Q & A

Alberta Torres, LCSW, RPT

I have read that self injury is used to cope with intense emotional pain. How can we explain to our classmates the irrational thoughts & self talk that precede self injurious behavior (SIB)? Especially the first time someone self inflicts. It seems counter-intuitive that someone would self inflict pain to deal with pain!
I have been a clinician for 15 years. My field of expertise is in the area of childhood sexual abuse. I do not consider myself specialized in SIB, but have had training in working with clients who self-harm. Sexual abuse is one area in the field of psychotherapy that you do see SIB.

I do believe that self-injury is used to deal with emotional pain, sometimes conscious and sometimes unconscious. A client with SIB may be engaged in emotional numbing and disconnection with their physical body. SIB may be way of proving to themselves that they exist and that they are alive. It is a symbolic way to externalize their emotional pain.

As for the irrationality of self-injury as a means to deal with pain, we have to begin with the understanding that the perception and experience of pain is very subjective. In many non-western primitive cultures “self-injury” is used as a tool to reach higher perceptions of reality/spirituality; dissociation is a purposeful means to an end.

For someone who dissociates as a defense acquired during past trauma, cutting does not have the same meaning that it does for those of us who are well grounded in our physical bodies.

Dissociation, a great self-defense, has continued past its’ usefulness and has left the person numb emotionally and impacted their experience of reality and relationship.

A distorted reality leads to distorted thinking. Distorted thinking is the general foundation of many mental health issues as well as “normal” human problems.

With regards to empathy, what tools/skills will be most beneficial in making a connection with clients who self-injure? What would be the least helpful?
Empathy has to do with understanding where your client lives in his/her head/heart. I find that this is impossible if you are not a curious detective. To be genuinely and respectfully curious requires that you get out of your head/heart and make room for your client’s set of values, beliefs and reality without getting lost.

Always assume that your client is like no other, that s/he is a unique individual no matter the label or diagnoses. The least helpful is to think that your client doesn’t already have all the answers.

In your opinion, what is the most damaging misconception about people who cut and how does it contribute to their feeling misunderstood and alone? Do your clients who self-injure ever use the word "shame" to describe how they are feeling?
I believe the most damaging misconception of people with SIB is to think that they are suicidal when in fact what they want is to exist, and to exist without emotional pain (like the rest of us).

They are screaming for help but no one understands their language, and they may lack the words to make us understand; and so they isolate and seek solace from others who self-injure.

Clients that I have worked with have not used the word shame, because I think it’s not a word that is well understood. They will say things like “I’m stupid”, “I’m a burden on my family”, etc.

Where did you find the most surprising sources of inspiration?
My source of inspiration is almost always my client’s resiliency and inner reality.

Can you share any "self injury" stories
I can briefly share with you one of my client’s stories:
This client I will call Mary was 15 years of age and had been sexually abused by three older teenage boys after leaving her home at night without her mother’s permission.

She had subsequent losses as well, the death of her grandmother who she was close to, her family had moved her from her previous school and she lost her best friend. And now she was grounded for an indefinite period of time. She began cutting as a result of hearing about this from other girls in school who were cutting.

Her pattern was generally that she would cut after an argument with her mother or some kind of disappointment. She would isolate herself in her room and stew in her anger which eventually led to her feelings of “being stupid” and going over the events of the night that preceded her sexual assault and all the “shoulds”; I should have called my friend and talked to her instead of going out with the boys, etc.

Before bedtime she would pull the box where she kept all her “instruments” from under her beg and go through an elaborate ritual of picking her instrument for cutting and picking a spot on her body that she would cut.

She shared that after she cut and saw the blood oozing out she immediately began to feel “calm” and could then go to sleep. Her main refrain was “I feel stupid”. She felt stupid for sneaking out of her home that day and for going into an empty apartment with boys that she thought were her friends.

I engaged her in sandplay therapy followed by talk therapy, using cognitive reframe and dream exploration. We talked about how she understood intellectually that what happened wasn’t her fault but how this was separate from the emotional reality.

She had a “support” circle of friends that had been cutting who were now trying to quit and with their support and the work she did in therapy she was able to stop cutting and form close relationships with her friends and was beginning to re-integrate with her family.

We explored various ways that she could mourn her losses including the cutting and rituals that she might perform. She was very clear that she didn’t know if she would go back to cutting one day but for now she had found alternate ways to deal with her feelings.

Veronique Vaillancourt, LCSW

Are you working as a therapist?
Yes, and I do see patients who cut. I have been a therapist for over 10 years. I am however not a specialist on cutting.

I have read that self injury is used to cope with intense emotional pain. How can we explain to our classmates the irrational thoughts & self talk that precede self injurious behavior (SIB)? Especially the first time someone self inflicts. It seems counter-intuitive that someone would self inflict pain to deal with pain!
Firstly, I think that you enter dangerous territority by labeling the thoughts that occur prior to cutting as "irrational". Though the person doing the behavior is thinking in a distorted manner, it makes very clear sense to them at the time, and really seems like the only solution or way out. Their thinking is distorted perhaps, but irrational...it implies a certain judgement.

Cutting (the most common SIB) is a coping strategy for handling emotional pain. In some ways it resembles using drugs/alcohol/food/gambling/Internet/TV or any addictive behavior in that it allows the person to "distract" themselves from what they are feeling emotionally. Intense emotional pain, anger towards self or others often precedes cutting.

Self talk (both the first time and after) varies greatly from person to person. Most often the thought process is likely to be something along the lines of "This situation, emotional pain etc is too much for me to handle, if I can just cut I will have something else to focus on".

It is also believed to be a way to externalize and show outwardly how much the person is hurting internally. Most clients report that it is much less painful than the emotional pain they feel at the time of self injury.

With regards to empathy, what tools/skills will be most beneficial in making a connection with clients who self-injure?
I believe that they are the same tools that one uses with clients with any problems. Understanding, empathy, validation, reflective listening. It also helps to offer alternative coping strategies, though the person has to stop the SIB for these to work.

What would be the least helpful?
Shaming, minimalizing, telling the person to just stop it, acting fearful, assuming that it is a suicidal gesture, judgeing them, labelling them, avoiding the topic/not addressing it.

In your opinion, what is the most damaging misconception about people who cut and how does it contribute to their feeling misunderstood and alone?
That they are suicidal, crazy, needing to be admitted to the hospital, that there is something "really wrong with them", that the behavior is to get attention (though that is the case with a handful of patients, it is by no means the case for most). "...how does it contribute to their feeling misunderstood and alone..." they feel they have to hide it. That there must be something really wrong with them.

Do your clients who self-injure ever use the word "shame" to describe how they are feeling?
No. They typically use words like "I hate myself" "I hate what I did" "I hate my feelings". Hate, Guilty, Bad.... but I think that is because many people do not understand the difference between those words.

What's the most hurtful stereotype your clients face?
Being found out and told that they are crazy.

Where did you find the most surprising sources of inspiration?
In my experience, most people who cut are not people who are suicidal. They are people struggling with handling a huge amount of internal pain. Often very hurt and angry with themselves and the world.

The main source of inspiration comes from knowing that them talking about their anger, and pain, often helps reduce the symptoms. Helping to validate their feelings and express their feelings/realities typically decreases the SIB.

Can triggers lead to SIB/cutting?
Yes usually what triggers SIB behavior is some intense emotional upset, interaction or feeling that is overwhelming to theperson, thus leading the sib. Ex: verbal argument with husband leaves wife feeling very upset, and then a few hours unable to handle anger towards self or husband, wife cuts.

Do you address the triggers that lead to SIB in therapy?
Most often, the primary focus will be to look at finding different healthier strategies to handle overwhelming feelings that lead to the SIB/cutting behavior. So yes addressing the triggers that lead to SIB is central to treatment.