f15h 0u7 0f H2O

Sitting this morning on the psych ward. My patient is a cutter, and her roommate is an addict, so I feel completely at home. We talked a little, my patient and I, about her admission and how she thinks it’s ridiculous that she was hospitalized for having some paperclips jabbed into her arm. I understand the hospital’s position, from a liability standpoint–overkill is better than letting someone slip through the cracks to death or serious injury. The stakes are high. Still, I don’t believe the psychiatric mainstream really understands self-mutilation.

Cutting is almost never suicidal behavior. In most cases, self-harm is the best tool the patient trusts and know how to use to manage overwhelming mental and emotional stress, often the torment of a bleak major depression mixed with useless, chaotic, agitated energy. (This is not to say for sure that my patient has no suicidal impulses or plans–the other event that brought her here this time was a gross overdose on Tylenol. Was that another coping mechanism gone out of control, an accident, or a deliberate attempt? I don’t know.) Is there a better way for physicians, nurses, therapists to conceive of and treat self-mutilation?

When my mother was teaching young children, there came into fashion a method of literacy instruction in which a child’s own interpretation of spelling and pronunciation were given credibility and praise, and no immediate correction. The theory was that the best developmental foundations for the child are self-esteem and a sense of accomplishment rather than knowledge of a somewhat rigid, culturally codified linguistic system. There is something to this; there is also something in critics’ objection that the children were being coddled and “dumbed down.”

When my daughter was very young, I instituted (but not necessarily as a conscious decision) an approach involving acknowledgment of her way of doing things, and education in alternate ways for different contexts. Honor expression, but teach communication at the same time. I attempted to use the same model in teaching Freshman Composition at a state university years later, though that would have been much easier had I been at least functional in my students’ 10 or so collective non-English first languages. The model worked more successfully for teaching larger structures, translating the architecture of a VH1 Behind the Music script into narrative flow and paragraph transitions (“She was at the height of her career. Then, some awful event sent her plummeting back to the depths.” Cue commercial.)

Cutters have spent time–often years, often under constrictive and bewildering circumstances–developing the coping skills that have served them better than any others they know. The self-mutilation will not stop overnight because a couple doctors and a handful of counselors briefly introduce you to a few new (or familiar but discarded) ideas that will (A) require a lot of work, (B) offer no guarantee, and (C)–unlike cutting–have little or no immediate effect. Nor are repetitions of the potential harms of self-harm–infection, blood-borne disease, accidental death–likely to have any real effect. Cutters are used to others failing to understand. They have long since given up trying to get their points across, if they ever tried at all. To label them “suicidal” is to persuade them conclusively that you don’t have a clue. So what should healthcare and mental health professional so with self-mutilators?

1. Recognize self-mutilation for what it is: a coping mechanism that has been effective where others have failed or been absent; an immediate gratifier with addictive potential; a dangerous behavior (but–jesus!–not that dangerous, in the scheme of things); the patient’s best friend, without whom she can’t imagine life, although she’ll tell you it’s not that important, just like she won’t tell you she has a sneaking suspicion that her best friend is really stabbing her in the back (no pun intended).
2. Don’t just pay this lip service–really, truly, deeply understand this.
3. Moderate your impulse to make a big deal out of the self-harm. Unless there are other signs to the contrary, don’t tell the patient she’s a suicide because she has cut herself (but keep an eye on her without arousing her fear or contempt). The most effective message, I believe, begins with a well-communicated understanding of the patient’s point of view. From there, you only have to more or less convince her that the old best coping mechanism is failing her. Years of avoiding long-term psychiatric treatment and substituting short-term pain relieving acts for more integrated and responsive (rather than reactive) patterns often lead to worsening depression (and/or other psychiatric problems), progressively dysfunctional relationships, and increasing isolation. The patient will likely believe that life will always be this way … but that is fairly characteristic of depressives in general, for whom mental health professionals are better prepared.
4. Bridge the old coping mechanism to the new, make analogies, draw connections. Exercise releases endorphins, as does self-mutilation. Creativity can externalize pain, much like cutting. Be creative, but try to stay grounded in the patient’s reality as well as the healthier reality you are attempting to help her see.
5. Be prepared to stay in this for the long haul, or to make sure that the patient has someone else for long-term monitoring and therapy. Emphasize the importance of and facilitate the implementation of a support network, a solid structure to ease the transition from the psych hospital, psych ward, or day program to the outside world and increase the likelihood that more positive coping skills will win out over old mechanisms when the patient once again faces the tumultuous, howling darkness of the barren inner landscape. Self-harm is a failing survival mechanism and an addiction as drinking booze is for alcoholics, and many will not succeed without cutting the first time around. Resilience and support are the keys. Without a radical revision in the understanding and treatment of the self-harming patient, the work of the mental health professional with these patients in institutional settings will almost always come to nothing.