Preamble

An estimated 4% of American adults use physical self-injury as a way of coping with stress. Rates are higher among adolescents, who seem to be at an increased risk for self-injury, with approximately 15% of teens reporting some form of self-injury. Studies show an even higher risk for self-injury among college students, with rates ranging from 17%-35%. The rate of self-injury in other industrial nations is probably similar.

Still, self-injury remains a taboo subject—a behavior that is considered freakish or outlandish and is highly stigmatized by medical professionals and the lay public alike. Self-injury (also called self-harm, self-inflicted violence, or self-mutilation) can be defined as self-inflicted physical harm severe enough to cause tissue damage or leave visible marks that do not fade within a few hours. Acts done for purposes of suicide or for ritual, sexual, or ornamentation purposes are not considered self-injury. This document refers to what is commonly known as moderate or superficial self-injury, particularly repetitive SI. These guidelines do not hold for cases of major self-mutilation (i.e., castration, eye enucleation, or amputation).

Because of the stigma and lack of readily available information about self-injury, people who resort to this method of coping often receive treatment from physicians (particularly in emergency rooms) and mental health professionals who can cause harm rather than healing. Based on hundreds of negative experiences reported by people who self-injure, the following Bill of Rights is an attempt to provide information to medical and mental health personnel. The goal of this project is to enable them to more clearly understand the emotions behind self-injury and to respond to self-injurious behavior in a way that protects the patient as well as the practitioner.

 

The Bill of Rights for Those Who Self-Injure

The right to caring, humane medical treatment. Self-injurers should receive the same level and quality of care that a person presenting with an identical but accidental injury would receive. Procedures should be done as gently as they would be for others. If stitches are required, local anesthesia should be used. Treatment of accidental injury and self-inflicted injury should be identical.

The right to participate fully in decisions about emergency psychiatric treatment (so long as no one’s life is in immediate danger). When a person presents at the emergency room with a self-inflicted injury, his or her opinion about the need for a psychological assessment should be considered. If the person is not in obvious distress and is not suicidal, he or she should not be subjected to an arduous psych evaluation. Doctors should be trained to assess suicidality/homicidality and should realize that, although referral for outpatient follow-up may be advisable, hospitalization for self-injurious behavior alone is rarely warranted.

The right to body privacy. Visual examinations to determine the extent and frequency of self-inflicted injury should be performed only when absolutely necessary and done in a way that maintains the patient’s dignity. Many who SI have been abused; the humiliation of a strip-search can re-traumatize the patient, and may be likely to increase the amount and intensity of future self-injury while making the person subject to the searches look for better ways to hide the marks.

The right to have the feelings behind the SI validated. Self-injury doesn’t occur in a vacuum. The person who self-injures usually does so in response to distressing feelings, and those feelings should be recognized and validated. Although the care provider might not understand why a particular situation is extremely upsetting, she or he can at least understand that it is distressing and respect the self-injurer’s right to be upset about it.

The right to disclose to whom they choose only what they choose. No care provider should disclose to others that injuries are self-inflicted without obtaining the permission of the person involved. Exceptions can be made in the case of team-based hospital treatment or other medical care providers when the information that the injuries were self-inflicted is essential knowledge for proper medical care. Patients should be notified when others are told about their SI and, as always, gossiping about any patient is unprofessional.

The right to choose what coping mechanisms they will use. No person should be forced to choose between self-injury and treatment. Outpatient therapists should never demand that clients sign a no-harm contract; instead, client and provider should develop a plan for dealing with self-injurious impulses and acts during the treatment. No client should feel they must lie about SI or be kicked out of outpatient therapy. Exceptions to this may be made in hospital or ER treatment, when a contract may be required by hospital legal policies.

The right to have care providers who do not allow their feelings about SI to distort the therapy. Those who work with clients who self-injure should keep their own fear, revulsion, anger, and anxiety out of the therapeutic setting. This is crucial for basic medical care of self-inflicted wounds but holds for therapists as well. A person who is struggling with self-injury has enough baggage without taking on the prejudices and biases of their care providers.

The right to have the role SI has played as a coping mechanism validated. No one should be shamed, admonished, or chastised for having self-injured. Self-injury works as a coping mechanism, sometimes for people who have no other way to cope. They may use SI as a last-ditch effort to avoid suicide. The self-injurer should be taught to honor the positive things that self-injury has done for him/her as well as to recognize that the negatives of SI far outweigh those positives and that it is possible to learn methods of coping that aren’t as destructive and life-interfering.

The right not to be automatically considered a dangerous person simply because of self-inflicted injury. No one should be put in restraints or locked in a treatment room in an emergency room solely because his or her injuries are self-inflicted. No one should ever be involuntarily committed simply because of SI; physicians should make the decision to commit based on the presence of psychosis, suicidality, or homicidality.

The right to have self-injury regarded as an attempt to communicate, not manipulate. Most people who hurt themselves are trying to express things they can say in no other way. Although sometimes these attempts to communicate seem manipulative, treating them as manipulation only makes the situation worse. Providers should respect the communicative function of SI and assume it is not manipulative behavior until there is clear evidence to the contrary.

What self-injury is—and isn’t:

You’ll hear it called many things—self-inflicted violence, self-injury, self-harm, self-abuse, self-mutilation (this last particularly seems to annoy people who self-injure). Broadly speaking, self-injury is the act of attempting to alter a mood state by inflicting physical harm serious enough to cause tissue damage to your body. This can include cutting (with knives, razors, glass, pins, any sharp object), burning, hitting your body with an object or your fists, hitting a heavy object (like a wall), picking at skin until it bleeds, biting yourself, pulling your hair out, etc. The most commonly seen forms are cutting, burning, and headbanging. “Tissue damage” usually refers to damage that tears, bruises, or burns the skin—something that causes bleeding or marks that don’t go away in a few minutes. A mood state can be positive or negative, or even neither; some people self-injure to end a dissociated or unreal-feeling state, to ground themselves and come back to reality.

It’s not self-injury if your primary purpose is:

• sexual pleasure
• body decoration
• spiritual enlightenment via ritual
• fitting in or being cool

The sort of self-injury this site discusses is repetitive self-harm. People learn that hurting themselves brings them relief from some kinds of distress and turn to it as a primary coping mechanism.

Calling it self-mutilation often angers people who self-injure. Other terms (self-inflicted violence, self-harm, self-injury) don’t speak to motivation. They simply describe the behavior. “Self-mutilation” implies falsely that the primary intent is to mark or maim the body, and in most cases this isn’t so.

Why does self-injury make some people feel better?

There are a few possibilities, and the answer is probably a mixture of them. Biological predisposition, reduction of tension, and lack of experience in dealing with strong emotions are all factors.

It reduces physiological and psychological tension rapidly

Studies have suggested that when people who self-injure get emotionally overwhelmed, an act of self-harm brings their levels of psychological and physiological tension and arousal back to a bearable baseline level almost immediately. In other words, they feel a strong uncomfortable emotion, don’t know how to handle it, and know that hurting themselves will reduce the emotional discomfort extremely quickly. They may still feel bad (or not), but they don’t have that panicky jittery trapped feeling; it’s a calm bad feeling.

This explains why self-injury has addictive qualities: it works. When you have a quick, easy way to make the bad stuff go away for a while, why would you want to go through the hard work of finding other ways to cope? Eventually, though, the negative consequences add up, and people do seek help.

Some people never get a chance to learn how to cope effectively

We aren’t born knowing how to express and cope with our emotions—we learn from our parents, our siblings, our friends, schoolteachers—everyone in our lives. One factor common to most people who self-injure, whether they were abused or not, is invalidation. They were taught at an early age that their interpretations of and feelings about the things around them were bad and wrong. They learned that certain feelings weren’t allowed. In abusive homes, they may have been severely punished for expressing certain thoughts and feelings. At the same time, they had no good role models for coping. You can’t learn to cope effectively with distress unless you grow up around people who are coping effectively with distress. How could you learn to cook if you’d never seen anyone work in a kitchen?

Although a history of abuse is common among self-injurers, not everyone who self-injures was abused. Sometimes, invalidation and lack of role models for coping are enough, especially if the person’s brain chemistry has already primed them for choosing this sort of coping.

Problems with neurotransmitters may play a role

Just as it’s suspected that the way the brain uses serotonin may play a role in depression, so scientists think that problems in the serotonin system may predispose some people to self-injury by making them tend to be more aggressive and impulsive than most people. This tendency toward impulsive aggression, combined with a belief that their feelings are bad or wrong, can lead to the aggression being turned on the self. Of course, once this happens, the person harming himself learns that self-injury reduces his level of distress, and the cycle begins.

What kinds of people self-injure?

Self-injurers come from all walks of life and all economic brackets. Some people who SI manage to function effectively in demanding jobs; some are on disability. Their ages range from early teens to early 60s, maybe older and younger. In fact, the incidence of self-injury is about the same as that of eating disorders, but because it’s so highly stigmatized, most people hide their scars, burns, and bruises carefully. They also have excuses to pull out when someone asks about the scars (there are a lot of really vicious cats around).

Aren’t people who would deliberately cut or burn themselves psychotic?

No more than people who drown their sorrows in a bottle of vodka are. It’s a coping mechanism, just not one that’s as understandable to most people and as accepted by society as alcoholism, drug abuse, overeating, anorexia, bulimia, workaholism, smoking cigarettes, and other forms of problem avoidance are.

Okay, then isn’t it just another way to describe a “failed” suicide attempt?

NO. People who inflict physical harm on themselves are often doing it in an attempt to maintain psychological integrity—it’s a way to keep from killing themselves. They release unbearable feelings and pressures through self-harm, and that eases their urge toward suicide. And although some people who self-injure do later attempt suicide, they almost always use a method different from their preferred method of self-harm. Self-injury is a maladaptive coping mechanism, a way to stay alive. Unfortunately, some people don’t understand this and think that involuntary commitment is the only way to deal with a person who self-harms. Hospitalization, especially forced, can do more harm than good.

Can anything be done for people who hurt themselves?

Yes. Here are some self-help ideas, as well as some advice for family and friends of those who self-injure. Research into medications that stabilize mood, ease depression, and calm anxiety is being done; some of these drugs help people stop their self-harm. Many therapeutic approaches have been and are being developed to help people who engage in self-injury learn new coping mechanisms and teach them how to start using those techniques instead of self-injury. They reflect a growing belief among mental health workers that once a client’s patterns of self-inflicted violence stabilize, real work can be done on the problems and issues underlying the self-injury.

This does not mean that patients should be coerced into stopping self-injury. Any attempts to reduce or control the amount of self-harm a person does should be based in the client’s willingness to undertake the difficult work of controlling and/or stopped self-injury. Treatment should not be based on a practitioner’s personal feelings about the practice of self-harm.

Self-injury brings out many uncomfortable feelings in people who don’t do it: revulsion, anger, fear, and distaste, to name a few. If a medical professional is unable to cope with her own feelings about self-harm, then she has an obligation to herself and to her client to find a practitioner willing to do this work. In addition, she has the responsibility to be certain the client understands that the referral is due to her own inability to deal with self-injury and not to any inadequacies in the client.

People who self-injure do generally do so because of an internal dynamic, and not in order to annoy, anger or irritate others. Their self-injury is a behavioral response to an emotional state, and is usually not done in order to frustrate caretakers. In emergency rooms, people with self-inflicted wounds are often told directly and indirectly, that they are not as deserving of care as someone who has an accidental injury. They are treated badly by the same doctors who would not hesitate to do everything possible to preserve the life of an overweight, sedentary heart-attack patient.

Doctors in emergency rooms and urgent-care clinics should be sensitive to the needs of patients who come in to have self-inflicted wounds treated. If the patient is calm, denies suicidal intent, and has a history of self-inflicted violence, the doctor should treat the wounds as they would treat non-self-inflicted injuries. Refusing to give anesthesia for stitches, making disparaging remarks, and treating the patient as an inconvenient nuisance simply further the feelings of invalidation and unworthiness the self-injurer already feels. Although offering mental-health follow-up services is appropriate, psychological evaluations with an eye toward hospitalization should be avoided in the ER unless the person is clearly a danger to his/her own life or to others. In places where people know that self-inflicted injuries are liable to lead to mistreatment and lengthy psychological evaluations, they are much less likely to seek medical attention for their wounds and thus are at a higher risk for wound infections and other complications.

“to be nobody-but-myself in a world which is doing its best, night and day, to make me everybody else means to fight the hardest battle which any human being can fight, and never stop fighting” — ee cummings

As much as we’d like it to be, self-injury isn’t something that can be tucked away in a little corner of your life where it doesn’t touch anything else. Even after you’ve stopped, it continues to affect who you are and how you interact with people. Scars fade but never disappear entirely. Feelings of alienation may subside but still lurk in the background. If you’re still actively hurting yourself, life gets even more complicated. This page is meant to offer some answers for the unique dilemmas self-injury brings into your life: telling others, answering intrusive questions, hiding and healing scars, and a few medical issues. I am not a medical professional and these pages are presented for informational purposes only. No diagnosis or treatment is intended.

Coming out

Admitting to the people in your life that you self-injure is analogous in many ways to the process of coming out. This list of things to consider when deciding to tell those you love about your way of coping with stress is adapted from a coming-out list in Bass and Kaufman 1996.

The assumption here is that you’ll tell people about your SI in a conversation, but that’s not the only way to come out. Some people have found that writing down everything they want to say and presenting it to someone has worked for them. If you choose this approach, follow the general guidelines below and be sure you remain available for discussion after the person has read what you’ve told them. If you want to come out to someone via email, I’d suggest you follow up immediately with a chat session or a telephone call.

Be willing to give the other person some time to digest, though — if you follow up with them and they say, “I’d like to think about this for a while,” give them space. Ask them to let you know when they’re ready to talk, and let it go.

Be sensitive to the other person’s feelings

It can be nearly as hard for them to hear it as it is for you to tell them. Realize that they’re probably wondering what they did wrong or how they could have prevented you from feeling so much pain or why you turned out “sick.” You don’t have to accept their value judgments about your SI, but be open to hearing what they have to say about it. You might learn something, and you can teach them a great deal.

Explain that coming out is an act of love

Let them know that your deciding to tell them about self-injury is a sign of your love for and trust in them. Usually, a person decides to tell someone about their SI because they love the other person, wants or needs their loving support, and is tired of keeping a whole part of themselves hidden. The desire to be open and to trust outweighs the fear of rejection or hatred or disgust. Let the person you’re telling about your self-harm know you’re not trying to punish. manipulate, or guilt-trip them.

Pick a place that is private and a time that is unhurried

This is serious stuff. Find a time when everyone involved is available for a long conversation. Do it in a place where everyone’s comfortable and there’s no need to worry about being overheard. If you’re rushed or hurried or afraid other people nearby will hear and react, you’re not going to be able to give your full attention to the conversation and neither will anyone else.

Don’t tell others in anger

Don’t use your SI as a weapon: “Oh, yeah, well look, you made me cut/burn/scratch/hit!” To get the love and understanding you’re seeking, you may have to give some in return. Whether or not the person you have decided to share your secret with has contributed to the problems that led to your SI is irrelevant to the coming-out conversation. If you start getting angry and blaming, you’re going to put the other person on the defensive and they’ll get angry. The whole process will bog down and be hideously unpleasant and unproductive. Using SI as a weapon also increases the likelihood that the person you’re coming out to will react in exactly the ways you’re hoping they won’t.

Consider enlisting an ally

If you have a friend or therapist who understands your SI you might want to ask them to sit in on the conversation. A neutral third person can help keep things calm.

Provide as much information as you can

This is crucial. The more someone knows about something, the less they fear it. Many people have never heard of self-injury or have heard weird sensationalized tabloid reports. Be prepared to give the person books or names of books, articles, photocopies, printouts, addresses of web sites, etc. Gather as much information as you can so you can answer their questions accurately and honestly.

Be willing (and prepared) to answer their questions

You may have to educate them about SI. Encourage them to ask whatever questions they may have. If they ask a question you don’t have an answer to,say “I don’t know” or “I can’t say” or even “I prefer not to get into that right now.” Be as open as you can. You might want to anticipate questions they’ll ask and get an idea of how you want to answer those before you come out. You can ask other people who’ve come out what they were asked to get some ideas.

You should also have a good idea in your mind of what you want to do about the self-injury — they’re going to ask. Do you want treatment? What sort? If not, what’s the rationale for not treating it? Do you want them to help you stop or control it? How can they help? What’s too intrusive and what isn’t? Now is a good time to start setting boundaries.

It’s not necessary to bring up the most disturbing topics in the first conversation

Don’t start by describing in technicolor detail the time you needed 43 stitches and a transfusion. It’s probably best to avoid graphic descriptions of what you do; if asked, just say “I cut myself on the wrist” or “I hit the walls until I get bruises” or whatever. Try not to freak them out; you can give details (if necessary) in some other conversation.

Trust your own judgment

Do what feels natural to you. You know yourself and your family and friends far better than I ever will.

Communicate

Be willing to talk to the people you’re coming out to about your reactions, and ask them to let you know what they’re thinking. Communication goes both ways.

Scars

For some people, scars aren’t an issue — they self-injure in ways that don’t leave permanent marks or they only injure in places that are normally covered by clothing (the torso, shoulders, etc). For most people who cut or burn, though, scars happen. Some people like their scars and look on them as battle wounds or even life-maps. Many others hate their scars and want to find ways to get rid of them. Both attitudes are equally valid.
The two most common scar questions I hear are “How do I explain them?” and “How do I make them go away?”

Dealing with unpleasant questions

It happens sooner or later – you’re at school or work, on the bus, in a shop, and someone notices. “What happened to your {arm, leg, face, whatever}?”
People aren’t usually trying to make you uncomfortable. Quite often, they’re just making conversation; they don’t really want to know why you have scars, but it’s something to say. Nevertheless, you’re stuck coming up with an answer.

Quite often, the easiest solution is to half-laugh or make a rueful face and say “It’s a long story.” Then change the topic. This deflects most people; if they persist, you can say, “I would really rather not discuss this.” You can be a bit icy here — after all, they’re being a bit rude by asking you personal questions and not letting you gracefully avoid answering.

On the other hand, you could try some of the suggestions that came up during a discussion of excuses on the bus email list. You prolly won’t use most of them, but read them for the laughs:

I had unprotected sex with a porcupine.
I took my lizards for a walk and they held on for dear life.
The neighborhood cat and I had a disagreement about the paw prints on my truck.
The police didn’t comply with the terrorists’ demands fast enough, so they took it out on us hostages.
This first one is kind of lame, but it’s what I use most often: “Um, uh…I, uh….you see….I…uh…Well,….” At which they usually try to help me out by replying, “Did you fall?” And I say, “Yes, thanks.”
Well, let me just tell you this: You should NEVER EVER, under ANY circumstances, go out with a guy/girl that you met on the internet.
I hurt myself.
I keep falling off of cliffs trying to catch that damned roadrunner.
“I was oyster hunting.” They give me a blank stare. Then I say, with a wink, “You’ve obviously never been oyster hunting before.”
“It’s a long story.” They usually leave me alone, but this one guy said, “I’ve got time.” Then I said, “I fell. [long pause] Ok, so it’s obviously not THAT long.”
I was at this party with Marilyn Manson and everyone was giving out hugs.
I lost a fight with a can of tuna fish.
I slipped while making a salad.
I fell asleep, and the clown got me.
I’ll just put it this way: when they tell you not to feed the bears, it’s for a damned good reason.
I thought those security tags on pants just sprayed ink, but apparently they spray shards of broken glass, too.
Those aren’t cuts, they’re mehendi.
Don’t worry about it. Because of me, they now have a warning label!
What are you talking about?? (as I quickly pull my sleeves up.)
Damn Cat.
Well, when I was younger, I had this dream that a dog was following me…he ran, and I ran, but the faster I ran, the more he sped up. I wanted to get to safety, to my house…I was almost there…but right when I got to the front porch, he bit me. Everywhere. Lots of times. Making marks that don’t look like bites at all. And when I woke up… ::wide eyes:: and I had THESE.
“What scars?” They usually reply “those ones,” to which I reply, “I don’t see anything.”
The voices told me to do it.
I wrestle Tigers…
I got them climbing a fence to escape this hell-hole. (said at school)
(said to a guy who thinks I worship the devil) I did this as a sacramental offering to my dark lord, you prick. ::Smile::
(about scars on my stomach) “Oh, those are from having my baby.” “You don’t have a baby!” “No, but I could.”
None of your business, you stupid (insert appropriate curse word here)
I did it. (Hey, honesty works sometimes)
Dealing with scars themselves

If you hate your scars and want to do something about them, you have two options: You can find ways to conceal your scars, or you can try to heal/minimize them.
Hiding scars

Sometimes it’s possible to hide scars.
Wrist scars can be covered by long sleeves, bracelets, or watches.
In summer, wear long-sleeved shirts of light material (silk, gauzy cotton, and the like).
Another summer idea is to wear a long-sleeved shirt open over a tank top or t-shirt. If anyone questions it, you can tell them you’re worried about sun exposure.
Some leg scars in women can be hidden by pantyhose or tights.
Concealer makeup (like Dermablend) can be used to hide some scars. You can get more info at dermablend.com. People have reported getting very good results with Dermablend, which was formulated for covering port-wine birthmarks and skin conditions like vitiligo. It’s waterproof and can be blended to match skin color very closely.
Healing scars

The first step in healing scars is probably good wound care. Wash with Betadine if appropriate, and use a good antibiotic ointment (like Neosporin) on the wound daily. Johnson & Johnson make a new bandage, Band-Aid Advanced Healing, that seals the wound completely. Fluids from the wound are absorbed by special particles in the bandage that turn them into a gel to cushion the wound. This keeps the wound moist, which reduces itching and helps it heal faster. It also can reduce the urge to pick at the wound, because you are meant to keep the bandage on continuously until the wound has healed, or about a week.

For some types of scarring, special creams or bandages may help. Mederma is a cream designed to minimize scarring, but it must be used when the scar is very new. Reports on its efficacy are mixed.

There are several brands of silicone sheets and pads available:

Rejuveness

Syprex

Clinicel (a cushion)

Cicacare
ReTouch
ScarFX
ScarEase

Mepiform

to name a few. Syprex also makes a cream, a topical gel, and a special cleansing wipe. A new product, ScarGuard, combines liquid silicone, mild cortisone, and vitamin E. You paint the liquid over the scars to form something similar to a silicone sheet, and use it in the same way you use the sheets.
Silicone sheets are taped tightly (a few now are self-adhesive) over the scars for several hours each day. Treatment continues for varying lengths of time (days to weeks). The manufacturers claim that these sheet can soften and fade most raised or red scars, even keloids. Some burn centers do use them to help diminish scarring after grafts, and unlike Mederma, they are meant for old scars as well as new. None of these products will make scars disappear but they can help make them less obvious (and cut down on intrusive questions. I’ve seen Rejuveness and Cicacare at Walgreen’s in the US.

Curad recently introduced ScarTherapy, a new product for reducing scar tissue. It uses polyurethane instead of silicone, which allows air to get through; instead of wearing the sheet a few hours every day, you wear it continually; each day you take off the old sheet and put on a new self-adhesive one. Like the silicone sheets, it claims to be able to flatten and lighten scars (in other words, none of these will do much for flat scars that are paler than surrounding skin). I’m interested in hearing reports on this product; if you try this, email me.

Plastic surgery might be effective for some sorts of scarring, but it is very expensive and leaves scars of its own. Dermabrasion might work for very light scarring, but I’ve heard from several people who found it useless, expensive, and painful. The same holds for laser resurfacing. I’ve not heard of either working well for SI scars — if you know of someone it’s helped (or it helped you), please email me.

Cortisone injections combined with laser therapy can flatten large keloids, but you’ll still have a remnant of a scar. The treatment can be painful, and results aren’t guaranteed.

Skin grafts can be done to reduce a network of scars to one big scar which can be more easily explained, but they still leave you with a big ugly scar. Someone reported having wedge surgery in which the scarred areas were cut out in a wedge and skin edges sewn back together, leaving one long scar. I’ve also heard about a procedure in which balloons are slipped under the skin and slowly inflated to stretch the skin out. The loose skin is then sewn over the scarred area. If you know anything about this, I’d love to hear details.

If you decide to have plastic surgery done, you will have to convince your surgeon that you are through self-injuring; most doctors will not help you cover scars if they think you’re going to go out and get new ones right away. Some may require that you be SI-free for a set period of time before they’ll consider doing the surgery.

Tattooing over scars may be an option for some people, but scarred skin is very difficult to work with and may not hold ink well. If you want to try this route, ask around and check references until you find a very good, very experienced tattoo artist and set up a meeting to discuss the possibilities. If the artist thinks tattoos wouldn’t work well on your scar, it might be best to drop the idea. Again, this is something to do only if you’re pretty sure you’re not going to scar the area afterward.

A good source for information about scars and plastic surgery is http://www.scarcare.org. Remember that nothing can make the scar go away completely; treatments can only change the shape, appearance, or location of it.

Medical concerns for people who cut

If you are still using self-injury as a way to cope with overwhelming situations, you need to pay attention to your health and monitor yourself for symptoms of anemia or dehydration.
If you cut, you’re losing two important things: fluid (plasma) and red blood cells. Your body can replace the plasma in about 48 hours if you drink enough liquid. The red cells will take about two months to be replenished.

Dehydration can send you into shock. The most common symptom is dizziness, especially when changing positions (for example, standing up after having been lying down for a while). You may also have a very rapid pulse. If the dehydration is severe (you’re very dizzy, your eyes look sunken, you can’t keep fluids down, your skin is clammy and you feel weak), go to the doctor immediately — they’ll give you IV fluids and you’ll be fine in a few hours. To avoid getting to that point, be sure to drink 8 glasses of water daily (more on days you’ve lost blood). If you feel dizzy after SI, drink as much water or juice as you can and monitor yourself for symptoms of shock.

Anemia happens when you lose too much iron by losing too many red cells. If you are anemic, you will be pale and feel very weak. You might be irritable and short of breath and just feel bad. If you have these symptoms, you can see a doctor and have the anemia confirmed; the doctor will then give you iron supplements and vitamin C and tell you that you’ll feel better in a couple of months. If you want to avoid becoming anemic, but you’re not ready to stop cutting, you should take a multivitamin with iron and vitamin C daily and stop the bleeding on your cuts as quickly as possible.

This section contains a variety of ways that you can stop yourself from making that cut or burn or bruise right now.

 

How do I know if I’m ready to stop?

Deciding to stop self-injuring is a very personal decision. You may have to consider it for a long time before you decide that you’re ready to commit to a life without scars and bruises. Don’t be discouraged if you conclude the time isn’t right for you to stop yet; you can still exert more control over your self-injury by choosing when and how much you harm yourself, by setting limits for your self-harm, and by taking responsibility for it. If you choose to do this, you should take care to remain safe when harming yourself: don’t share cutting implements and know basic first aid for treating your injuries.

Alderman (1997) suggests this useful checklist of things to ask yourself before you begin walking away from self-harm (it isn’t necessary that you be able to answer all of the questions “yes,” but the more of these things you can set up for yourself, the easier it will be to stop hurting yourself):

While it is not necessary that you meet all of these criteria before stopping SIV, the more of these statements that are true for you before you decide to stop this behavior, the better.

• I have a solid emotional support system of friends, family, and/or professionals that I can use if I feel like hurting myself.
• There are at least two people in my life that I can call if I want to hurt myself.
• I feel at least somewhat comfortable talking about SIV with three different people.
• I have a list of at least ten things I can do instead of hurting myself.
• I have a place to go if I need to leave my house so as not to hurt myself.
• I feel confident that I could get rid of all the things that I might be likely to use to hurt myself.
• I have told at least two other people that I am going to stop hurting myself.
• I am willing to feel uncomfortable, scared, and frustrated.
• I feel confident that I can endure thinking about hurting myself without having to actually do so.
• I want to stop hurting myself.

[Alderman (1997) p. 132]

How do I stop? And anyway, aren’t some of these techniques just as “bad” as SI?

There are several different flat-out-crisis-in-the-moment strategies typically suggested. My favorite is doing anything that isn’t SI and produces intense sensation: squeezing ice, taking a cold bath or hot or cold shower, biting into something strongly flavored (hot peppers, ginger root, unpeeled lemon/lime/grapefruit), rubbing Ben-Gay® or Icy-Hot® or Vap-O-Rub® under your nose, sex, etc. Matching reactions and feelings is extremely useful.

These strategies work because the intense emotions that provoke SI are transient; they come and go like waves, and if you can stay upright through one, you get some breathing room before the next (and you strengthen your muscles). The more waves you tolerate without falling over, the stronger you become.

But, the question arises, aren’t these things equivalent to punishing yourself by cutting or burning or hitting or whatever? The key difference is that they don’t produce lasting results. If you squeeze a handful of ice until it melts or stick a couple of fingers into some ice cream for a few minutes, it’ll hurt like (to quote someone I respect) “a cast-iron bitch” but it won’t leave scars. It won’t leave anything you’ll have to explain away later. You most likely won’t feel guilty after — a little foolish, maybe, and kinda proud that you weathered a crisis without SI, but not guilty.

This kind of distraction isn’t intended to cure the roots of your self-injury; you can’t run a marathon when you’re too tired to cross the room. These techniques serve, rather, to help you get through an intense moment of badness without making things worse for yourself in the long run. They’re training wheels, and they teach you that you can get through a crisis without hurting yourself. You will refine them, even devise more productive coping mechanisms, later, as the urge to self-injure lessens and loses the hold it has on your life. Use these interim methods to demonstrate to yourself that you can cope with distress without permanently injuring your body. Every time you do you score another point and you make SI that much less likely next time you’re in crisis.

Your first task when you’ve decided to stop is to break the cycle, to force yourself to try new coping mechanisms. And you do have to force yourself to do this; it doesn’t just come. You can’t theorize about new coping techniques until one day they’re all in place and your life is changed. You have to work, to struggle, to make yourself do different things. When you pick up that knife or that lighter or get ready to hit that wall, you have to make a conscious decision to do something else. At first, the something else will be a gut-level primitive, maybe even punishing thing, and that’s okay—the important thing is that you made the decision, you chose to do something else. Even if you don’t make that decision the next time, nothing can take away that moment of mastery, of having decided that you were not going to do it that time. If you choose to hurt yourself in the next crisis time, you will know that it is a choice, which implies the existence of alternative choices. It takes the helplessness out of the equation.

So what do I do instead?

Many people try substitute activities as described above and report that sometimes they work, sometimes not. One way to increase the chances of a distraction/substitution helping calm the urge to harm is to match what you do to how you are feeling at the moment.

First, take a few moments and look behind the urge. What are you feeling? Are you angry? Frustrated? Restless? Sad? Craving the feeling of SI? Depersonalized and unreal or numb? Unfocused?

angry, frustrated, restless

Try something physical and violent, something not directed at a living thing:
Slash an empty plastic soda bottle or a piece of heavy cardboard or an old shirt or sock.
Make a soft cloth doll to represent the things you are angry at. Cut and tear it instead of yourself.
Flatten aluminum cans for recycling, seeing how fast you can go.
Hit a punching bag.
Use a pillow to hit a wall, pillow-fight style.
Rip up an old newspaper or phone book.
On a sketch or photo of yourself, mark in red ink what you want to do. Cut and tear the picture.
Make Play-Doh or Sculpey or other clay models and cut or smash them.
Throw ice into the bathtub or against a brick wall hard enough to shatter it.
Break sticks.
I’ve found that these things work even better if I rant at the thing I am cutting/tearing/hitting. I start out slowly, explaining why I am hurt and angry, but sometimes end up swearing and crying and yelling. It helps a lot to vent like that.
Crank up the music and dance.
Clean your room (or your whole house).
Go for a walk/jog/run.
Stomp around in heavy shoes.
Play handball or tennis.

sad, soft, melancholy, depressed, unhappy

Do something slow and soothing, like taking a hot bath with bath oil or bubbles, curling up under a comforter with hot cocoa and a good book, babying yourself somehow. Do whatever makes you feel taken care of and comforted. Light sweet-smelling incense. Listen to soothing music. Smooth nice body lotion into the parts or yourself you want to hurt. Call a friend and just talk about things that you like. Make a tray of special treats and tuck yourself into bed with it and watch TV or read. Visit a friend.

craving sensation, feeling depersonalized, dissociating, feeling unreal

Do something that creates a sharp physical sensation:
Squeeze ice hard (this really hurts). (Note: putting ice on a spot you want to burn gives you a strong painful sensation and leaves a red mark afterward, kind of like burning would.)
Put a finger into a frozen food (like ice cream) for a minute.
Bite into a hot pepper or chew a piece of ginger root.
Rub liniment under your nose.
Slap a tabletop hard.
Snap your wrist with a rubber band.
Take a cold bath.
Stomp your feet on the ground.
Focus on how it feels to breathe. Notice the way your chest and stomach move with each breath.
[NOTE: Some people report that being online while dissociating increases their sense of unreality; be cautious about logging on in a dissociative state until you know how it affects you.]

wanting focus

Do a task that is exacting and requires focus and concentration.
Eat a raisin mindfully. Pick it up, noticing how it feels in your hand. Look at it carefully; see the asymmetries and think about the changes the grape went through. Roll the raisin in your fingers and notice the texture; try to describe it. Bring the raisin up to your mouth, paying attention to how it feels to move your hand that way. Smell the raisin; what does it remind you of? How does a raisin smell? Notice that you’re beginning to salivate, and see how that feels. Open your mouth and put the raisin in, taking time to think about how the raisin feels to your tongue. Chew slowly, noticing how the texture and even the taste of the raisin change as you chew it. Are there little seeds or stems? How is the inside different from the outside? Finally, swallow.
Choose an object in the room. Examine it carefully and then write as detailed a description of it as you can. Include everything: size, weight, texture, shape, color, possible uses, feel, etc.
Choose a random object, like a paper clip, and try to list 30 different uses for it.
Pick a subject and research it on the web.

wanting to see blood

Draw on yourself with a red felt-tip pen.
Take a small bottle of liquid red food coloring and warm it slightly by dropping it into a cup of hot water for a few minutes. Uncap the bottle and press its tip against the place you want to cut. Draw the bottle in a cutting motion while squeezing it slightly to let the food color trickle out.
Draw on the areas you want to cut using ice that you’ve made by dropping six or seven drops of red food color into each of the ice-cube tray wells.
Paint yourself with red tempera paint.

wanting to see scars or pick scabs

Get a henna tattoo kit. You put the henna on as a paste and leave it overnight; the next day you can pick it off as you would a scab and it leaves an orange-red mark behind.

 

the 15 minute game

Another thing that helps sometimes is the fifteen-minute game. Tell yourself that if you still want to harm yourself in 15 minutes, you can. When the time is up, see if you can go another 15. I’ve been able to get through a whole night that way before.

I tried all of that. I still want to hurt myself.

Sometimes you will make a good-faith effort to keep from harming yourself but nothing seems to work. You’ve slashed a bottle, your hand is numb from the ice, and the urge is still twisting you into knots. You feel that if you don’t harm yourself, you’ll explode. What now?

Answer these as honestly and in as much detail as you are able to right now. No one is going to see the answers except you, and lying to yourself is pretty pointless. If, in all honesty, you see no other answer to #8 but yes, then give yourself permission, but set definite limits. Do not allow the urge to control you; if you choose to give in to it, then choose it. Decide beforehand exactly what you will allow yourself to do and how much is enough, and stick to those limits. Keep yourself as safe as you can while injuring yourself, and take responsibility for the injury.

The questions:

1. Why do I feel I need to hurt myself? What has brought me to this point?
2. Have I been here before? What did I do to deal with it? How did I feel then?
3. What I have done to ease this discomfort so far? What else can I do that won’t hurt me?
4. How do I feel right now?
5. How will I feel when I am hurting myself?
6. How will I feel after hurting myself? How will I feel tomorrow morning?
7. Can I avoid this stressor, or deal with it better in the future?
8. Do I need to hurt myself?

 

Staying safe while hurting yourself

A few things to keep in mind should you decide that you do need to hurt yourself:

• Don’t share cutting implements with anyone; you can get the same diseases (hepatitis, HIV, etc) substance users get from sharing needles.
• Try to keep cuts shallow. Keep first aid supplies on hand and know what to do in the case of emergencies.
• Do only the minimum required to ease your distress. Set limits. Decide how much you are going to allow yourself to do (how many cuts/burns/bruises, how deep/severe, how long you will allow yourself to engage in SI), keep within those boundaries, and clean up and bandage yourself later. If you can manage that much, then at least you will be exerting some control over your SI.

 

What is “fake pain” and why does it matter?

The concept of “fake pain” helps to explain why distress-tolerance skills are so crucial.

Observation of myself and interviews with others have convinced me that one of the reasons people self-injure is to deflect unknown, frightening pain into understandable, sort-of-controllable “pseudo” or “fake” pain. Calling this phenomenon “fake pain” is in no way intended to suggest that it doesn’t hurt; it hurts like hell. When memories or thoughts or beliefs or events are excessively painful, instead of facing them directly and feeling “genuine” pain, we sometimes deflect distress into pain that seems understandable and controllable, like that of self-injury. The real feelings associated with the event you’re avoiding get overridden by those of the situation you create to distract yourself. It still hurts like hell, but it’s a controllable familiar hell, whereas the real pain you’re avoiding seems scary and poised to take over your world like the monster who ate Detroit.

It’s easy to revert to “fake” pain. Trying to find the source of your distress can be scary as hell, because you often don’t know what you’re going to unleash. Fake pain, although very painful and traumatic, is something that you understand and can control and can handle. It’s familiar, not mysterious and scary like the real pain behind it. You might feel that if you ever exposed yourself to the real pain you’d lose control: “If I ever start crying, I’ll never stop” or “If I let myself get mad about that, I’ll never stop screaming.”

Instead, you unconsciously deflect the distress away from the memories or feelings that generated it and into self-injury. SI is seductive: you control it. You know the boundaries, even when you feel out of control. It makes sense and it makes the distress go away, at least for a while. It’s a clever mechanism—it takes what seems unbearable and transforms it into something you can control. The only problem is that when you deflect pain, you never face up directly to what it is that has caused this much tumult in your life. So long as you channel distress into fake pain, you never deal with the real pain and it never lessens in intensity. It keeps coming back and you have to keep cutting.

You have to deal with the unbearable if you ever want to make it lose its power over you. Every time you can meet the real pain head-on and feel it and tolerate the distress, it loses a little of its ability to wipe you out and eventually it becomes just a memory. The process is like building tolerance to a drug. Narcotics users take a little bit more of their drug every day as tolerance builds, until eventually they’re routinely taking amounts of drug that would kill an ordinary person. The poisonous events in your past work in a similar way. Exposure (with the help of a trained therapist) over time will build your tolerance to these events and enable you to lay them to rest. The key is learning to tolerate distress.

DBT-related skills

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy developed by Dr. Marsha Linehan. It began with efforts to treat borderline personality disorder (BPD). DBT has proven useful in treating mood disorders, suicidal ideation, and for change in behavioral patterns such as self-harm and substance abuse. Linehan’s Skills Training Manual has several helpful worksheets for getting through crisis situations. Though they are best used as part of a DBT program with a trained therapist, you might find some of them helpful.

Accepting Reality

This concept focuses on learning to accept reality as it is. Accepting it doesn’t mean you like it or are willing to allow it to continue unchanged; it means realizing that the basic facts of the situation are even if they aren’t what you’d like them to be. Without this kind of radical acceptance, change isn’t possible.

Letting Go of Emotional Suffering

In this worksheet, you learn ways to observe and describe your emotion, separate yourself from it, and let go of it. One of Linehan’s basic principles is that emotion loves emotion, and this worksheet is designed to help you experience your emotions with amplifying them or get caught in a feedback loop.

Distraction

Distraction is simply doing other things to keep yourself from self-harming. Most of the techniques mentioned above are distraction techniques; you bring something else in to change the feeling. Using ice, rubber bands, etc, is substituting other intense feelings for the self-injury. Other things Linehan suggest substituting include experiences that change your current feelings, tasks (like counting the colors you can see in your immediate environment) that don’t require much effort but do take a great deal of concentration, and volunteer work.

Improve the Moment

This worksheet focuses on ways to make the present moment more bearable. It differs from distraction in that it’s not just a diverting of the mind but a complete change of attitude in the moment.

Evaluating the Pros and Cons of Tolerating Distress

As the name implies, this worksheet leads you through an evaluation: what are the benefits of doing this self-harming thing? What are the benefits of not doing it? What are the bad things about doing it? About not doing it? Sometimes writing this down can help you make a decision not to harm.

Self-Soothing

This, like improving the moment and distracting, is a distress tolerance technique. It’s pretty straightforward: use things that are pleasing to your senses to soothe yourself. Some people find that active distraction works better for violent angry feelings and soothing is more effective for soft, sad ones.

Reducing Vulnerability to Negative Emotion

Prevention of states in which you are likely to self-harm is covered in this worksheet, which suggests ways of taking care of yourself in order to minimize the times when you feel the urge to hurt yourself. If you’re balancing eating, sleeping, and self-care, you’re less likely to be overwhelmed by emotion.

Interpersonal Effectiveness

Being clear about what you want and about your priorities in an interaction are crucial to good communication, and this worksheet offers a series of questions and steps to follow to help you determine how to approach a difficult interpersonal interaction. It is truly amazing how much going through these steps can help.

More information about Dialectical Behavioral Therapy can be found here.

S.A.F.E.

In 1984 Karen Conterio (then of Hartgrove) established a support group for self-injurers called SAFE (Self-Abuse Finally Ends). SAFE groups were not like 12-step groups or most self-help groups; they were short-term groups run by a professional facilitator. SAFE no longer offers these groups, but they do have a 30-day inpatient program. SAFE operates on the belief that the underlying emotional conflict is the primary problem, not the self-injury. More information about SAFE can be obtained on their website or at 1-800-DONTCUT.

First-Aid Basics

If you’ve already injured yourself and need to know how to care for the wounds, this list of first-aid basics might be helpful.

I stopped a few weeks ago, but I keep obsessing about hurting myself. Help?

It’s not uncommon for people to continue thinking obsessively about self-injury for a while after they’ve made the decision to stop. Hurting yourself has been a huge part of your life up until recently, and you’re used to dwelling on it. You might think that you’re supposed to be “cured” now and that all thoughts of SI should magically vanish from your head, so when you catch yourself thinking about that blade or lighter or whatever, you get angry and frustrated and shove the thought away.

Foa and Wilson (1991) deal with intrusive thoughts by a combination of giving yourself permission to think about it and exposure/habituation techniques combined with ritual prevention. Exposure refers to repeatedly presenting someone with the situation about which they obsess, and habituation happens when, after much exposure without resulting to usual actions, the person gets used to the situation and it no longer distresses them.

To adapt these techniques, first make yourself safe. If you’re in a mindset in which self-injury seems very very likely, it might be better to use distraction techniques to get past that place. Line up a support person whom you can call if you get overwhelmed by this technique. Try to tolerate it for as long as you can, even if you’re uncomfortable.

First, designate two 10 or 15 minute time periods daily. Choose times when you will be alone and able to think without being interrupted. To begin, set a timer for the designated amount of time. Then obsess about hurting yourself. Think about what it would feel like, how you would feel afterwards, how much you want to do this—all those thoughts you’ve been trying to suppress. Get as distressed as you can, and stay focused on the topic of injuring yourself. You may find, especially after the first few times, that you get really bored toward the end of your time period. That’s a good sign—you’re becoming habituated.

When the time is up, stop thinking about SI. If thoughts of wanting to harm come into your mind at other times during the day, acknowledge them and remind yourself that you will think about them later, when it’s time. Then let them go. If they come back, repeat the process. Don’t shove them away or try to ignore them; just acknowledge, remind yourself they have their time soon, and let go.

After a week or so you will notice an improvement (maybe even after just a few days). One crucial thing: no matter what, do not act on the thoughts of SI. They are just thoughts, and you can use the skills that you used to stop harming to get through these times. In order for habituation to occur, you have to get through the exposure without resorting to the old behavior. Use distraction and substitution for SI (ritual) prevention.

Now what? Perhaps someone you care about has honored you by trusting you with information about their self-injury, or maybe you’ve inadvertently discovered it. Regardless of how you found out, you know about it now, and you can’t pretend it away—you have to respond in some way. Here are some guidelines for dealing with SI in a friend or family member.

Don’t take it personally.

Self-injurious behavior is more about the person who does it than about the people around him/her. The person you’re concerned about is not cutting, burning, hitting, or whatever just to make you feel bad or guilty. Even if it feels like a manipulation, it probably isn’t intended as one. People generally do not SI to be dramatic, to annoy others, or to make a point.

Educate yourself.

Get as much information as you can about self-injury in general. This page is a good start; there are also some very informative books out there (in particular, Bodies Under Siege by Favazza, The Scarred Soul by Alderman, and A Bright Red Scream by Strong). The Favazza book is more scholarly in tone, the Alderman book is oriented toward self-help, and Strong’s book presents the voice of self-injurers talking about what they do and why — it lets you inside the mind of people who SI. All contain much valuable information and advice.

Understand your feelings.

Be honest with yourself about how this self-injury makes you feel. Don’t pretend to yourself that it’s okay if it’s not — many people find self-injury repulsive, frightening, or provoking (Favazza, 1996; Alderman, 1997). If you need help dealing with the feelings aroused in you by self-injury, find a good therapist. Be careful, though, that you not try to get “surrogate therapy” for your family member/friend — what goes on in your therapy sessions should remain between you and your therapist. Don’t ask your therapist to try to diagnose or treat the person you’re concerned about, and if the self-injurer seeks treatment, be sure that s/he is seeing a different therapist than you are. Don’t discuss the content of your therapy sessions in any but the most general terms, and never say anything like “My therapist says you should…” Therapy is a tool for self-understanding, not for getting others to change.

Be supportive without reinforcing the behavior.

It’s important that your friend, lover, child, sibling know that you can separate who they are from what they do, and that you love them independently of whether they self-injure. Be available as much as you can be. Set aside your personal feelings of fear or revulsion about the behavior and focus on what’s going on with the person.

Some good ways of showing support include:

1. 1. • Don’t avoid the subject of self-injury. Let it be known that you’re willing to talk, and then follow the other person’s lead. Tell the person that if you don’t bring the subject up, it’s because you’re respecting their space, not because of aversion.
      • Make the initial approach. “I know that sometimes you hurt yourself and I’d like to understand it. People do it for so many reasons; if you could help me understand yours, I’d be grateful.” Don’t push it after that; if the person says they’d rather not talk about it, accept this gracefully and drop the subject, perhaps reminding them that you’re willing to listen if they ever do want to talk about it.
      • Be available. You can’t be supportive of someone if you can’t be reached.
      • Set reasonable limits. “I cannot handle talking to you while you are actually cutting yourself because I care about you greatly and it hurts too much to see you doing that” is a reasonable statement, for example. “I will stop loving you if you cut yourself” isn’t reasonable if your goal is to keep the relationship intact.
      • Make it clear from your behavior that the person doesn’t need to self-injure in order to get displays of love and caring from you. Be free with loving, caring gestures, even if they aren’t returned always (or even often). Don’t withdraw your love from the person. The way to avoid reinforcing SIV is to be consistently caring, so that taking care of the person after they injure is nothing special or extraordinary.
      • Provide distractions if necessary. Sometimes just being distracted (taken to a movie, on a walk, out for ice cream; talked to about things that have nothing to do with self-injury) can work wonders. If someone you care about is feeling depressed, you can sometimes help by bringing something pleasant and diverting into their lives. This doesn’t mean that you should ignore their feelings; you can acknowledge that they feel lousy and still do something nice and distracting. (This is NOT the same as trying to cajole them out of a mood or telling them to just get over it — it’s an attempt to break a negative cycle by injecting something positive. It could be as simple as bringing the person a flower. Don’t expect your efforts to be a permanent cure, though; this is a simple improve-the-moment technique.)
      • If you live apart from the person you’re concerned about, offer physical safe space: “I’m worried about you; would you come sleep over at my house tonight?” Even if the offer is declined, just knowing it’s there can be comforting.
      • Don’t ask “Is there anything I can do?” Find things that you can do and ask “Can I ?” People who feel really bad often can’t think of anything that might make them feel better; asking if you can take them to a movie or wash those (month-old) dishes (if done nonjudgmentally) can be really helpful. Spontaneous acts of kindness (“I saw this flower at the store and knew you’d love to have it”) work wonders.

Take care of yourself.

It sounds like hard work, and it is. And if you try to be completely supportive to someone else 24/7, you’re going to burn out (and they won’t have any incentive to change). You have to find ways to be sure your needs are being met.

Take a break from it when you need to. When setting limits, remember that as much as you love someone, sometimes you’re going to need to get away from them for a while. Tell the person that sometimes you need to recharge and that it doesn’t affect your love for him/her. Only break into this personal time in cases of absolute life-or-death crisis.

The balance here is tricky, because if you make yourself more and more distant, you might get a reaction of increasing levels of crisis from the other person. If you let them know that they don’t have to be about to die to get love and attention from you, you can take breaks without freaking the person out. The key is developing trust, a process that will take some time. Once you prove that you are someone who isn’t going to go away at the first sign of trouble, you will be able to go away in non-crisis times without provoking a crisis response.

Ultimatums do NOT work. Ever.

Loving someone who injures him/herself is an exercise in knowing your limitations. No matter how much you care about someone, you cannot force them to behave as you’d prefer them to. In nearly two years of running the bodies under siege mailing list, I have yet to hear of a single case in which an ultimatum worked. Sometimes SI is suppressed for a while, but when it inevitably surfaces it’s often more destructive and intense than it had been before. Sometimes the behavior is just driven underground. One person I know responded to periodic strip searches by simply finding more and more hidden places to cut. Confiscating tools used for SIV is worse than useless — it just encourages the person to be creative in finding implements. People have managed to cut themselves with plastic eating utensils.

Punishments just feed the cycle of self-hatred and unpleasantness that leads to SIV. Guilt-tripping does the same. Both of these are incredibly common and both make things infinitely worse. The major fallacy here is in believing that SIV is about you; it almost invariably isn’t (except in the most casual ways).

Accept your limitations.

Acknowledge the pain of your loved one.

Accepting and acknowledging that someone is in pain doesn’t make the pain go away, but it can make it more bearable. Let them know you understand that SIV isn’t an attempt to be willful or to make life hard for you or to be unpleasant; acknowledge that it’s caused by genuine pain they can find no other way to handle. Be hopeful about the possibility of learning other ways to cope with pain. If they’re open to it, discuss possibilities for treatment with them.

Don’t force things.

If you make overtures and they’re rejected, back off for a few days or weeks. Don’t push it. Some people need time to decide to trust someone else, particularly if they’ve received a lot of negative feedback about their SI before. Be patient.

Self-Injury Outreach and Support is a Canadian non-profit outreach initiative providing information and resources about self-injury to those who self-injure, those who have recovered, and those who want to help.

If you would like more formal crisis support, you can call the National Suicide Prevention Lifeline at 800-273-8255, Trans Lifeline at 877-565-8860 (U.S.) or 877-330-6366 (Canada), or The Trevor Project at 866-488-7386. If you don’t like talking on the phone, you can text HOME to 741741 to get to Crisis Text Line. If you’d like to talk to a peer, warmline.org contains links to warmlines in the United States. If you’re not in the U.S., click here for a connection to crisis centers around the world.

NOTE: Many of these resources could utilize restrictive interventions, like active rescues (wellness or welfare checks) involving law enforcement or emergency services. A warmline is least likely to do this, but still might have these policies. You can ask if this is a possibility at any point in your conversation if this is a concern for you.

** Neither Peerly Human online support groups nor Trans Lifeline implement any restrictive interventions for people considering suicide.