Nancy May, RN
Bryn Mawr Hospital Department of Psychiatry

"When you change the way you look at things, things you look at change." (Wayne W. Dwyer, Author and Motivational Speaker)  Research conducted at Stanford University has verified that mentally picturing doing an action in our minds causes our nervous system to react as if we were actually doing the action being imagined.

 "The skin becomes a battlefield as a demonstration of internal chaos.  The place where the self meets the world is a canvas or Tabula-Rasa on which is displayed how bad one feels inside."  (Scott Lines, Psychologist)

"When I cut myself I can see where the pain is coming from and watch it heal…And I can easily care for it….'This' pain doesn't have a specific place, It moves around and creeps into strange places."  (From A Bright Red Scream by Marilee Strong)

People self-harm and self-mutilate, not for attention or to commit suicide as is frequently assumed by health-care workers and others, but because it is a coping skill to deal with fear, anger, rage, and a multiplicity of other rationalizations that usually stem from some horrific trauma.  The pain of self-mutilation (SM) is not nearly as intense as that of the original trauma, but since the individual has not been able to verbalize the intensity of the original pain, SM becomes an outward sign or symptom of the original pain or trauma.

As reported by James Kot, Ph.D., Executive/Clinical Director of Alternative Counseling Associates, Inc., in Pottstown, Pennsylvania, some 3 million Americans self-injure.  By far, the greater majority are females, typically in their mid-20's to early 30's, who began self-injury in their teens.  Most are of middle or upper-middle socio-economic class, intelligent, well-educated, and frequently have a background of physical and/or sexual abuse, OR have a home with at least one alcoholic/drug-addicted parent.  Eating disorders are also prevalent among this population, and there is a high correlation with individuals who are diagnosed with Borderline Personality Disorder.  Males tend to join gangs or group where they can "act out" whereas females "act in" or against themselves.

Assessment and treatment of these individuals is a challenge, even to the most skilled mental health worker.  Above all, the primary premise is that we must treat these persons with honor, respect, and compassion.   To provide effective treatment, one must consider the spiritual, cultural, as well as the pathological implications that pertain to the person.  "Effective treatment requires putting aside any bias and prejudices as they relate to self-harm and listening compassionately to the narrative stories presented by the individual."  (Dr. Kot)  We need to avoid condemning the individual's behavior and focus on assisting the person to identify alternative, positive coping skills.   Going back to the first quote, we need to change the mindset of the individual, recognizing that our belief systems are extremely influential on our behavior, that is, if an individual has a negative self-image, we need to help that person develop a positive self-image of who they want to be and can become, all the while reinforcing our belief in them and their ability to overcome this destructive behavior.

Dr. Kot has suggested that while it is true that a decision not to self-harm is a prerequisite to recovery, it is also true that one must do more than just require the person to "stop cutting."  Self-mutilation has an addictive potential and is contagious, this is especially true among adolescents.  Nonetheless, the individual makes the choice to self-mutilate or not, and the time and effort on the mental health professional's part to develop a rapport with and trust of the individual so that she has enough strength and belief in self to accomplish this first step is crucial.  Because those who self-mutilate have often had multiple unsuccessful treatment attempts, one approach that gets to the crux of the problem quickly is to ask the individual to "train me how to work with you."

Generally speaking, medications do not have a great deal of effect on self-mutilating behavior, although some antidepressants and mood stabilizing medications have been useful in treating the underlying depression.  Studies have shown that self-injurious behavior may result from decreases in necessary brain chemicals, and there have also been noted similarities between Obsessive-Compulsive Disorder and self-mutilating behavior.  It is important to remember that self-mutilating behaviors are the symptom, and focusing on medication can divert attention from the underlying issues and impede the healing process.

While a number of techniques have been identified as useful tools in long term therapy, the overall goal is to "teach individuals to recognize their positive attributes and to accept the negatives…teach people to be deaf when people say you can't do it… unless convinced that (s)he can do it, will never be successful…teach them to believe in themselves." (Dr. Kot)

"I like who I am."
"I am a winner."  (You are right.)
"I am a loser."  (You are right.)