Cutting Away at Emotional Pain Handout (Nuestras Voces Conference 2010)

This is the handout I am providing for the November 2, 2010 Arte Sana Nuestras Voces / Our Voices National Conference on self-injury.  If you need a MS Word copy, let me know.

Cutting Away at Emotional Pain Handout

Renee Baker, Ph.D. / www.renee-baker.com / 214-607-5620

History

  • 1938-Karl Menninger wrote Man Against Himself delineating self-injury separate from suicidal behavior
  • 1996-Princess Diana volunteered that she was a cutter

Self-mutilation

  • A self-injurious behavior with no intention of suicide and is distinct from sanctioned piercings, etc.

DSM-V

  • Non-Suicidal Self-Injury is proposed as a new entry in the upcoming DSM.

Three categories

  • Superficial (considered today and below)

o   Common form seen in adolescents and includes cutting (most common), skin pricking, severe nail biting, stabbing, scratching, burning or scalding, hair pulling, chafing and interfering w/ wound healing.

o   Common items used include pencil tips, paper clips, pins, glass, razors, box cutters, scissors and drink can tabs.

o   Areas commonly cut are wrists, arms, ankles, calves, inner thighs, belly, brassier line, armpits and feet.

  • Stereotypic

o   Generally seen in autistics, individuals with intellectual disability or Tourette’s syndrome

o   Common behaviors are rhythmic hitting oneself, head banging, orifice digging, throat and eye gouging, self-biting and joint dislocation

  • Major

o   Commonly seen in those that are psychotic or intoxicated

o   Extreme nature resulting in significant tissue damage

o   Self-destruction includes such things as eye enucleation, genital mutilation or castration, limb amputations and bone breaking

Etiology (superficial)

  • Much research is yet to be done to understand this complex issue
  • Best predictors of self injuring

o   Childhood sexual abuse

o   Family violence

o   Loss of a parent or guardian

o   Childhood illness

o   History of substance abuse

o   Another family member self-injures

o   Poor mood regulation

o   Eating disorders such as anorexia or bulimia

o   Trauma as a child – trauma severity is associated with injury severity

o   Previously stayed on the street

  • Motivations

o   Still not understood, but not masochistic (pleasure of pain is not sought)

o   Reduced coping skills to manage the situation or perceived stressors

o   Intolerable & intense levels of anxiety and tension or depression or loneliness

o   To feel pain on the outside, not the inside (physical / emotional tradeoff)

o   To overcome numbness, to feel something, to cut matter so they “matter” – I’m real

o   Way to gain control over urges for sex or death

o   Aggression turned inward (body not perceived as self, but as an object)

o   Self-punishment or an act of religious atonement

o   To simulate feelings of past physical or sexual abuse, to unconsciously reconnect to the abuser

o   A cry for help in a nonverbal way – confronting an injustice – an un-redressed grievance

o   Way to self-medicate – pain leads to endorphins being released

  • The Two Root Characteristics of all Self-Mutilators

o   1) A feeling of mental disintegration where one has an inability to think

o   2 ) A feeling of rage that can’t be expressed, or even consciously perceived, towards a powerful figure or figures in their life, commonly a parent – one is afraid to argue or articulate – no outlet – fear of punishment or disapproval (Levenkron)

o   Physical pain or sight of one’s own blood is a way to drown out one of these two feelings

Parental Factors

  • Parent could be fragile and child is afraid to harm their parent by expressing anger
  • Parent could be neglectful or abusive or controlling or incestuous
  • Parent could have a financial stress, alcohol issues, emotional distress, marital distress, death
  • Not about blame, everyone is doing the best they can

Prevalence

  • Adult population prevalence is 4%, clinical adult population up to 21%
  • Adolescent population prevalence is anywhere from 14 to 39%, clinical adolescent is 40-61%
  • College student prevalence is 32%
  • Levenkron estimates 1 in 50 adolescents
  • LGBT youth at Youth First Texas rates were 36%
  • Among homeless youth, 69% self injure

Premeditative or compulsive

  • 19% think about it days or hours ahead of time
  • 27% thought of it 6 minutes or up to an hour ahead of time
  • 55% thought of it less than five minutes before the action
  • Levenkron ultimately considers it to be compulsive from a trancelike state

Sex, Class, Rural

  • Three large studies show no sex association though Levenkron says mostly females cut
  • No class associations
  • No rural/urban associations

Counselor

  • Must be exceedingly empathetic and not punitive or repulsed
  • Need to take “boy scout/girl scout” stance and see past the frightening self-infliction
  • Often requires intervention, referrals to physician, monitoring of wounds
  • Must become desensitized and sit with the client in their pain/rage/despair, get close to it
  • Must be informed so as to inform the client with straight facts
  • Need to understand the client’s pain, listen to their story and value them, give them voice
  • Break identification with being a cutter toward being someone who once cut – illness is not identity
  • Basic task: form a relationship based on trust that encourages dependency and healthy attachment
  • Timberlawn in Dallas has a treatment center for cutting
  • There may be hereditary factors or predispositions, but they are not a “sentence”

Reference:

  • Cutting: Understanding and Overcoming Self-Mutilation, Steven Levenkron
  • For this handout, literature review and Dallas Voice article that led to this panel

o   http://www.renee-baker.com/topics/self-injury/

Acknowledgment:

  • I would like to thank Melina Castillo of ARTE SANA for suggesting the idea for this panel!
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