Moments before the session started, I dug through a random pile of pens, rubber bands, and note cards in an unfamiliar desk drawer, looking for anything sharp.
It’s okay, I’ll fix it, I reassured myself. “It was” an immense feeling of frustration following a difficult interaction with a colleague.
I craved what I knew would reduce the intensity of frustration – the feeling of a slight pain on the skin of my forearm. When I couldn’t find anything in the drawer and was forced to open Zoom and start the session, I instead chewed on an ulcer on the side of my cheek.
I was not a teenager. I was in my mid-thirties and worked as a clinician at an outpatient mental health center.
About six months ago, I first experienced the power of piercing the skin to relieve an overwhelming negative emotion. Under the stress of a project deadline and following a meeting where everyone seemed exhausted and irritable, I instinctively grabbed my left forearm, wrist and hand in my right hand. Hard. Within seconds, all of my rage, pain, and outrage evaporated, and I took notice.
My self-harm escalated over the course of a few months. With each incident, I became less shocked by what I had done to myself, and therefore willing to use tools that were more and more likely to cause injury and scarring.
Cutting is perhaps the best-known form of nonsuicidal self-harm (NSDI), a term used to describe any deliberate injury to oneself without the intent of suicide. Other forms of NSAID include burning or hitting or scratching at existing wounds.
Most people who self-harm hurt themselves trying to relieve uncomfortable strong emotions, like I did. Others may feel numb and want to feel something, try to gain a sense of control or resolve past trauma, or use self-harm to prevent other potentially more destructive behavior, among other reasons.
At the time, I was so overwhelmed that if I didn’t, the emotion – usually a combination of anger, grief, anxiety, guilt and vindictiveness – would consume me and rob me of my ability to function. .
Oh good? I scolded myself. Are you starting this now? You’ve been in the job market for over a decade. You hold two master’s degrees, in public health and clinical social work! If anyone should know better, it’s you.
Guess what is the result of self-humiliation? Intense emotion. And intense emotion leads, in the absence of other coping methods, to more cutting. I confessed my feelings and actions to both my own therapist and my clinical supervisor, who responded perfectly, without shock or condemnation.
“You were trying to cope,” my therapist said simply, after I described being overwhelmed with regret – yet again – that my 15-year college medical career plans hadn’t come to fruition.
Eyes lowered in shame, I confessed to him that I had relieved this distress by cutting myself. She asked me to identify other coping strategies I could use instead, but only after acknowledging that the feelings leading to the behavior were understandable.
We need to give everyone who self-harms the same validation. Sure cutting makes sense as a way to cope, as it immediately reduces emotional intensity. And there are other strategies that carry less risk. We validate first, then we work on behavior change. This balance between acceptance and change is the guiding principle of Dialectical Behavior Therapy (DBT), the gold standard treatment for ALC. In DBT skills training groups, clients learn to be fully present in the moment, tolerate distressing situations, communicate more effectively, and regulate their emotions.
I was familiar with DBT and occasionally suggested a DBT skills worksheet to a client, but I had yet to internalize their skills to the point of using them in my own life. The development of knowledge and skills is distinct. Skills take practice and the person who practices will be wrong. We are not born knowing how to regulate our emotions and, unfortunately, many of us did not learn this in childhood or adolescence.
Why did I start in my thirties? I had struggled with anxiety since childhood and depression for most of my adult life, yet I had never deliberately pierced my skin before. This wasn’t the first time I’d encountered work-related stress, and I hadn’t had any recent major life changes, such as a marriage, divorce, move, or serious diagnosis.
Yet, I was not alone. Studies indicate that between 4% and 23% of adults self-harm, and those who begin this behavior in adolescence but fail to learn alternative skills often continue to self-harm into adulthood.
Evidence suggests that people who self-harm, particularly those with certain psychological traits, can learn their self-harming behavior when they see the behavior modeled by someone else. In other words, NSAID can be contagious and I may have “caught” it through exposure to other people who use it to deal with a strong emotion. When I was a teenager and young adult, I didn’t know anyone around me who cut their skin to cope, even though I had seen the behavior portrayed in the media. When I became a therapist, that changed. My clients were cutting themselves, and this time it was up to me to find out.
Why did I “catch” the cut when other therapists who work with people who self-harm don’t start doing it themselves? I’ve always had trouble with emotion regulation, I’ve realized it, and I’ve never acknowledged it. In the past, I’ve coped by hitting steering wheels, desks and chairs, and slamming doors. I was already ready to turn to the cut when my emotions felt overwhelming.
“Why did I ‘catch’ a cut when other therapists who work with people who self-harm don’t start doing it themselves? I’ve always had problems regulating emotions, I’ve realized it, and I’ve never acknowledged it.
A few days after going through that desk drawer at the office, I decided that I would no longer self-harm in any way, including chewing my cheek and pricking my skin when I was anxious. I had learned about alternative coping techniques. The only missing piece was my commitment to practice them. I grabbed some scrap paper and jotted down a list of strategies, promising myself to go through the whole list before I cut myself, or hit myself or hit something hard in anger, or chewed my cheeks to shreds. I wrote at the bottom of the page that any form of self-harm is unacceptable. Then I took a photo and saved it to my phone’s “favorites” photo album for easy access.
The word “unacceptable” stuck in my mind in a DBT-based book I had read in an attempt to help a client who was cutting himself. The book validated the desire to self-harm to cope with strong emotions, but also called the behavior “unacceptable”. Another reader may have felt ashamed, but I felt motivated to commit to changing my response to a strong emotion. When we label the behavior as unacceptable, we are still acknowledging that it is our current reality.
To tell myself that self-harm was unacceptable, I had to make other actions acceptable. I had to give myself permission to cancel my clients’ sessions at the last minute if I was not mentally capable of practicing at my best. I had to remind myself that my therapist and supervisor aren’t embarrassed or mad at me if I have to contact them between scheduled meetings. I had to weigh the real — and questionable — risks and benefits of using fast-acting anti-anxiety medication versus cutting myself.
Then I had to practice identifying my emotions and naming them to myself. Often, simply putting a word on my inner experience dampened the emotion without further intervention. Yet this step proved to be surprisingly difficult. The feeling of overwhelming emotion was very familiar to me, but it didn’t always have a name. Often, during the time it took me to wonder if I felt outrage, sadness, worry, anger, or all four, the emotional intensity diminished.
The emotion naming strategy is supported by neuroscience. When we ask ourselves to name our emotion, we activate the prefrontal cortex, the region of the brain where high-level thinking and reasoning occurs. With the brain thinking online, the amygdala – the part of the brain that processes strong emotions – recedes.
The first few times I encountered overwhelming stress after taking my engagement, I struggled to convince myself that trying out my skill list was worth it, when I knew the cut would reliably calm me down. and fast.
One day, a communication breakdown with the vet’s office prevented me from getting my sick cat’s prescription medication before it closed for the weekend. After hanging up with the vet’s administrative assistant, I found myself with my whole body shaking and the urge to cut.
“Stop it,” I said to myself. “You promised you wouldn’t do this again.”
Name the emotion: Anger – both at the vet and myself. Concern for my cat.
Count the seconds of each breath: One, two, three, four…in. One, two, three, four…out.
Mark the wrist with a pen where I want to cut.
Text a friend to report what happened with the chat‘s prescription and receive support.
Remember that nothing lasts forever, including overwhelming emotion.
After going through the steps, I was still angry and worried. However, the intensity had diminished and I could think clearly without hurting myself. Even better, the success has reinforced that the skills work, with practice.
Brandy E. Wyant is a clinical social worker and writer based in the Boston area. You can find her on Instagram and Twitter at @bewyant.
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