Helping someone who practices self-mutilation

Right. I'm assuming here that the person is self-mutilating (I prefer the term self-injury, but never mind) as the symptom of a mental illness such as depression, bipolar, or borderline personality disorder (much as I don't like that diagnosis), and by 'help' you mean helping them to stop.

Short answer? It's difficult. It may be that you can't. And if you wanted a short answer, quick fix, conscience-soothing easy way out, then you really can't.

Long answer?


Short Term

• If someone comes to you and they have just injured themselves, first aid will often be a necessity.
• Minor cuts: the bleeding should be stopped by applying pressure, and elevating the limb if necessary. The cut should always be cleaned out and antisepticed; infection is often a problem for self-injurers. Dress the cut if necessary.
• If the cut is gaping, deep (seeing the subcutaneous fat layer is a Very Bad Thing) or has not stopped bleeding within 30 minutes, the person technically needs medical attention. However, many self-injurers are ashamed, and worried about people finding out and/or being misunderstood. You will have to use your judgement. If the person refuses to go to hospital, England has NHS walk-in centres where cuts can be cleaned, glued shut and dressed.
• Burns should be run under cold water for at least 10 minutes, after which you should apply antiseptic cream and dress the wound with a clean, dry bandage. Large (bigger than a 50 pence piece - about 3 cm across) and serious (beyond the first skin layers) burns need medical attention.
• With serious wounds and/or blood loss, there is the risk of shock. If the person goes into shock (signs to look out for include confusion, stammering, dizziness, unusual quietness and complaints of feeling cold), get them to hospital. Shock can be fatal.

• Your attitude is important. If someone opens up to you, do not get judgemental, horrified, derisive or emotionally blackmailing.
• As LaggedyAnne points out, you cannot shame someone into stopping. Trying to guilt-trip them, or yelling at them, will probably just drive the behaviour underground - moving from forearms to thighs, for instance.
• Remember that your average self-injurer is desperate. They are physically harming themselves because it is the only way they can feel better. Eliminate words such as attention and seeking from your vocabulary.
• Ask him or her why she has self-injured. Express sorrow. Make him or her understand that you care.
• Remember that self-injury is, usually, a symptom. It is not the primary problem but, to the person, the only solution.
• Nor does self injury suggest suicidal intent. True, many suicides are also self-injurers. However, both are symptoms and results of a larger problem. Self-injury does not necessarily lead to suicide.
• The best you can do is be there for the person in a caring, non-judgemental way. Be ready to talk to them. Eco's excellent wu under suicide prevention is a brilliant crash-course in how to deal with the mentally ill and desperate.
• You're going to have to deal with a lot of shit. Cutters can be high-maintenance and really fucked up. I cannot emphasise it enough: someone who is slicing, burning or bruising their own flesh is desperate. She (and it is statistically more likely to be a female) is feeling like shit. She may be dealing with a lot of: depression, self-hatred, numbness, trauma, fear and/or anger. Self-injury is often the only coping mechanism that the person has to deal with these things. Removing, or trying to remove, a coping mechanism without at least attempting to understand the problems is a quick route to disaster. Aspirin for a pickaxe wound to the skull will not work. For many self-injurers, hurting themselves is the only way to make the bad things go away. For others, it can be the only way to feel anything at all. Either way, you are going to be dealing with a lot of shit. Good luck.

• This is the person's decision. However, if he or she wants to get help, you can assist and encourage.
• Take professional titles with a pinch of salt. You may encounter doctors, psychiatrists, psychologists, therapists and counsellors. To my knowledge, only two of these titles, doctor and psychiatrist, require a degree in medicine. Psychologists do, I believe, have a degree in psychology but are not medical doctors. Therapists and counsellors may be brilliant or may be quacks: do your homework.
• Also bear in mind that different professionals do different things. If you think drugs such as antidepressants are the way to go, only doctors and psychiatrists are qualified doctors and may prescribe them. If, however, talking is needed, you may be better off with a therapist or counsellor.
• Getting in touch with other people going through similar things may also be helpful. Bodies Under Siege is a support mailing list which can be joined at htp://buslist.org/subs; BusCentral website is at http://buslist.org. Many other support groups, for many conditions, exist both on- and offline: feeding keywords to search engines should find them.

Footnote - If you ask someone, "What the hell happened to your arms?" you may well get one of the following responses:

• "It was the cat" (hey, this excuse is just traditional)
• "Rampant, unprotected sex with a porcupine"
• "I got caught in a drive-by cutting"
• "Piranha attack"
• "I was learning to juggle knives. I'm not very good."
• "What the hell happened to your manners?"

I've found this to be a remarkable way to create a sense of understanding between yourself and another cutter. It's extremely simple, and in the cases I've tried it, it's always been effective. If it's not, nothing is lost.

Ask them if they can't stop looking at their scars.

Most cutters I know, and most cutters the cutters I know know, have a strange predilection for looking at their cuts all the time; neither myself nor anyone I've talked to has any idea why this is. They generally won't even realize they're doing it until you ask them.

Although it does little to help them physically or mentally, emotionally this does wonders, making the person you're trying to help feel much less alone. Even if they don't feel like they're the only one with that problem, it binds you to them in a way of secret understanding; while I was not necessarily feeling like the only one in the world that cuts himself, my friend asked me this, and I felt a whole new sense of connection with her that was utterly amazing, and though I knew she had gone through the same kind of thing, I never realized how much she understood what I was feeling well enough to pick out something totally obscure like that and bring it to light.

Just a suggestion, and YMMV, as always.

Someone who practices self-mutilation may need the help of others in order to stop. Unfortunately, she (or he, it's a problem for males also!) may have a great deal of difficulty in seeking and/or obtaining this aid. Self-injury is seen as incomprehensible and irrational by many people, and self-injurers are often ignored or even scorned. Worse still, misguided attempts at helping can result in serious psychological and physical damage. Understanding the mental processes behind self-injury is vital to bringing about a change for the better. In my experience, the thoughts that lead to self-injury fall into one or more of these patterns:

• Psychological Disorders. Self-injury goes along with a few different disorders; in my experience, most of the people in this category are either having a major depressive episode, are bipolar (manic-depressive), or have borderline personality disorder.
• Masochism. Voluntary pain is pleasurable to some folks. This is only a problem if the person decides that it is. Masochism is often expressed in different ways than self-injury; body modification is a common outlet. It is distinct from other forms of self-injury, in that it stems from seeking pleasure rather than self-destruction. Many of the masochists I know were once self-destructive. They use it as outlet for their desires, not as a way of punishing or harming themselves.
• Repressed Emotions. This is a widely-held idea, and a bit of an oversimplification of the self-injurer mentality. The person has anger she can't express, communication problems, and/or some specific barrier that she sees as being impossible to overcome. She cuts as a way to express frustration, cry for help, and she may gain a physical release as well. The physical aspect is important: Self-injury stimulates both adrenaline and dopamine release, giving an intense, addictive rush.
• Revenge or Power. Closely tied into repressed emotion, she may be feeling isolated or ignored; self-injury brings attention. She may also be using it as a way of hurting those who care about her, for emotionally harmful acts; most often, this is part of a bad breakup. She may also feel guilty for using self-injury in one of these ways, and so she may try to hide it. This can form a downward spiral -- injuring to get attention, then feeling guilty, hiding the marks, and injuring again. Helping someone that is in this mode of thinking requires breaking that cycle. Show that you care about her whether or not she is harming herself. Listen to the cries for attention. Do NOT accuse her of being manipulative, do not ignore her -- this can lead to escalation. If you find that the injurer is controlling your life by her problems, get others to help her if need be. Abandoning the person does NOT work. (I tried it once when I thought I was out of ideas..)
• Addiction. "I can't stop myself." This is a very common statement of a self-injurer seeking help. It may actually be a symptom of a psychological disorder, masochistic tendencies, and/or repressed emotions. Whatever the underlying cause, the person finds herself injuring, and is unable to stop. Listen and ask questions. If there is something deeper, find it and help the person overcome it. Otherwise, just give them support in stopping. Quitting any addiction is often a rocky road. Know that there will be breakdowns along the way. Have courage, and build their confidence in themselves any way you can. A change of scene, such as a vacation or relocation, is one thing that can help. There are many others.

Judging someone as broken when you find out that she is a self-injurer is a bad move. It produces a kind of "help" that comes from the helper's desire to boost his own ego, rather than a truly magnanimous intent. As such, it is prone to do damage; a frequent result is emotional blackmail. So, the first step in helping another is to examine your own motivations for doing so.

Having been both helper and helped, I have experienced firsthand the potential damage of twisted motivation. About a month after I started putting scars on myself, I sought solace in a relationship with a very codependent person. She needed someone to fix, and I thought I needed someone to fix me: as such, it seemed like a good idea at the time for us. The trouble with that approach was that she was only interested in me as long as I was self-injuring. When I tried to move the conversation in positive directions that were not focused on my own mental anguish, she would lose interest. As such, I found myself in a state where I needed to continue my self-injury in order to keep the relationship going.

If you are certain that your motives are driven by a true desire to give aid, the next step is to listen carefully to what the injurer needs. Let her set a specific goal of her own. This may be different than what you are expecting. Self-injurers are a diverse group; it is important to try and see things from their viewpoint, rather than pushing judgement and/or threats at them. Perhaps one of the least healthy things to do is to say, "If you don't stop cutting, I'm going to start too." This will likely lead to one of two outcomes:
1) The individual continues cutting. You start also. Now you act as triggers for each other, and there are two people with problems instead of one. (This has happened to me.)
2) The individual continues cutting. You don't start. Now you have lost their trust; they continue to injure themselves, and they are now a bit more isolated than they were before. (This happened to an acquaintance of mine.)

What is the best way to proceed?

As long as you avoid those pitfalls, you have the potential to be of great help to your friend/lover/spouse who is a self-injurer. The best, simplest way to help out another person through their psychologically turbulent times is to provide a friendly ear. Gain their trust. If they tell you something in confidence, don't repeat it to their friends/co-workers/family, unless there is a definite danger of suicide or permanent damage. If it becomes clear that the person needs more than just a confidant, you should ask them to consider seeing a therapist: a counselor, psychiatrist, or psychologist. This can be a hard thing to do:

• You may think that recommending that they seek help is a cop-out: telling someone you care about to get their help from someone they don't know can seem cold, uncaring, even traitorous. It isn't. Therapists are professionals at helping people with this sort of thing; techniques such as cognitive behavior therapy can work wonders. Also, a therapist can provide something you can't. Because you care about the injurer, they will likely feel some debt to you, some pressure. A therapist can be more comfortable for them to talk to, and so the injurer can be more honest. A cutter might have a hard time telling you that he had a complete breakdown and sliced his legs to ribbons, but it would be easier to tell an impartial stranger.
• You don't want to be judgemental or imply that the injurer is crazy, as you might lose some trust. This is why it is important to suggest therapy in a gentle manner. Inform the person of the possibility. Offer to come with them. Ask them if they would like to try it, and if they say yes, make sure they stick by that decision. If the injurer is depressed, you may want to consider getting the appointment for them, and ensuring that they get to it. A therapist can be an excellent tool: it will take some pressure off of both you and the injurer. It is not a replacement for listening to her, but it can speed up the recovery. Note that not all therapists are created equal; don't be afraid to call it off if the therapist is doing more harm than good. If the therapist tries to prescribe medication, use your own judgement; I believe everyone has the power to change without pharmaceutical aids, but I know people who have benefited from them.

• Prozac Nation, by Elizabeth Wurtzel (Focused more on depression, but a good read)
• Cut, by Patricia McCormick (Advised by an ex-cutter friend of mine.)
• Girl, Interrupted by Susanna Kaysen (An excellent book. It helped me to make sense of my own disjointed thoughts, which was a good first step towards rearranging them.)
• http://www.nshn.co.uk/ This UK-based website contains facts about self-harm, several emergency numbers, and an active forum.
• http://www.selfharm.org.uk/ Contains information on common types of self-injury. It has a good FAQ on self-injury, as well as links to resources in the UK.