’t really start making progress with my NSSI behaviour until I was referred to a dialectical behaviour therapy (DBT) group. DBT, developed by Marsha M. Linehan to treat BPD, is also useful for treating suicidal and self-harm behaviours (common symptoms of BPD—though people without BPD can also benefit from DBT). DBT is considered one of the best treatments for self-harm as it has the most scientific evidence to back up its efficacy. In a 1991 study, DBT was better a reducing self-harm and suicide attempts than other forms of treatment.
DBT comes in individual and group settings (many people will go through both). In individual therapy, a therapist and a client might look at a hierarchy of treatment targets, which is a list that helps the therapist and client figure out the most important behaviour to focus on in a given session. Individual DBT therapy also incorporates skills to help a patient cope with the behaviour. Many of these skills are developed or practiced in DBT group skills training settings. The goal of skills training is to help people learn the skills they need to improve their lives and stop problematic behaviours. DBT skills include emotion regulation skills, distress tolerance skills, mindfulness skills, and interpersonal skills. They all work together to help people overcome behaviours like self-harm; however, the skills I find most useful for coping with NSSI include:
The “temperature” portion of the TIPP skill: TIPP is a distress tolerance skill that stands for temperature, intense exercise, paced breathing, and paired muscle relaxation. When I’m struggling with the urge to self-harm, particularly when it relates to dissociation, submerging my face in cold water for at least 30 seconds at a time provides the physical sensation I need to snap myself back into my body. It also provides enough of a physical distraction to replace the need for self-harm in crisis moments.
Pros and cons: Another distress tolerance skill I practice to reduce self-harm is considering the pros and cons of acting on my crisis urges. I have a table I keep handy where I’ve filled out all the pros and cons of acting on my NSSI urges, and the pros and cons of resisting my crisis urges. If after the temperature portion of TIPP, I’m still struggling with self-harm, I pull it out. It looks something like this:
When I refer to the pros and cons sheet, I identify which points are short-term and which are long-term. When I start to consider the long-term, I can often pull myself out of the moment enough to consider whether NSSI is really the most effective coping skill.
Tracking urges: When I started DBT skills training, in the first session we were given a diary card to track impulsive urges or harmful coping mechanisms. I chose self-harm as one of the behaviours I wanted to track. For three months, I wrote down how strong my urges to self-harm were, how many times I engaged in the behaviour, and how often I used coping skills to help with my urges. The practice of noticing my urges, how strong they were, how often I indulged them, and what skills I used to overcome them built up a mindfulness around the behaviour that allowed me to reduce how often I engaged in NSSI over time.
As I’ve become more aware of my patterns of self-harm through DBT, I’ve been able to identify situations that are likely to trigger NSSI urges and create a plan to minimize or avoid them. For example, due to the intensity of my emotions, I find I can only be in highly-charged emotional situations for short periods of time before I have to take a break. If I can’t take a break from the situation, the pain and turmoil is more likely to become unbearable and trigger my self-harm urges.
Emotion Regulation Group Therapy (ERGT)
Emotion regulation group therapy (ERGT) was developed by Kim Gratz as a short-term treatment to help women with BPD reduce self-harm. The idea behind this treatment is teaching women who self-harm healthier ways to respond to their emotions. Like DBT, instead of focusing on keeping emotions in check, ERGT teaches people skills to learn to accept their emotions. Skills in this group also come from acceptance and commitment (ACT) therapy. In a 2006 study, women who participated in ERGT had fewer episodes of self-harm, were less likely to suppress their emotions, and had less depression, anxiety, and stress.
During the first two weeks of ERGT, women learn more about self-harm and what they get from it, what their emotions do for them, and how to identify their own negative beliefs about emotions. The next three weeks consist of labelling emotions, learning about whether feelings have to do with something that just happened (primary emotions) or are self-punishment for feeling or behaving a certain way (secondary emotions), and learning how to identify and act on emotions in a healthy and adaptive way. In weeks seven and eight, women learn about the downsides of avoiding emotions and skills for accepting them. The next two weeks cover coping strategies for managing emotions, controlling self-harm, and learning how to reward oneself for resisting urges. The last four weeks examine individual long-term goals, and delve into ACT skills like identifying personal values and committing to acting in accordance with them.
Though I haven’t had the opportunity to participate in ERGT, I’m familiar with a number of skills practiced in the sessions, and found the following to be helpful in minimizing NSSI:
Self-soothing: Self-soothing is a DBT skill to help with distress tolerance that’s also practiced in ERGT. It helps with managing emotions instead of avoiding them. Self-soothing is an easy skill to remember as it relies on each of the five senses. When I’m experiencing painful emotions, I can sit with them with the help of vision (lighting a candle and watching the flame, noticing nature around me, etc.), hearing (paying attention to the sounds of my surroundings), smell (burning incense or lighting a candle), taste (mindful eating or drinking), or touch (taking a long bath, petting the cats, etc.). When I practice soothing my senses during times of distress, it can reduce the strength of my emotions.
Accumulating positive emotions: Accumulating positive emotions is the first step in the DBT emotion regulation skill ABC PLEASE, which is also utilized in ERGT. This skill reduces vulnerability to “emotion mind,” the state of mind that only uses emotions to make decisions. I accumulate positive emotions in the short-term by increasing the number of pleasant events in my life, I avoid avoiding, I’m mindful of my positive experiences, and unmindful of worries like whether or not I deserve a positive experience. To accumulate positive emotions in the long-term, I avoid doing what is needed to build the life I want, identify values that are really important to me, and choose one to work on. From there, I come up with specific goals that will make this value a part of my life, choose one goal to work on immediately, and break down small action steps toward that goal. Then I simply take the first step. Through building a life that is more emotionally and spiritually fulfilling, I reduce the painful emotions I experience, which limits my need to self-harm.
Observing emotions: Observing emotions is another DBT skill that can be found in ERGT. A mindfulness skill, the purpose of observing (as opposed to reacting to) emotions is to move closer to something called “wise mind.” Wise mind is a state when a person can incorporate both reason and emotion to make decisions. It’s about finding the “middle path” in thinking and moving out of either reasonable mind, ruled by facts, reason, and logic, or emotion mind, ruled by feelings urges and moods. When I’m trying to move into wise mind when coping with NSSI urges, I attempt to observe my emotions. I notice my bodily sensations (and use the five senses prompt discussed above), I direct my attention to the present moment without pushing away or clinging to painful thoughts that come up. I practice wordless watching, which is when I allow thoughts to come into my mind but let them float right by like clouds on the horizon. I also make a point to notice my surroundings to better ground myself in reality. Mindful observation allows me to move out of emotional mind, which is the state I’m in when I self-harm.
Mentalization-based treatment (MBT)
Mentalization-based treatment (MBT) is another treatment for people with BPD that’s effective in reducing self-harm. Developed by Anthony Bateman and Peter Fonagy, MBT is based on the principle that some individuals with BPD suffer from disorganized attachment, a type of attachment pattern children form with their mother or caregiver. Children brought up by caregivers with disorganized attachment styles are likely to see their parent as both a source of comfort and fear, leading to disorganized behaviour and a failure to develop mentalization skills. Mentalization is the process humans use to explicitly and implicitly interpret their actions and the actions of others to comprehend intentions and affects. For example, as noted in my interview with Dorde Radosavljevic, a person with poor mentalization skills might interpret a loved one leaving the room as dire: “They must have left the room because they hate me.” The goal of MBT is to help people with BPD increase their mentalization capacity, which can strengthen interpersonal relationships and improve affect regulation (the attempt to alter or control mood or emotional states to maximize pleasant experiences).
Unlike the previous treatments, MBT is more of a talk therapy than a behavioural therapy, but also includes individual and group therapy. It focuses on a person’s sense of who they are, and addresses the BPD symptom of a poor sense of self. In MBT, self-harm is seen as an attempt to maintain a sense of self during stressful times. In individual therapy, a therapist will work with a person to understand their actions and reactions and how behaviours stem from thoughts, feelings, and desires. They will also spend time discussing how a person’s actions are related to the actions of others to demonstrate how they’re linked to events and reactions. People in MBT and their therapists practice a stance of open curiosity—not assuming one person can completely understand what the other is experiencing. The secure attachment relationship the therapist provides allows the person in MBT to safely explore the mind of someone else. In MBT group therapy, participants are also asked to take a position of “not knowing” to try to better understand how their behaviours are related to behaviours of other members of the group.
In a 1999 study, Bateman and Fonagy found that MBT delivered in a hospital setting to people with BPD was better at reducing suicide attempts, depression, anxiety, and self-harm than those who received care in the community. In a 2008 follow-up study, Bateman and Fonagy found that people with BPD who had received MBT had fewer hospitalizations, less medication use, fewer suicidal behaviours, and better overall functioning than people who received standard care.
There’s no simple or graceful solution to coping with self-harm. It’s always going to be a painful, scary, and shame-burdened experience but I hope this newsletter will add to the chorus of voices already brave enough to speak (or write) about it, give readers the information they need to better understand the coping behaviour, and give those who struggle with NSSI the resources they need to begin their recovery.
Mad History
This issue: Needle girls
Two of the more harmful present-day myths about NSSI can be traced all the way back to the Victorian era: that self-harm is manipulative and that it’s primarily a female issue. In the 1897 book, Anomalies and Curiosities of Medicine by doctors George M. Gould and Walter L. Pyle, in a short section on self-mutilation, the authors drew attention to women they called needle girls (playing on the widespread interest in “fasting girls”) who engaged in “a peculiar type of self-mutilation… sometimes seen in hysteric persons of piercing their flesh with numerous needles or pins.” Though the authors also examine cases of self-castration, self-enucleation, and people who intentionally broke their bones to collect insurance damages in the same section, only needle girls are linked to hysteria, a pejorative 19th century diagnosis for women who were thought to be predisposed to mental and behavioural conditions.
As noted in Sarah Chaney’s thesis paper, Self-Mutilation and Psychiatry: Impulse, Identity, and the Unconscious in British Explanations of Self-Inflicted Injury c. 1864 – 1914, medical attitudes at the time fostered and perpetuated the myth that hysteria, and self-harm arising from it, was ultimately an issue of a poor and manipulative character. In her thesis, Chaney analyzed prominent self-injury case studies from the Victorian era and found they described needle girls or privileged women who engaged in self-harm as, “‘highly neurotic, sly, and deceitful,’ and some concluded that any such case was evidence of ‘hysterical deception,’ making self-inflicted injury synonymous with deceit.”
In a 2019 piece for the British Psychological Society, Chaney also raised the possibility that Gould and Pyle’s selection of cases was biased. “Of seven ‘needle girls’ articles in the book, the one referring to a man…did not specify his sex… leaving the reader to wrongly assume that the patient was a woman.” In her thesis paper, Chaney examined the Royal London Hospital’s surgical case notes from 1893 to 1910 and found that more male than female patients were admitted to the hospital with foreign objects embedded in their skin. Early British medical professionals not only introduced the concept that NSSI is manipulative, they made it a female issue despite very real evidence to the contrary.
Recommended Reading
Freedom from Self-Harm: Overcoming Self-Injury with Skills from DBT and Other Treatment
By: Kim L. Gratz and Alexander L. Chapman
Freedom from Self-Harm is a complete guide to coping with NSSI that looks at understanding self-harm, getting help, and coping strategies. Written directly to people who self-harm, the book separates information about self-harm and coping strategies with opportunities for therapeutic self-reflection that allow the reader to become more mindful about the role NSSI plays in their life. Freedom from Self-Harm is an accessible starting point for anyone struggling with self-harm and is looking to replace the behaviour with healthy coping skills.
Thank you for sharing such a detailed and vulnerable piece about a commonly misunderstood condition.