Moments before the session was due to start, I dug through a haphazard stack of pens and rubber bands and notecards in an unfamiliar desk drawer, searching for something sharp.
It’s OK, I’m going to fix it, I reassured myself. “It” was an overwhelming sense of frustration following a difficult interaction with a colleague.
I craved what I knew would lower the frustration’s intensity ― the sensation of mild pain on the skin of my forearm. When I couldn’t find anything in the drawer, and was forced to open Zoom and begin the session, I chewed an ulcer into the side of my cheek instead.
I was not a teenager. I was in my mid-30s and working as a clinician in an outpatient mental health center.
About six months earlier, I first experienced the power of piercing one’s skin to relieve overwhelming negative emotion. Under the stress of a project deadline and following a meeting in which everyone seemed burnt out and irritable, I instinctively gripped my left forearm, wrist and hand in my right hand. Hard. In a matter of seconds, all my rage and hurt and indignation evaporated, and I took note.
My self-harm escalated over the course of a few months. With each incident, I became less shocked at what I had done to myself, and therefore willing to use tools increasingly likely to cause injury and scarring.
Cutting is perhaps the most familiar form of non-suicidal self-injury (NSSI), a term used to describe any deliberate injury to oneself without the intention of suicide. Other forms of NSSI include burning or hitting oneself or picking at existing wounds.
Most people who engage in NSSI hurt themselves in an attempt to relieve uncomfortably strong emotions, as I did. Others may feel numb and want to feel something, are trying to gain a sense of control or resolve a past trauma, or use self-harm to prevent another and potentially more destructive behavior, among other reasons.
In the moment, I was so overwhelmed that if I didn’t do it, the emotion ― usually some combination of anger, grief, anxiety, guilt and vindictiveness ― would consume me and strip away my ability to function.
Really? I berated myself. You’re starting this now? You’ve been in the workforce for over a decade. You have two master’s degrees, in public health and clinical social work! If anyone should know better, it’s you.
Guess what the result of self-shaming is? Intense emotion. And intense emotion leads, in the absence of other methods of coping, to more cutting. I did confess my feelings and actions to both my own therapist and clinical supervisor, who responded perfectly ― without shock or condemnation.
“You were trying to cope,” my therapist stated simply, after I described becoming overwhelmed with regret ― again ― that my 15-year-old plans for an academic medical career didn’t pan out.
Eyes lowered in shame, I admitted to her that I had relieved this distress by cutting myself. She directed me to identify other coping strategies that I could use instead, but only after acknowledging that the feelings leading to the behavior were understandable.
We need to give everyone who self-harms the same validation. Of course cutting makes sense as a way to cope, because it lowers emotional intensity immediately. And there are other strategies that carry fewer risks. First we validate, then we work toward behavior change. This balance between acceptance and change is the guiding principle behind dialectical behavior therapy (DBT), the gold standard treatment for NSSI. In DBT skills training groups, clients learn to be fully present in the moment, tolerate distressing situations, communicate more effectively, and regulate their emotions.
I was familiar with DBT and occasionally suggested a DBT skills worksheet to a client, but I had not yet internalized its skills to the point that I used them in my own life. Knowledge and skill building are distinct. The skills take practice, and the person practicing will slip up. We are not born knowing how to regulate our emotions, and unfortunately many of us are not taught as children or adolescents.
Why did I start in my 30s? I’d been battling anxiety since childhood and depression for most of my adult life, and yet I’d never deliberately pierced my skin before. This wasn’t the first time I’d encountered work-related stress, and I hadn’t had any recent major life changes, such as marriage, divorce, moving or serious diagnoses.
Yet I wasn’t alone. Studies indicate that between 4% and 23% of adults engage in NSSI, and those who start the behavior as adolescents but do not successfully acquire alternative skills often continue to self-harm into adulthood.
Evidence suggests that people who self-harm, particularly those with certain psychological traits, may learn their self-harming behavior when they see the behavior modeled by someone else. In other words, NSSI may be contagious, and I may have “caught” it through exposure to other people using it to cope with strong emotion. When I was an adolescent and young adult, I did not know of anyone in my social circle who cut their skin to cope, though I had seen the behavior described in media. When I became a therapist, that changed. My clients cut themselves, and this time, it was my business to know all about it.
Why did I “catch” cutting when other therapists who work with people who self-harm don’t start doing it themselves? I have always had problems with emotion regulation, I realized, and I never recognized it. In the past, I have coped by punching steering wheels, desks and chairs, and by slamming doors. I was already primed to turn to cutting when my emotions felt overwhelming.
“Why did I 'catch' cutting when other therapists who work with people who self-harm don’t start doing it themselves? I have always had problems with emotion regulation, I realized, and I never recognized it.”
A few days after I searched that desk drawer at the office, I decided that I would no longer self-harm in any way, including chewing on my cheek and picking at my skin when anxious. I had learned the alternative coping skills. The only piece missing was my commitment to practicing them. I grabbed some scrap paper and jotted down a list of strategies, promising myself that I would go through the entire list before cutting myself, or punching myself or a hard object in anger, or chewing my cheeks to shreds. I wrote at the bottom of the page that any form of self-harm was unacceptable. Then I took a photo and saved it to the “favorites” photo album on my phone for easy access.
The word “unacceptable” stuck in my mind from a DBT-based book that I had read in an attempt to help a client who was cutting. The book validated the desire to self-harm to cope with strong emotions yet also labeled the behavior as “unacceptable.” Another reader may have felt shamed, but I felt motivated to commit to changing my response to strong emotion. When we label the behavior as unacceptable, we still acknowledge that it is our present reality.
In order to tell myself that self-harm was unacceptable, I had to make other actions acceptable. I had to give myself permission to cancel my clients’ sessions at the last minute if I was not mentally able to practice at my best. I had to remind myself that my therapist and supervisor are not inconvenienced or angry at me if I need to reach out to them between scheduled meetings. I had to weigh the real ― and debatable ― risks and benefits of using a fast-acting anti-anxiety medication rather than cut myself.
Next, I had to train myself to identify my emotions and name them to myself. Often the simple act of putting a word to my internal experience lessened the emotion without any further intervention. Yet this step proved surprisingly difficult. The feeling of overwhelming emotion was very familiar to me, but it didn’t always have a name. Often in the time it took me to puzzle over whether I felt indignation, sadness, worry, anger, or all four, the emotional intensity decreased.
The naming emotion strategy is backed by neuroscience. When we ask ourselves to name our emotion, we turn on the prefrontal cortex, the region in the brain where high-level thinking and reasoning occur. With the thinking brain online, the amygdala ― the part of the brain that processes strong emotion ― backs off.
The first few times I encountered overwhelming stress after making my commitment, I struggled to convince myself that trying my list of skills was worth it, when I knew that cutting would calm me down reliably and quickly.
One day, a communication breakdown with the veterinarian’s office meant that I couldn’t get my sick cat’s prescription medication before it closed for the weekend. After hanging up with the vet’s administrative assistant, I found myself with my whole body shaking and the urge to cut.
“Stop,” I told myself. “You promised you wouldn’t do this anymore.”
Name the emotion: Anger — at both the vet’s office and myself. Concern for my cat.
Count the seconds of each breath: One, two, three, four ... in. One, two, three, four ... out.
Mark wrist with a pen where I want to cut.
Text a friend to report what happened with the cat’s prescription and receive support.
Remind self that nothing lasts forever, including overwhelming emotion.
After going through the steps, I was still angry and concerned. Yet the intensity had lessened, and I could think clearly without hurting myself. Best of all, the success reinforced that the skills work, with practice.