On October 23rd, 2014, we updated our
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A Pain Too Deep
Lynne E. Muller, PhD, NCC, LCPC
Mary Ann Mathews
1. Who self injures?
2.Why do they do it?
3.What it is and is not.
4.How can we help?
“I needed to cut the way your
lungs scream for air when you
swim the length of the pool
underwater in one breath. It
was a craving so organic it
seemed to have risen from my
• Some forms of hair pulling
• Inserting foreign objects into the body
• Interference with wound healing
• Ingesting toxins
• Unexplained frequent cuts or burns
• Wearing long sleeves or pants in warm
• Avoiding swimming pools or the beach
• Wearing thick bracelets to cover wrists
• Having sharp objects in purse, book bag, or
• Difficulty expressing feelings
• Withdrawal from close relationships
Self injury is the
intentional harm of one’s
own body without conscious
(Aldeman, 1998, Favazza, 1998, van der Kolk, et al., 1991)
What Self Injury is NOT
• It is not a suicide attempt
(attempting to feel better, not escape all
• It is not usually attention seeking
• It is not a danger signal to others
• Roughly 2% (1-4%) of the population. In
some studies reported as high as 8 million
• 30 times the rate of suicide attempts
• 140 times the rate of completed suicides
• May also suffer from eating disorders
• 90% who cut began as teenagers
• Typical profile
• Mid 20’s to early 30’s
• Began cutting as a teen
• Middle to upper class
• Intelligent, well
• Males and females
• All races and socio-economic
• Ages 15-50’s
• Not easily identifiable
• are often depressed, feel powerless or
• have low self esteem /negative body image
• have difficulty expressing their emotions
• experience difficulty with relationships
• aim for perfection
• often have negative body image
• lack impulse control/suppressed anger
• do not have a repertoire of coping skills
• may have serotonin dysfunction
• possible trauma
• Many who self-injure did not
suffer childhood abuse (Zweg-Frank, et.al,
1995, Brodsky, et. al., 1998)
• 50-60% suffered childhood abuse or
trauma. That means that 40-50% did
• Invalidating environments (Lineham,
• Expression of private experiences and
feelings are not validated
• Feelings are trivialized, punished or
• Experience of painful emotions are
• Child’s interpretation of his or her
behavior is dismissed
In their own words . . .
“There are times when I hurt too deep for
tears, so I cut and it lets out some of the
hurt. It’s like when you see the blood
flowing out, the pain and fear are flowing
“Watching the blood flow out makes me
feel clean, purified. It feels like
something bad or dirty is leaving with the
2 & 3
In their own words . . .
“The stopped voice becomes a hand lifting knife,
razor, broken glass to cut, burn, scrape, pop,
gouge. The skin erupts in a mouth, tongue less,
toothless. A voice drips out, liquid…a voice
sears itself for a moment, in the flesh. This is a
voice emerging on the skin, a mouth appearing
on the skin. The body which could not be air on
the larynx becomes the stroke of a razor on
the breastbone or of a red-hot-knife-tip upon
the wrist…” .
Janice McLane (1996)
Why do they harm
• To release intense feelings
• The physical pain may be easier to
deal with than the emotional pain
• To feel real, alive
• To exert some control
• Acting out self punishment
Cycle of Cutting
Mounting anxiety, anger
or self hatred, alienation
Into the Void
“I felt like I was isolated from the
world, dead, with no emotions at all.
The blood told me I was alive, that I
could feel…Also I couldn’t cry, and
bleeding was a different form of
(Lindsay in Strong, p.57)
SI is often associated with:
• Borderline Personality Disorder
• Obsessive-Compulsive Disorder
• Post-Traumatic Stress Disorder
• Dissociative Identity Disorder
• Eating Disorders
• Substance Abuse
• Encourage communication about self-
injury and relevant aspects of the
• Improve the quality of client’s life as it
relates to self-injury.
• Explore themes of guilt and shame.
• Diminish use of self-injury as the
coping skill when client desires to make
changes. (Conners, Rubin, et, al,2002).
Helping: What to Do
• Learn about self-injury.
• Talk about SI. Ask about it.
• Be supportive. Show you care.
• Acknowledge the effort to cope with very
• Set limits
• Be available, but refer when appropriate
• Don’t discourage self-injury
• Recognize the severity of the distress
What Not to Do
• Be afraid to ask the question, “Do you self-
• Make eliminating the behavior the primary
• Make a safety contract or use contracts as
a reward or punishment
• Visibly monitor their injuries
• Make him or her feel ashamed or guilty
about the behavior
“This is yet another secret I must hold to
myself because my therapist has given
me an ultimatum, either no more
hurting myself or we will have to
discontinue our therapy. So a little
distance comes between us now, a secret
that hold great importance which we
could both learn from, if I was able to
Respond to the following statements by writing “A” for
“agree” if you mostly agree with the statement or “D”
for “disagree” if you mostly disagree. Be ready to
explain your responses.
___Self-injurers are survivors.
___Self-injurers are weak people.
___Self-injurers are harming themselves to get
___Self-injurers are perfectionists.
___Self-injury is a type of suicidal behavior.
___Self-injurers are proud of their scars.
___Self-injury helps people cope.
___Self-injurers are more sensitive than most other
•If my wound could talk it would
Taking Care of Yourself
• Monitor your own horror and
• Broaden your perspective past the
behavior to the intent behind it
• Seek consultation
• Get support for yourself
Care and Concern
• The capacity to derive comfort
from another is the single
biggest predictor of whether
traumatized patients are able
to give up their self-
destructive habits. (van der Kolk)
Care and Concern
• The development of a safe and
trusting relationship is vital for the
child to learn to sooth and care for
him or herself in a healthy manner
by internalizing their therapist’s
care and concern. (Strong, 1988)
Care and Concern
“_____ was the first to acknowledge that
maybe I was in pain, as opposed to ‘doing
it for attention’ . This affirmation of my
inner pain was a healing force. “ Shelley
• Why the upsurge in self-injurious
• Students who look for fist fights?
• Tattoos and piercing?