
                            How Can I Help Myself?
                                       
   Ah, this is the million dollar question, isn't it? Unfortunately I
   can't give one pat answer. No one can. Self-injury is a very complex
   behavior that no one fully understands or knows how to treat. Yet
   people DO stop harming themselves. As pointed out by both Favazza and
   Hawton, hope and a relatively optimistic attitude about the long term
   future are reasonable for most people who cut themselves and for those
   who fit the description of repetitive self-harm syndrome. For many
   people this behavior seems to run a natural course and then end.
   
   The following suggestions were gathered from my own experience, from
   the experiences of others who self-harm or have stopped completely,
   extrapolated from various theories, and from the very limited
   information on this subject available in the literature. Many thanks
   to those of you who shared your own techniques. Hawton's (1990)
   chapter on the prevention of Self-Cutting, Favazza's book Bodies Under
   Siege (1987), and Miller's book Women Who Hurt Themselves (1994), also
   provided some useful ideas which I've adapted for self-help purposes.
   
Suggestions of Things to Do:

    1. EVALUATE AND CHANGE YOUR LIFE CIRCUMSTANCES IF NECESSARY. I put
       this first because as long as you are in a physically or
       emotionally unsafe environment, it will be much harder (maybe
       impossible) for you to stop providing yourself with relief through
       self-injury. Ask yourself how you feel about where you are
       living....who you are living with....how you spend your days. Are
       you comfortable with these things? If not, start focusing on
       changing them. Support groups or therapists can be helpful for
       this.
    2. DECIDE IF YOU WANT TO STOP SELF-INJURING NOW. For some people, the
       rewards that they get from hurting themselves so far outweigh the
       negative consequences that they have little desire to stop this
       behavior immediately and the idea of doing so is very threatening.
       If this is the case for you, you may want to focus on longer term
       suggestions for changing your life, rather than focusing on
       immediate control of your self-injury behavior.
    3. IF YOU WANT TO STOP NOW: think about the times that you've hurt
       yourself and see if you can identify certain kinds of events that
       provoke the feelings that make you want to hurt yourself, or
       thoughts that you start thinking before you self-harm. Write these
       down. Try to recognize these events, or thoughts in the future,
       when they start to occur, rather than waiting till the feelings
       are overwhelming.
    4. IF YOU FEEL LIKE YOU MIGHT HURT YOURSELF (or recognize events or
       thoughts that precede self-harm for you):
          + [These bracketed entries are things that have worked well for
            me, deb, and are not part of the original list.
            The 15-minute method. Give yourself permission to do it, but
            make it a condition that you wait 15 minutes first. When the
            time is up, reassess. Can you wait another 15? Do it if you
            can.
          + Ask what you're feeling. Are you angry? Why? If it involves a
            possible confrontation with another person, see Linehan's
            worksheet on [1]dealing with interpersonal conflict for an
            excellent resource for being cool and competent in dealing
            with the situation.
            Are you afraid? Of what? Get together with someone and
            brainstorm: what's the worst that could happen and how could
            you respond? What's the best that could happen?
          + Breathe. Sit comfortably with both feet on the floor. Feel
            the grounded-ness of your feet. Inhale through your nose for
            a count of six, eyes closed, mind clear. Hold the breath for
            a slow count of six. Exhale through your mouth for a count of
            6.
          + Carrol Alvarez, of the University of Washington, explained to
            me that many times, trauma victims who can talk about their
            past trauma without obvious affect (emotion) have a
            fragmented memory of the event(s): the episode has become
            separated from the feelings that accompanied it. Episodes of
            free-floating fear, rage, or anxiety that are triggered by
            something in the present can be thought of as having recalled
            those emotional memory fragments. To deal with them, Carrol
            suggests that you think about an episode in the past when you
            felt as you do now. Write down what happened then and what's
            happening now. Then make two lists: one of similarities
            between the two, one of differences. This can help you build
            perspective.] On to the original list:
          + Stay in the company of others. People usually injure
            themselves privately. Spend as much time as possible in
            public places, stay overnight with a trusted friend or family
            member if you can.
          + Try to delay the act in any way you can. Favazza calls the
            willingness and ability to delay self injury the first step
            to recovery. You might try distracting yourself by calling a
            friend, going somewhere, writing in a journal, watching a
            movie, painting a picture, exercising, etc. Even if you end
            up hurting yourself, recognize that you made progress by
            delaying the act and try to delay longer in the future. This
            is a HARD thing to do. As in substance addictions, some
            people find that the longer they go without harming
            themselves, the easier it becomes to resist.
          + Stay away from the materials that you know you might hurt
            yourself with, like razors, glass, pins, etc. Many people
            find it helpful in the short term to remove razor blades or
            other tempting items from their home.
          + Some people find that the impulse to injure themselves passes
            if a loved one holds them tightly when they feel overwhelmed
            by feelings or out of touch with their bodies. Since many
            people who self-harm have been abused in some way, this may
            not work for them, or the choice of who can hold them should
            be made very carefully. Sometimes having someone hold your
            hand, or stroke your arm is helpful.
          + Remind yourself of the long term consequences of self-injury
            (scars, having to wear long sleeves, and social rejection
            being a few possibilities);
          + Some people find it helpful to say "NO!" or "STOP!" out loud
            to themselves when they think of hurting themselves, and this
            seems to interrupt the immediacy of their usual self-injury
            response to stress. In essence, it helps them think before
            acting and take responsibility for their self-harm.
          + STAY AWAY FROM DRUGS AND ALCOHOL, even caffeine, since these
            have been linked to self-harm behaviors. Unless your doctor
            has prescribed a medication (and is aware of your
            self-injurious behavior), avoid all medications. Even if your
            doctor has prescribed them, I would recommend staying away
            from drugs that you know decrease your inhibitions or impulse
            control (like Valium and other minor tranquilizers) when you
            feel as though you may hurt yourself. Many people have
            described them as contraindicated in the immediate prevention
            of self-injury.
    5. IF YOU MUST HURT YOURSELF:
          + Try to substitute more socially accepted methods such as
            piercing your ears (again), or better yet get your hair cut
            or your hair color changed.
          + Don't beat yourself up about it. That will only make matters
            worse. This is a VERY hard behavior to change. Try to focus
            on longer term ways to decrease your stress, finding new ways
            to communicate and express your feelings, or increasing your
            control over self-harm instead of on the fact that you hurt
            yourself again.
          + NEVER SHARE razors with other people who cut themselves,
            since this has been identified as a potential new route of
            HIV transmission. Here's one place where you could cross the
            line and accidentally turn a non-lethal act into a lethal
            one. Because many people who self-harm also abuse substances,
            those who cut might be at higher risk for carrying HIV. [i
            would add to this "Always clean your razors and your skin to
            avoid infection. Just wiping them down with alcohol helps."]
    6. LIFESTYLE CHANGES TO DECREASE SELF-INJURY OVER THE LONG TERM:
          + Find new ways to cope with your feelings. Learn new ways to
            calm, soothe, and comfort yourself. These may not work when
            you are aroused to the point of feeling overwhelmed, but may
            be effective if practiced on a regular basis or when you feel
            tension beginning. Meditation, physical exercise, relaxation
            exercises, visual imagery, relaxing music, deep breathing,
            warm baths, and playing a musical instrument are just a few
            examples of ways that people can soothe themselves.
          + Several people told me that learning to nurture and protect
            themselves was an important part of their recovery, as it was
            in mine. This is not an easy thing to do, and may take many
            years of work. Try doing things to take care of yourself and
            make yourself feel pampered and loved. Buy a beautiful
            journal and write in it. Sit under a big soft quilt and read
            a good book. Whatever it is that makes you feel loved, do it.
            Realize what strength it takes to live through what you've
            lived through. Next time you think of hurting yourself tell
            yourself that you deserve to be protected.
          + If you feel a lot of anger, you might try vigorous activities
            like handball, running, swimming, yard work or martial arts,
            or squeezing a rubber ball till your hand hurts. Some people
            told me that it helps them to tear up rags, punch pillows, or
            paint when they feel anger rising. [I would add here the
            suggestion, seen on the walkers-in-darkness mailing list, of
            "slashing" yourself with a red magic marker as an alternative
            to cutting.]
          + Practice communicating your feelings instead of engaging in
            impulsive, addictive behaviors like self-injury or substance
            abuse to escape them. Find someone safe to communicate your
            feelings to and try letting someone be there for you. This
            might be a very close friend, loved one, or therapist. For
            many of us who have experienced abuse or been raised in
            households where negative feelings are not expressed
            verbally, this is not an easy thing to do. Try letting
            someone you trust comfort you when you are upset. Try
            expressing your anger directly through words and see what
            happens. A therapist or counselor can often help you with
            this.
          + Assertiveness training groups or self-help book about
            developing assertiveness skills can also help you learn to
            get your needs met more directly.
          + As a general rule, avoid overuse of caffeine, alcohol, and
            other non-prescribed psychoactive substances. People who
            self-injure sometimes experience mood swings and these
            substances can enhance this. If self-injury is an attempt to
            decrease or increase arousal, these substances might really
            throw us out of kilter.
          + Try not to spend time with others who self-injure or engage
            in self-destructive lifestyles. Self-injury sometime has a
            "contagious" quality to it, and your behavior might be
            triggered by the company of others who are harming
            themselves.
          + Seek out a therapist to help you make changes in your life.
            Be a consumer and PROTECT yourself. Victims of abuse or
            neglect are often highly sensitive to invalidating
            therapists/approaches to therapy since their earlier abuse or
            neglect was the ultimate in invalidation. Some therapists
            place themselves in a superior position to their clients, and
            act as though their approach is the only one that works, and
            as though they know more about you than you do. If your
            therapist doesn't hear you or respect your needs for
            information, control, feelings of safety, and respect, find
            another therapist! Ask a prospective therapist (or your
            current therapist) about his or her views on self-injury: why
            people do it, how to approach it therapeutically, what to
            expect in terms of outcome. Make sure the answers are ones
            that feel comfortable to you. Although there is no shortage
            of theories about why people hurt themselves, no form of
            therapy has been shown to work better than any other for
            helping people to control this behavior. Find a therapist
            that you can TRUST and work WITH, preferably one who makes
            you feel empowered rather than sick. Find someone who views
            this behavior in a way that is comfortable for you, and gives
            you hope.
          + Self-help or support groups can be helpful, especially when
            geared specifically towards people who self-injure. Crisis
            lines, women's resource centers, and rape or sexual abuse
            organizations may be sources of information about such groups
            in your area.
       
How Can I Help my Friend/Child/Loved One Control His/Her Self-Harm?

    1. [To these suggestions, I'd add only this one.] In any situation,
       but *especially* if your loved one is under a great deal of stress
       and on the verge of self-harm, try to use the SET model of
       communicating: Support, Empathy, Truth. First offer a supportive
       statement: "I'm really concerned about your well-being; I care
       about you a great deal and you seem very upset." Then, provide
       empathy -- identify their feelings: "It sounds like you're feeling
       really awful." Finally, provide truth: "The situation isn't
       impossible, and we can work together and find a way out." It's
       extremely important that Support statements not be condescending,
       Empathy statements not turn into sympathy, and Truth statements
       not be angry or abusive.
    2. Maintain an accepting, open attitude about the self-injury. Most
       people who self-harm have problems with low self-esteem and are
       disgusted by their own self-injury behavior. Try to make him/her
       feel safe discussing it, and accepted regardless of it. Try not to
       pay more attention to the self-injury behaviors than the healthier
       things that this person does.
    3. Recognize the severity of this person's distress and the inability
       to stop hurting him or herself. Try not to get angry at him/her
       for self-harm behaviors, since this merely reinforces the
       self-disgust and discouragement that is already there. If he/she
       could stop, he/she would. Don't minimize how much distress a
       person is in, regardless of how insignificant the stressor might
       appear to you, with statements like "it's not that bad," or "you
       can't be that upset about it." Acknowledge that the person is
       under a lot of stress, and that you are there if there's anything
       that you can do to help. Don't shame the person for failed
       attempts at controlling self-injury, and praise any success in
       delaying the act.
    4. If he or she is not already doing so, encourage the person to find
       a professional therapist that meets her/his needs, preferably one
       with knowledge and experience with repetitive self-injury.
       Encourage self-injury support groups if such a thing exists in
       your area.
    5. If you think this person is in immediate danger of cutting or
       other superficial or moderate self-injury, stay with him or her
       until the impulse passes or encourage him or her not to be alone.
       Physical contact through hand holding or hugging can sometimes be
       helpful if the relationship is appropriate and trust is
       sufficient.
    6. Self-injury is an extremely stressful, frustrating, and
       anxiety-provoking thing for everyone involved. Get support for
       yourself if you need it, through a counselor or therapist,
       preferably one with knowledge and experience with self-injury.
       
   If you would like to discuss this further, I can be reached through
   the anonymous server at:
   an22340@anon.penet.fi
   
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References

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   2. file://localhost/usr/home/llama/Web/psych/injury.html
