From the Sanguinary Files, Part Two

I’ve had dreams about credibility.

I’ve watched and studied and obsessed over the elusive qualities that allow some people the privilege of being taken at face value. How can they do that? How can I learn to do that? What makes them so much more believable than I am? That easy credence, the knowing, confident air, projections of reassurance–I admire and envy and fantasize about them. Perhaps it’s normal; we all desire what we’ve never had.

As I mentioned last post, discussions of self-injury (at least, the ones involving me) are contentious, rage-provoking, and usually prematurely terminated. But even those who stick to the conversation without being reduced to incoherent fury are still a tough sell on the idea that psychotherapy for self-injurers is worth opposing. Even if I’m right that not all pain-seekers are emotionally distressed, I admit that some are. Isn’t it better to help someone who may not need it than to withhold help from someone who does?

Three premises are embedded in this question: First, that the psychotherapeutic model helps people who experience distress-related self-injury. Second, that it does not harm people who experience non-distress-related self-injury. Third, that the absence of psychotherapeutic intervention harms people who experience distress-related self-injury. To assess the validity of these premises, let’s look at what the psychotherapeutic model entails, from medical sources themselves. All links culled from mainstream sources, as determined by the layman’s arbiter of mainstream sources, i.e. Google.

From WebMD:

Many kids haven’t thought about it at all — exactly why they self-injure, says Lader. “It’s like any addiction, if I can take a pill or self-medicate in some way, why deal with the problem? We teach people that cutting only works in the short term, and that it will only get worse and worse.”

When kids learn to face their problems, they will quit self-harming, she adds. “Our goal is to get them to communicate what’s wrong. Babies don’t have the capacity for language, so they use behavior. These adolescents regress to that preverbal state when they self-harm.”

Individual and group therapy are the hubs of this treatment program. If there is underlying depression or anxiety, antidepressants may be prescribed. The patients also write regularly in their journals — to learn to explore and express their feelings.

Helping them gain self-respect and self-esteem is a critical treatment goal, Conterio tells WebMD.

From Mayo Clinic:

There’s no one single or simple cause that leads someone to self-injure. The mix of emotions that triggers self-injury is complex. In general, self-injury is usually the result of an inability to cope in healthy ways with deep psychological pain. For instance, you may have a hard time regulating, expressing or understanding your emotions. Physical injury distracts you from these painful emotions or helps you feel a sense of control over an otherwise uncontrollable situation.

When you feel emotionally empty, self-injury is a way to feel something, anything, even if it’s physical pain. It also offers an external way to express internal feelings. You may also turn to self-injury as a way to punish yourself for perceived faults. Sometimes self-injury may be an attempt to seek attention or to manipulate others.

Try to find ways to cope other than injuring yourself, such as reaching out to a friend, practicing relaxation techniques, contacting a support group or getting in touch with your doctor.

Also known as talk therapy, counseling or behavior therapy, psychotherapy can help you identify and manage underlying issues that trigger self-injury. Therapy can also help you learn skills to better tolerate stress, regulate your emotions, boost your self-image, better your relationships and improve your problem-solving skills.

From “Self-Mutilation Index“:

Effective medical treatment should involve a combination of psychotherapy and possibly medication. An effective therapist will help an individual identify the feelings and emotions associated with self-mutilation. Furthermore, therapy should focus on learning to use positive behaviors as an alternative to self-mutilation.

From public presentation “The Behavioral Treatment of Self-Mutilation” (which refers to self-injury as “parasuicide”):

Specifically, psychodynamic theorists have stated that both self-mutilation and suicide attempts are the result of anger turned inward (Liebowitz, 1987; Friedman, et al. 1972) and results in emotional catharsis (Gardner & Cowdry, 1985). In contrast, Linehan (1993) has presented a biosocial theory that describes chronic negative emotions and self-invalidation as primary factors that predispose BPD individuals to self-mutilation and suicide attempts.

Patients must agree that reducing all types of parasuicide, including self-mutilation, is the first priority in therapy. Patients are also asked to commit to not killing themselves while they are in DBT. Once an individual enters the treatment phase, the patient’s current behavior and goals and the DBT hierarchy of targets determines the treatment agenda. When patients fail to stay committed to stopping parasuicide, the “pre-treatment” phase may be reinstated to enhance commitment.
The first treatment stage in DBT focuses on getting self-mutilation and suicidal behaviors under control. Although the dialectic that parasuicidal behaviors and wishes to live can co-exist is understood within DBT, treatment cannot progress until this behavior stops. Patients’ explicit agreement to stop parasuicide must be maintained during this stage. Any parasuicidal behaviors, significant intent or urges to parasuicide, and significant changes in suicidal ideation are addressed in individual therapy immediately following their occurrence

Based on the primary assumption that the lives of BPD individuals with BPD are currently unbearable, DBT places great emphasis on change.

In DBT acceptance strategies are also considered very important when treating severely parasuicidal patients. These strategies help keep patients from dropping out of therapy prematurely, and help teach patients self-validation and acceptance. Furthermore, if therapists fail to validate sufficiently many patients fail to comply with cognitive-behavior therapy procedures that require effort or involve discomfort. Patients are also taught that to make important changes in life it is necessary to accept (though not approve of) those things that need to be changed. Pure acceptance and validation in therapy, however, would not likely be sufficient to change such serious problems. The conceptual division between change and acceptance strategies illustrates the fundamental dialectic that the DBT therapist must balance in treating chronically parasuicidal individuals. This balance is not necessarily achieved through equal amounts of acceptance and change strategies. Strategies are balanced according to the needs of the current situation. For example, therapists may choose to only use enough acceptance strategies as is necessary to keep the patient collaborating with the change process.

The therapist can search for and communicate the valid elements of even the most extreme dysfunctional behaviors (i.e., the “kernel of truth”). The dialectical dilemma is to find how the apparently unreasonable is in some way reasonable. By validating in this way patients are more likely to not feel blamed and therefore to collaborate in therapy.

It is important to remember, however, DBT therapists are proscribed from validating aspects of patients that are not truly valid. Although major dysfunctional behaviors may be validated in some ways, these behaviors are still treated as dysfunctional. Several situations illustrate this dialectical dilemmas: when a dysfunctional behavior makes sense historically, but not currently; when behaviors makes sense in terms of short-term, but not long-term, goals; when patients’ behaviors reflect valid conclusions from invalid assumptions; and when a response is normal or understandable, but not effective. Similarly, a focus on the patient’s capabilities is balanced with a focus on the patient’s limitations and deficits.

The common theme in these descriptions of the mainstream psychotherapeutic model of self-injury treatment is the need to manipulate the self-injurious person to concede (or “accept”) that his tendencies are dysfunctional, maladaptive responses to emotional distress, which he absolutely must change (lest his life be unbearable). The client’s own interpretation of the cause of these tendencies, if it differs from the script, is merely an obstacle to treatment, surely not a valid self-assessment. Therapists resort to classic deceitful manipulation to “help” their clients see the light. Is this benign?

I think not.

I dream about credibility. I wonder what it would be like to speak my mind and be believed. I wonder if people who can express themselves in believable ways take their gift for granted.

Ethical questions about psychotherapeutic treatment for self-injury are compounded when they are used on children and underage teenagers, who are frequently not given a choice about treatment, and who are much more vulnerable to the manipulations of adult authority figures, which can have a severe and disproportionate effect on a young person’s growing sense of self.

This is the primary reason that I am skeptical of analyses citing high overlap between self-injurious tendencies and mental distress as proof of their premise. Correlation is not causation, and therapeutic treatments for self-injury can induce mental distress if it was not preexisting. The intense social stigma on self-injurious tendencies, reinforced by therapeutic treatments, can also provoke intense feelings of shame and embarrassment in self-injurers. Either of these factors could lead to distress and self-injury becoming linked in the client’s mind.

bloody needle

I remember rubbing my hands against the carpet on my bedroom floor until I got blisters. I remember pressing my hands against a hot stove. I remember flapping my hands when I walked. I remember pulling my hair so hard that my mother had to French-braid it daily to keep it from ripping out. I remember walking in circles for hours. I remember learning to sew and finding it much more enjoyable to stick the pins and needles in my fingers.

I was sent to doctors and therapists and school counselors and pull-out groups for problem children, where nice, trustworthy adults who could effortlessly snuff out my little life explained that I was neurotic and depressed. I was punishing myself, they said. I had low self-esteem. I was reenacting early childhood trauma. Of course I was unhappy, they said, and I should not be believed when I claimed otherwise. I was in denial.

Self-fulfilling prophesies don’t always work, but for too long, these worked on me. Adults told me I was punishing myself by liking pain and not behaving normally, so it must be true. I quickly caught on that I must, in fact, be inferior and deserving of punishment. Still, I fantasized about being believed. I fought against myself, part of me demurely believing the adults, and part of me rising to anger that they did not believe me. But they were big and powerful and had the power to lock me up; I could never win.

Some people, in response to such experiences, would become skilled, adept communicators. I did not. I communicate badly, even now. I contribute to my own lack of credibility with my awkward, wandering, unprofessional style. I recognize this, but cannot seem to control it. This post, I know, will not be believed. Denial. Attention-seeking. Pathetically transparent attempt to rationalize maladaptive behavior.

But a girl can dream.

I mentioned in Part One that self-injury is an openly defiant gesture asserting ownership of one’s own body. Similarly, rejecting psychotherapeutic treatment for it, and rejecting the “maladaptive emotional distress” narrative and all that it implies, is an assertion of ownership of one’s own mind. Doubly defiant—you can’t dictate what I do with my body, nor can you dictate how I feel about it. Breaking their rules and being happy about it is such a threat to the psychotherapists’ monopoly that the best they can do is catch us young, force us onto the curve, and deny the existence of any outliers.

I still fantasize about being believed. I’ve tasted short-lived snippets of it. I’ve met people, credulous and sympathetic and genuinely interested, who took me at my word when I described my experiences. Until something puts them off, or I say or do the wrong thing, and my efforts fail once again. I keep tinkering with the formula, striking a new balance, hoping to someday master the elusive power of credibility. Someday I will curl my hair evenly, apply eyeshadow neatly, walk without shaking, and speak and be believed. Someday. A girl can dream.

I don’t have credibility. But at least there’s righteous anger.

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3 Responses to From the Sanguinary Files, Part Two

  1. Alicia Lile says:

    I self-injury, I do it when I’m in pain and can’t cope with it and I wish to stop but it’s not something I think too much about stopping except when others talk to me about it, I have real problems that actually hurt me, that’s one of the reasons I hurt myself, I was harmed by therapy to cure self-injury, I am ashamed of SI and I think acceptance is better, being ashamed of it makes me want to hurt myself, that is counterproductive.
    I believe some people can injure themselves because they like it, it’s a choice, it shouldn’t be a problem. I believe some people do that because they are in pain, they don’t want it, they shouldn’t feel ashamed of it or be manipulated, they should be actually helped with what they need to feel better.
    The stigma of SI is terrible, it doesn’t matter if it’s something you enjoy or want to stop, the treatments I got and know about use that stigma and use shame, it can make you stop for some time but it won’t cure you.

  2. Sanguine says:

    I’m supportive of SI and believe it to be another expression of ones’ self. How are tattoos and piercings any different than SI?

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