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Difficulties in various areas of impulse control, as manifested in problems with eating behaviors or substance abuse.
A history of childhood illness, or severe illness or disability in a family member.
Low capacity to form and sustain stable relationships. Self-injurers often complain of poor social skills, including hypersensitivity to other people's faults and an inability to tune in to the needs and concerns of others. They are irritated beyond belief by "lazy" and "annoying" habits of others, and often believe this behavior is targeted toward them, or done deliberately to annoy them.
Fear of change. This can be a fear of everyday changes in their environment, or of any kind of new experience: people, places, events. It can also involve an intense fear of changing their behavior in relationship to others, and a fear of the changes they may need to make in order to get well.
An inability or unwillingness to take adequate care of themselves. Many patients ignore their own needs for a nutritional diet, sufficient exercise and sleep, and good hygiene. Most say they fail to nurture themselves out of laziness and apathy, or because they consider themselves undeserving. In a supplementary category are patients who fail to take care of their basic safety needs. Kelly B., for example, would take money out of bank automated teller machines in dangerous neighborhoods at night.
Self-injurers tend to have low self-esteem, coupled with a powerful need for love and acceptance from others. They go to extremes to exact demonstrations of love and caring from others, including taking on too much responsibility for what happens in relationships (excessive self-blame), or adopting a "caretaking" role even when it is unhealthy or dangerous for them to do so. For instance, one patient at S.A.F.E. who was a recovering drug addict agreed, when asked by her mother, to take in her drug-addicted brother, despite the fact that this would put her and her family in jeopardy.
Some self-injurers manage to find more adaptive ways to meet their needs for affection, in their career choices (many choose medical fields or social services) or love of pets. Most of our patients have at least one pet, often more than one. Cats seem to be a favorite, perhaps because they are easier to keep than dogs. Pets give self-injurers the unqualified affection they are seeking, often unsuccessfully, from other people. We encourage patients to keep pets because of the responsibilities that pets entail. Gretchen I. says of her four cats, "If I didn't have them, I would have nobody to get better for. They need me."
Many patients deliberately enter the "helping professions"- nurse, physical therapist, massage therapist-to try to transform or transcend the anger and disappointment in their lives. They may be hoping that as "caretakers," someone will take care of them in return. Others are curious about the workings of the human body; they want to watch medical operations and to learn about anatomy.
Childhood histories replete with trauma or significant parenting deficits, which led to difficulties internalizing positive nurturing. Many self-injurers adapt to trauma by developing fantasies about being rescued from their grief. Our patients often explicitly acknowledge their desire for someone to swoop in and remove their pain. Some are seeking to attract the attention and care of someone who will nurture and protect them in ways their own parents did not.
Often a friend, lover, or family member will attempt to play the hero for a while. But nobody can sustain the role of "mother" to a fellow adult, so the strategy ultimately fails. When that happens, the self-injurer is confirmed in her belief that she is destined to be abandoned by others. Victoria R., for instance, described a friendship with someone who fell into the category of rescuer: "Natalie has taken actions-such as clearing out my apartment of sharp objects- to try to get me to stop. It hurts her to watch me hurt myself. She has offered everything in her power to try to keep me safe. I doubt few things would make her happier than to know that I was no longer self-harming." Natalie's actions, however, did not compel Victoria to alter her behavior.
Significantly, when Victoria was injuring, she also found great value in relationships with people who were not rescuers. Her friend Karen "has never been freaked out by my self-injury. She does not give me attention for it. She will listen to me when I need to talk about what has caused me to self-injure, but she isn't interested in what I actually do. She has been very supportive when I try to keep myself from self-injuring, like giving me some distractions or offering her apartment as a safe haven."
Victoria describes her brother-in-law similarly. "Andrew supports me while not focusing on my self-injury. He never acts shocked- in fact, he never comments on my injuries. He pushes me to continue with therapy and get the help that's available to me."
Rigid, all-or-nothing thinking. A self-injurer's signature catastrophic thoughts might include: "Nobody understands me," "I never get my needs met," "Nothing will ever change." Such a thinking style, combined with a chronically low self-image, tends to make sufferers more likely to reach for self-harm in a state of frustration, alarm, or impending rage.
For some, rigid thinking can manifest itself in perfectionism. This quality can be highly adaptive in some areas of the self-injurer's life; for instance, it can help her excel at school or on the job. Yet it tends to wreak havoc on her emotional stability when something unpredictable or stressful happens in her well-ordered universe, one of our goals during treatment is to help patients become more flexible in their everyday lives.
While perfectionism and workaholism are two common traits among self-injurers, the behavior takes hold of all types of people. Some of our patients, like Chrissie M., feel too incapacitated to hold a job, have a social life, or maintain a romantic relationship. Most of the time they feel too paralyzed by urges and fears even to leave the house.
Other self-injurers alternate between periods of cocooning, in which they hole up at home and refuse to socialize, and periods of functioning normally or participating in too many activities. In fact, they may function very well on the job and in many other aspects of life. They go to school, complete degrees, and hold responsible positions. "Most people assume you're going to get low-functioning people as a rule, that you're not going to get post-doctorates," says one recovered self-injurer, Nora A., who earned her Ph.D. in psychology and knew of two other people in her program at a large university who were also self-injurers. "It's a behavior that can interfere so badly that you have to drop out of school. I just took off for a year at a time when T was too sick."
Nora, who now runs
a psychology practice and supervises a staff of twenty, decided to quit self-injuring
after her two small children walked in on her in the act. "That made me realize
the true consequences of what I was doing," she says.
Reflection Exercise #5
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