Understanding the Self-Injurer

1. Understanding the Self-Injurer Shannon Gubser hwy507wyldlife@yahoo.com 360-481-3830

2. CREDITS…*Training at S.A.F.E. by Karen Conterio and Wendy Lader, Ph.D.*Our YL region (at that time led by Ky Griffin) paid for half of the training…they are behind us in our pursuit to help kids heal*The Lord’s Word (both written and rhema) have answers to our questions…if we will but just ask

3. How I began this journey… • Kids were suffering in their lives and were using SI to survive as a coping mechanism • Prayed with them and tried to help them but ultimately their behavior went back to SI • Saw girl who attended S.A.F.E. on TV…”This cannot be fixed by prayer alone, kids need to be taught new behaviors and how to change their thinking” • Yes…how can I help the whole person? If we are 3 parts…body, soul, and spirit • Went to S.A.F.E. for training…came back and used their tools as well as prayer and the Lord’s Word • Bigger then just “K”…set up camp for the region through intercession • Today is “expanding the tent pegs”…Isaiah 54:2

4. Let’s be honest… • When we are struggling or in pain (birthing contractions for example)…we want a way OUT! Or at least a distraction! • Often times when pain comes we: self-protect; self-promotion; self-provision; self-hatred; escapism • So…what if the option of the way we deal with our pain is taken away? Can you imagine taking the epidural away after you’ve been using it? • Our faithful and gentle God tells us (and backs it up with action) that we don’t have to do it this any longer…that He can be trusted to walk us through our pain • Step 1…we identify (or see) that we aren’t dealing with life in a healthy/God trusting manner…Step 2…we learn new ways to practice new behaviors (through the Word, through other people who love us well, and through circumstances)…Step 3…we practice our new behavior until it becomes a part of who we are (discipleship)…EXAMPLE…coaching hurdles • This will be the very same journey we walk our kids through…SI isn’t something to be feared…Jesus never feared hearing the hard stories or seeing demons…instead He met people where they were at…spoke truth…brought healing…and backed it up with action…AND…are we not an incarnational ministry as well?

5. Defining Self-Injury SELF INJURY IS… “Deliberate mutilation of the body or a body part, not with the intent to commit suicide but as a way of managing emotions that seem too painful for words to express” (Lader, 1998). Self abuse, self-injury, self mutilation is seen by the injurer as a form of self care to manage emotions SI is a radical means of emotion management SI communicates emotional pain; translates/communicates emotional pain through physical pain SELF INJURY IS NOT.. It’s not a half hearted attempt at suicide…rather it is often seen as a way to avoid suicide, seen as a way to get through the moment It’s not body modification taken to the extreme…body modification is seen as a way to beautify or improve looks It’s not demon possession…this is a gross simplification to treat a very complex issue It’s not a “way to get attention”… rather it’s often the opposite

6. Examples of Self-Injury • Cutting • Burning • Head banging • Scratching • Biting • Interfering with wound healing • Hair pulling • Injesting/injecting sharp objects or toxic substances • Breaking bones • Facial picking • Amputation/blinding

7. Has rock bottom self-esteem Is even “SELF-LOATHING” Often times feels: unloved, ugly, distain, hopeless, trapped Has probably had a lifetime of stuffed emotions Probably has never learned to express emotion in a healthy manner Often has feelings of profound abandonment Often feel they can never be right or good enough And often feel they are damaged goods Usually feels a lot of shame and guilt and therefore keeps this behavior secret General Profile of the Self-Injurer…

8. Why Might the SI feel “Self-Loathing”? • Trauma • Dysfunctional families • They feel that everything coming in validates “I am a bad person”

9. Covers all genders, SES, ethnicities, religions, etc May wear long sleeved shirts/pants even in the heat of summer May wear wrist covers May wear many bracelets that cover wrist area May be showing signs of depression or anger (feelings of isolation) May write about bleeding or cutting (check myspace/ facebook profile) May visit the bathroom frequently May hang out with other known SI (contagion factor) May have an achiever- perfectionistic lifestyle (i.e. excels in school, athletics, relationships, etc) May be a people pleaser who covers pain with a happy face May have a concurrent eating disorder (up to 80% of SI) Some Ways to Identify a SI

10. Bottom line… We can’t judge by appearance, we need to see their heart

11. Prevalence • It is estimated that 4% of the adult general population admits to at least occasional self-injury (Comtois, 2002) • A recent study of 2,875 high school and college aged students showed a lifetime prevalence of SI at 17% (Whitlock, 2006) • Research has show 90% of behavior begins as teenagers, with an average on-set at age 14 with increased severity through late 20’s (Penner, 2005) • DO THE MATH…

12. Other Related Statistics • It’s believed that between 50-80% of SI have been sexually abused and 100% have been emotionally abused or neglected in some fashion during childhood • Up to 40-50% of SI are male • SI crosses all races and economic backgrounds, although Caucasians may have a higher prevalence perhaps due to higher transient lifestyles/less extended family present • Up to 80% of SI have a concurrent eating disorder

13. 1st Exposures to SI • Movies/TV • Music • Friends • Impulse as a young child…destructive to self

14. What Precipitates an Incident of SI? • Cutters almost uniformly report the same sequence of events and emotional states before and after the episodes of SI • Generally precipitated by an experience (real or perceived) of loss or abandonment • Feelings provoked by this sense of loss or abandonment (tension, anger, rage, fear, anxiety, panic) build to an almost over-powering climax • They are unable to communicate their discomfort to others and therefore cannot draw support from others and they have not internalized their own self-soothing mechanisms to calm themselves and regain a sense of control • Then feelings of: helpless, being overwhelmed, utterly alone • Because they don’t seem to be able to express these emotions in a healthy manner nor can they be integrated, to discharge or release them they feel they must need an action or a physical response • Often times they enter into some form of a disassociative state

15. Other “Triggers” • Someone else talking about SI • Seeing SI on TV or on the computer • The sight of implements (i.e. scissors, knives, etc) • The physical feeling or touching of implements

16. During a SI Episode… • Often times feel no pain at the moment of cutting • Often oblivious to their surroundings • Some not aware of act itself until they “wake up” • Extent of injury is “controlled and carefully executed” • Either/or both the pain or sight of blood snaps the SI back into “normal consciousness”

17. Effects After a SI Episode… • Feelings of being alive again • Calm feeling • Reintegrated again • Real again • Transferred from a place of “passive helplessness to active control”, “peace and euphoria” • Then…often times feelings of shame and regret set in once they “come down” • Cutting seems to provide a temporary relief that is only that…temporary

18. Why People SI and Continue to SI • My behavior doesn’t affect or hurt anyone else (in reality isolates as well as has future implications) • It’s my body and I can do whatever I want with it, this is all I have left • It will hurt a lot more if I give it up, not sure of other options • Shows others how much pain I am in (my pain is real) • Scars are a reminder that “I can mange my pain” • Pushes people away when they get too close • I deserve to be punished; I am a horrible person • If I don’t self injure, I’ll probably kill myself (life management for them) • “It’s easier to do this then deal with life”

19. Some Purposes of SI Behavior • Analgesic Aim – trying to calm emotions, their fear is their emotions, they don’t believe that they will be able to survive or tolerate their emotions, car accident – adrenaline rush…not aware of the damage at the time, they need more and more to continue to get the same “relief”, relief from intense emotions, physiological studies have shown an actual release of endorphins when SI takes place

20. Some Purposes of SI Behavior • Communicative Aims (skin as bulletin board) – the skin is the largest organ of the body, it’s the first thing people see, often times SI feel misunderstood and not seen so they use their bodies as a bulletin board, shows history, where do I begin and end, who am I?, expression of emotion: self-hate/self-loathing, hurt, anger, fear, power, distain for self, maintain sense of security/ uniqueness, communicates inner turmoil, communicates need for support, permanent reminder of pain, shows others how much pain they are in, pushes people away when people get close

21. Some Purposes of SI Behavior • Religious/Discipline Implications – rituals have purpose, sense of self-sacrifice: hurt self rather than someone else, “I deserve this”, “I’m a bad person”, punish self • Other – ground in reality, I do exist, feel alive again, repress sexuality (often SI genitals or breasts), a way to deal with sexual self-loathing, express feelings of alienation, validating emotional pain, sense of self-control – faced and conquered it, prevention (preventing something worse from happening i.e. suicide or the actual dealing with the emotions)

22. They’ll say…But… • They’ll say they have to do it, but if we can help give them other tools they won’t need to. Understand the cycle of addictive behavior, addictions are traps (SI is not a life choice in an active sense). • They’ll say that life is too hard, but we can help them to recognize that they have a choice to feel and deal with life head on. Be prepared to help them challenge irrational thoughts that come up. • They’ll say this just happens…but something will have triggered the impulse. Help them discover what the impulse was…walk through what precipitated the impulse (can use the Impulse Log) • They’ll say they don’t want to feel the bad emotions, but no feelings are bad…they are just feelings. Help give them language to express the emotion (feelings sheet). • They may say they use it to “feel better”, but it is never about increased pleasure, it is about pain management • They may say they feel out of control and use SI as a way to get back in control, but in actuality the sense of reprieve lasts only a short time and then there are feelings of guilt, shame, and embarrassment when they are done • They say they cannot change how they manage their pain…but we can teach them new ways. Allow them to let their feelings show rather than SI

23. Why is SI More Prevalent Now? • Disenfranchised Society – change of jobs an average of every 3-4 yrs, more moving and change of venue, therefore loss of more long term relationships • Collapse of Extended Family – divorce / 2 households, latch key kids, strangers baby-sit, dinner not sacred like it used to be, loss of mentoring, loss of rites of passage or less meaning to them • Emphasis on the Quick Fix – need for immediate gratification, belief that everything should be easy, painless, and fast, cell phones, IM, no need to self-sooth

24. The A-holic Society – dysfunctional is chic (glorification rather than shame), victim mentality, nothing is my fault, behavior is normalized on TV, internet, etc • Body Focused Culture – women perfect body • Individualized Activities – Internet, computer games, listening to music with head phones, used to do board games and made eye contact with others, now many of our activities are not “face to face” with others, all of these create a sense of invisibility, kids don’t perceive ind behavior as rude when in groups • More Exposure – Movies, TV, internet sites, contagion factor

25. Sexual Abuse – people who have been sexually abused are more vulnerable and often feel as though they are different and are not like everyone else, traditionally rape is seen as the women’s fault and therefore they feel they are responsible for someone else hurting them (however, rape is a crime of power not about sex), SI is often a way of “uglification” to protect themselves and keep others away, they make the outside look like how they feel on the inside • General Differences / Not Fitting In – learning disabilities, physical infirmity, etc

26. Family Aspects Under parented • Emotional unavailability • Role reversal • Little or no conscious • Recognition of anger •Guilt becomes conscious feeling •”They need me” Over parented •Rigidity perfectionist / controlling / enmeshed •Individuation seen as betrayal •Met with anger/rage •Child sees anger as dangerous thus represses anger •”I need them”

27. SI and Eating Disorders • Control – both are trying to master things that others cannot, “tough enough to handle pain”, “tough enough to conquer hunger”, when really they are not tough enough to handle their emotion • Protection – both interfere with (they take the place of and protect from) social activities, keeps them from being intimate with others • Purge – both rid one of toxic feelings that are symbolized by food and blood

28. Self-Injury vs. Suicide • Behavior is a coping strategy • Desire to relieve pain • Pain is intermittent, gradually building to intolerable proportions • Pain is temporarily relieved through SI (a temporary escape) • Action is a permanent escape • Desire to terminate life • Pain is long term and perceived as unavoidable • Pain is perceived to be relieved only by death (a permanent escape)

29. SI and Suicide • SI can kill themselves accidentally, this is the number one reason given for motivation in attending the SAFE program • SI become hopeless when their coping strategy fails to work or their stressor is perceived to be too large, they may then perceive suicide as an option

30. Stats on SI and Suicide • Approximately 55-85% of SI have made at least one suicide attempt (Stanley, B. Gameroff, M.A., Michalsen, B.A., & Mann, M.D., 2001) • 28-41% of individuals who engage in SI behaviors report having suicidal thoughts at the time of the episode of self harm (Muehlenkamp, 2005) • Some who have SI have been hospitalized 2-400X because they were diagnosed as suicidal rather than as a SI

31. Differentiating SI from Suicide • Where did they injure? If tops of arms or legs probably not suicidal • What do they tell you about their intent? They usually know the difference between a suicide attempt or SI, they often feel very frustrated when others do not believe that they are not suicidal • Did they use their usual method of injury? They’ll use a more lethal type of behavior if they are trying to commit suicide

32. The Bad News/The Good News • The bad news for the future of maintaining this in their lives is the law of decreased returns, as they continue this behavior they’ll need more to get the same “buzz” relief…have to do more to get the same “high” • The good news is that this behavior is ultimately a choice, and when given new ways to cope they can learn to leave this behavior behind, the impulse may not go away…BUT, they can change the way they choose to respond to it • You can be a great first step, mediator, liaison for a therapist by letting them talk about how they are feeling

33. Denial – Be Aware • Before one can truly work with a SI, it would be helpful to be on the same page with mutual goals, good that they see this behavior as a problem and that it is not a healthy coping strategy (“Do you want to get well?”) • Many SI believe that the behavior is a valid coping strategy and that they need it to survive, rather, they are really not free • As this behavior becomes more common, it is not hard to find peer support for this belief system and then the behavior is normalized

34. Philosophy of Intervention (Adopted from S.A.F.E.)

35. Begins with the assumption that, although temporarily helpful, self-injurious behavior is ultimately a dangerous and futile coping strategy that interferes with intimacy, productivity, and happiness, and abundant life. • There is no safe or healthy amount of self-injury. • That self injury is not an addiction over which one is powerless for a lifetime. • Self-Injury can be transformed from a seemingly uncontrollable compulsion to a choice.

36. Goals of Intervention (Based on S.A.F.E.’s Model)

37. To get through defenses to core affect To help client identify and communicate experiences to others verbally and in an age appropriate manner To challenge their irrational thoughts and the lies of the enemy by teaching truth from God’s Word, as well as how to adapt that truth to their lives To learn to differentiate thoughts from feelings and behaviors Increase the “window of opportunity” between an impulse (thought) and an action (behavior) To experience feeling (i.e. anger) without an action (i.e. violence) To face fears directly and to challenge irrational thoughts, rather than running from/medicating with self-injury To mourn the loss of the idealized childhood To expose the character of the enemy and to reveal how he has influenced in their lives To reveal how the Lord brings freedom and life abundantly, overflowing, and to the full The obvious…eliminate all self-injurious behavior

38. Practical Methods of Intervention

39. How to Approach or Start a Conversation… • “How do you deal with stuff when it gets really hard? What do you do?” • “…tell me about this” while gently touching their arm (if cuts are visible) • “Everyone has a story to tell. Would you share your story with me?” • “I’ve been worried about you because I’ve seen…” • “Do you want to be well?”

40. How Can We Help a SI Find HOPE? We can respond relationally…

41. We Can Give Our Time and Presence “…He listened to her whole story” Mark 5:25-34 ♥ You don’t have to say anything but, “tell me more” (Mark 5:25-34), “would you share your story with me?” ♥ Listen deeply, actively, and non-judgmentally ♥ They have felt profoundly abandoned, so offer the ministry of presence ♥ YES…create boundaries, but you may have to bend the rules for this kind of kid to “talk them down when needed” ♥Be available but do not be frantic *be aware that some SI do go bad and accidentally become suicidal ♥ While we are with them accept them non-judgmentally (woman at the well, John 4) ♥ Hear them and accept them as a person NOT as their behavior♥ Provide medical objectivity if needed…” Let me look at those and decide if they need stitches” or clean wounds for them ♥ Give them language to express their feelings (handout) ♥ Keep being faithful…the journey to the destination is generally not a quick one unless the person has just begun this behavior …vaccination example (Exodus 23:30)

42. We Can Speak and Teach HOPE! “But be transformed by the renewing of your mind” Romans 12:2 Tell them you are proud of their courage to walk through their pain ♥ Show them (hold up) vision for the future ♥ challenge their irrational thoughts ♥ replace irrational thoughts with TRUTH (Luke 11:24-26) ♥ remind them it doesn’t have to be like this: where the Spirit of the Lord is, there is freedom (2 Cor 3:17) ♥ He is close to the brokenhearted (Psalm 34:18) ♥ I came to proclaim freedom for the captives…(Isaiah 61) ♥ I came to give life abundantly (John 10:10) ♥ you’re His workmanship created in advance to do good works (Eph 2:10) ♥ He has a hope and future for you (Jer 29:11) ♥ He is a father to the fatherless (Psalm 68:5) ♥ He knows the number of hairs on your head (Luke 12:7)♥ He has your name written on the palm of His hand (Isaiah 49:16) ♥ He’ll never leave you nor forsake you (Deut 31:8) ♥ He goes after His lost sheep (Luke 15:4) ♥ The Lord heals those who ask (Jer 17:14) ♥ He heals the broken hearted and binds up their wounds (Psalm 147:3) ♥ If choose to stop this behavior, replace old behavior with new behavior (Luke 11:24-26) ♥ Don’t give cheesy or contrived compliments but true words of affirmation ♥Give them language to express their feelings (handout) NO Biblical condemnation! They already live with tremendous guilt, shame, and despair, they don’t need biblical judgment too. p.s. anger is OK…many of them have believed anger is not good, or Christian, so it is one of those emotions they try to distract themselves from…but, Jesus got angry…it is what we do with the anger…express it in a healthy way…AND it doesn’t always require and action to walk through it p.p.s. anger is generally a secondary emotion (so get to the deeper emotion)…it can also be because of unmet expectations…ask what the expectations or hopes were that were unfulfilled

43. 3. We Can Live HOPE! Let’s live lives that are worthy of the kind of trust to allow deeply hurting kids to share their stories with us If we are untrustworthy as youth workers no one will want to come and talk to us. So, seek counsel about calling parents, don’t talk about it around the church, and keep confidentiality with wisdom Keep short accounts with the Lord We can model integrity…we are the same here, there, and everywhere

44. We Can Pray for Them • Pray that they would believe the Lord’s love for them (found in the written word, through the Lord revealing Himself, and our continued pointing to the Lord) and then back it up with your actions and faithfulness • Pray that they would have the courage to face their pain • Pray the Lord’s Prayer with their name inserted • Pray for scales to fall from their eyes • Pray for the desire to “get well” and to find healthy ways to cope • Pray that they would KNOW the Lord’s love for them • Pray for the Holy Spirit to protect them and that the assignments of the enemy would be cancelled • Pray for the full armor of the Lord to be upon them

45. As a SI begins the healing journey, you may find you need to help them walk through… • Seeing that chaos doesn’t have to be a constant part of their lives…they can live in peace. • Believing that you’ll love them and have a relationship with them even if they “don’t have a problem” • Teaching them the forgiveness process

46. Practical Tools in the Toolbox (Based on S.A.F.E.’s Model)

47. Book: Bodily Harm The Breakthrough Healing Program for Self-Injurers by Karen Conterio and Wendy Lader, PhD • Boundaries Set for Your Relationship (see attached) • Feelings List (see attached) • 5 Alternatives (see attached) • Impulse Control Logs (see attached) • Thoughts to Challenge (see attached) • Self-Injury Journaling Assignment if self-injury occurs (see attached) • Writing Assignments (see attached)

48. No-Harm Contract if they are ready (see attached) • Individual Therapy (Refer them to a qualified therapist, hunt and dig for one that works with juveniles, you need someone with wisdom and experience) • Contact S.A.F.E., it is the equivalent to AA for SI • Shannon Gubser’s cell phone number 360-481-3830 • JESUS! Pray for wisdom, safety, and that Jesus would be present in these kids’ lives…Remember that we come with power greater than ourselves…we come in the name of the Lord!

49. Boundaries • responsibilities of both parties • consequences as well as rewards for adhering to agreement • plan made for crisis situations, expectation to call before an action is taken - not after • expectations should be explicit • agreement on when hospitalization should be clear

50. Feelings List MAD Annoyed Irritated Furious Frustrated Enraged Livid Angry Aggravated Ticked Off GLAD Blissful Proud Ecstatic Curious Loving Cheerful Relaxed Relieved Happy ANXIOUS Vulnerable Excited Startled Frightened Terrified Agitated Shocked Surprised Scared SAD Depressed Agonized Exhausted Tired Grieving Hurt Lonely Miserable Empty