Online Conference Transcript

What is a personality disorder? How are different personality disorders diagnosed and what does the treatment of personality disorders consist of?

Our guest, Dr. Joni Mihura, a licensed psychologist and an assistant professor of psychology joined us to discuss why they develop, common traits among people who have personality disorders (awful time adjusting, self-esteem, and depressive problems, feeling of rejection and abandonment, unstable sense of themselves, unstable feelings, unstable identity, distorted perceptions of what is happening, feel abandoned, relationships may be poor, acting out behaviors), symptoms of various personality disorders (audience members had a lot of questions about Borderline Personality Disorder, BPD), general treatment guidelines and the big question: When it comes to the treatment of people with personality disorders, what are the chances of significant improvement?

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

---

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "The Development and Treatment of Personality Disorders." Our guest is Dr. Joni Mihura, a licensed psychologist and an assistant professor at the University of Toledo, where she teaches psychology courses.

Her post-doc training consisted of specializing in women's trauma and psychological assessment. Dr. Mihura's current specialties are psychodynamic therapy and personality assessment. Besides teaching, she has a part-time private practice and she just received an award as a national American Psychoanalytic Association Fellow.

Good evening, Dr. Mihura, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Just so everyone knows where you are coming from, can you please explain "psychodynamic therapy" to us in layman's terms?

Dr. Mihura: Good evening to you too, David. I'm glad to be here tonight. You could say that psychodynamic therapy addresses the fears and maladaptive coping that people have in response to their needs.

David: Thank you. Now onto our topic. What is a personality disorder?

Dr. Mihura: By the DSM-IV (the diagnostic manual), a personality disorder is an inflexible, persistent pattern of inner experience or behavior that leads to significant distress or dysfunction. The 'significant distress or dysfunction' is what makes it a 'disorder.'

David: When you say "inner experience or behavior," what does that mean?

Dr. Mihura: Basically, thoughts and feelings make up the inner experience. The thoughts can include words or images.

David: So, you're saying these problems really create a problem in allowing the person to function "normally"?

Dr. Mihura: Yes, you're right. In allowing the person to function adaptively and to have good well-being.

David: What causes someone to develop a personality disorder?

Dr. Mihura: There are many ideas on that, but they basically could be summarized as contributions from genetics and environment. There is evidence that personality is somewhat genetically related. And our environment--our interactions with other people, trauma, the general adaptiveness and type of our environment growing up. So it is both genetics and environment.

That is a global answer, the particulars also depend on the disorder. We need an environment, too, that is adaptive for our human needs like safety and attachment to caregivers.

David: - Here are all the different types of personality disorders: Personality Disorders includes: Antisocial Personality Disorder, Avoidant Personality Disorder, Borderline Personality Disorder (BPD), Dependent Personality Disorder, Histrionic Personality Disorder, Narcissistic Personality Disorder, Obsessive-Compulsive Personality Disorder, Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder.

I know that each personality disorder has its own particular traits, but are there common traits among people who have personality disorders?

Dr. Mihura: That's a good question. Mainly, there are commonalities between clusters of personality disorders. The basic commonality they share is the general description that I gave. Concerning the commonalities between groups of personality disorders, for example, schizoid, schizotypal, and paranoid are considered in the 'odd or eccentric' group. They often don't have close relationships, and may not want them.

David: How about when it comes to taking responsibility for their own lives and feelings? Is that another commonality?

Dr. Mihura: Yes, there is something very related to that concerning the way that they see their problems. The types of behaviors they show are usually not what they consider to be the problem. They may, however, take responsibility for their lives in many other ways. Like, the obsessive-compulsive may work a lot and be hyper-concerned with responsibility, but this person's relationships may be poor because they do not take responsibility for the lack of emotional closeness that they may show.

David: How do you evaluate a person for a personality disorder?

Dr. Mihura: Evaluating a person for a personality disorder is often more difficult than other disorders, like depression, and this is very related to the fact that they do not usually see their behaviors as being the problem, so they may not report the behaviors a psychologist considers to be part of their personality disorder to be 'the problem.'

Largely, a clinician will use the criteria in the DSM-IV manual, as they would for any other disorder, but often you will have to ask them more directly about these things. And you may need to observe over time or get information from other respondents. For example, someone with an antisocial personality is not that likely to want to tell you about their criminal activity.

David: That I can understand :) On the subject of diagnosis, here's an audience question, Dr. Mihura:

moonNstars: Is this a disorder that can be diagnosed with a single visit to a doctor?

Dr. Mihura: Sometimes, yes, it can be. Often, clinicians will have enough information to diagnose on the first visit, but not always. I'm sorry to give the 'it depends' answer, but I wanted to say that it can be diagnosed in one visit. Just not always.

David: What about treatment of personality disorders? I have heard that most people with personality disorders of any type have a poor prognosis; a poor chance of getting significantly better, even with therapy. Is that true?

Dr. Mihura: That is a good question, and you are right about the difficulty with treatment, but the amount of difficulty also does depend on the disorder. For example, many people with borderline personality disorder can get much better with treatment, but it takes a long time. The good news is that it can get better, which has been shown by research.

David: In general, what types of treatments are available?

Dr. Mihura: People often use an eclectic approach to treatment, which means several different methods are used. For example, cognitive-behavioral components can help people monitor their thoughts and notice when they are starting to get very angry. Social skills training can be used for those people who have significant interpersonal problems, and is used for problems like borderline or avoidant personality disorder. Often, people will use what is called a 'psychodynamically informed' approach, where you try to understand why the person might be feeling and acting as they are now, and what to do about it. Often, a person will have a difficult time with dynamic therapy initially if they have a personality disorder, but it can inform treatment throughout.

David: And when you say "a long time" to get better with treatment, are you saying 3-6 months or years of constant, intensive therapy?

Dr. Mihura: I am saying that it may be as long as two years. However, this depends on what your goal is. If it is to significantly change the personality, it is that long or longer. To address crises or for supportive therapy, it can be much shorter until the person stabilizes. For example, a person with narcissistic personality disorder may suffer a loss and have an awful time adjusting, with self-esteem and depressive problems. Therapy can be focused on supporting the person through their loss in an empathic manner that will help the person's self-esteem recover, and help them grieve their loss without major depressive problems.

David: We have many audience questions, let's get to them:

ladyofthelake: Why is it that different members of the same family living with similar genetics and heredity develop different disorders?

Dr. Mihura: It is the same reason that people with the same genetics also don't look exactly like each other. There are many combinations of genes that can result. Also, there are environmental factors, like how the person is raised and the events that happen in their lives.

lostsoul2: The feeling of rejection and abandonment is really hurting me and I can't get over those negative feelings. Can you tell me how I can "stop" this or if it can be stopped?

Dr. Mihura: Often people can use a cognitive behavioral approach for this, which asks you what are the underlying beliefs and what evidence do you have for them. For example, sometimes people believe that they are not lovable or not loving people, and this is what makes them feel so bad and like it will last forever. But, if that is your belief, you need to challenge it.

ladyw5horses: My 16 year old daughter has been diagnosed as BPD (borderline personality disorder). I am not sure of how to handle her. We talk, she tells me how she feels... I'm not sure about what BPD means.

Dr. Mihura: It does sound like you will need outside assistance with a professional. It can be very difficult. It sounds like you are trying. People with BPD have a very unstable sense of themselves, unstable feelings, unstable identity. Often their emotions overwhelm their ability to take perspective, and they feel caught up in any one moment. They may have distorted perceptions of what is happening and may easily feel abandoned, like they are being attacked, and/or being cruelly rejected. It is a painful experience. At any one time, it is difficult for them to see the whole person, the whole situation, especially in close emotional relationships. But this disorder has been shown to be responsive to treatment. It can take some time, (so can finding a professional she can make a good alliance with) but it can be helped by treatment.

ladyw5horses: Some of my daughter's problems are similar but are compounded by problems in school, relationships with peers, etc. How can I help my daughter? A psychiatrist told me that I could not affect her, just offer suggestions when she asked me my opinion.

Dr. Mihura: I don't know if you 'could not affect her,' but perhaps she or he was saying that you cannot completely change the situation. You just need to be there, open for her emotionally, letting her know you aren't intruding but are there as a strong emotional source.

David: ladyw5horses, we have an excellent site on Borderline Personality Disorder in the HealthyPlace.com Personality Disorders Community. It's called "Life at the Border."

If you haven't been on the main HealthyPlace.com site yet, I invite you to take a look. There's over 9000 pages of content.

Here's the link to the HealthyPlace.com Personality Disorders Community. You can click on this link and sign up for the mail list at the side of the page, so you can keep up with events like this.

Here's the next question:

SuzyR: Is it at all possible for a person with a personality disorder to 'just decide' to get better?

Dr. Mihura: I'm not completely sure of your question. If you are asking if one can 'just decide' to get better and everything will markedly change, that is not likely. But 'just deciding to get better,' could be rephrased by saying that one could decide 'to change.' And then one can make progress towards that change by identifying the problems and the methods and ways to address them.

terriej: How much success have you had with treatment of PPD (Paranoid Personality Disorder)? If they are suspicious of everything and will not accept blame or dismiss the idea of having the slightest problem, it seems that the efforts would be in vain

Dr. Mihura: You are very right in the sense that PPD is a very difficult problem to treat. Part of the initial problem is that the person is not likely to be present for therapy on their own accord, because they have such a lack of trust and expect malevolent intent and actions from others. And therapists are 'others.' I have treated PPD in an inpatient setting, but not in an outpatient basis. You are right, it is very difficult. In treating PPD, it takes a long time to build trust and address the anger.

mj679: Do you find that behavioral methods or medications are more successful in treating personality disorders, or is some combination of both best?

Dr. Mihura: Those methods have been effective with certain disorders and symptoms of the disorder. For example, people with Schizotypal Personality Disorder can sometimes be helped with a low-dose anti-psychotic. For people with borderline personality disorder, sometimes different combinations of medications are used to address the problematic symptoms, like labile mood or transient psychotic symptoms. The issue is that the personality disorders are treated by different methods depending on the disorder, and also, that some people within personality disorders may use some therapies better or have different types of predominant symptoms to address.

David: Here's the next audience question:

C.U.: Is it rare for me to see my acting out behaviors as a problem for others but not for myself?

Dr. Mihura: To not see one's acting out behaviors as a problem for themselves is common. I'm not sure whether you mean 'a problem for others' as in 'that is their problem' or you are concerned that it might be a problem for others. That is a complicated question, either way because sometimes people who have acting out problems may see it not as a problem for others at the time, but at other times, they can see that it was a problem for others. Often people with acting out problems may think that it is someone else's problem, not theirs, as they can't see the problems that arise from their behavior, yet someone is telling them that there are problems. So it must be 'their problem.'

seeking peace: Please advise me on where to go for help. My therapist and several clinics have refused to help. I am bipolar with psychosis. I had therapy for years and was recently diagnosed with BPD and have no more services.

Dr. Mihura: It depends on the specifics of why they refuse to help. I am certainly not familiar with that happening. If it is because of financial problems, community mental health centers should be able to help because they will treat those people with severe disorders, and bipolar with psychosis would fit this category.

ladyofthelake: How difficult is it to get a person with a personality disorder to realize they have a disorder and that they may need help?

Dr. Mihura: It often takes a meaningful event in their lives to bring them to therapy. And the 'distress or dysfunction' part of the disorder is key here. Often, it is something negative that happened that is very meaningful in their lives, like a relationship or their job, and either it was a highly significant thing, and/or it has happened over and over again. The events must hold significance to the person, and/or the distress has gotten to where the person feels they have tried everything possible and nothing has helped.

I am speaking, by the way, about someone who is having difficulty acknowledging a problem and seeking treatment. Some people more easily will seek therapy, but for most people, it is still a difficult decision. Sometimes people will seek treatment to relieve distress, and often that will bring them to therapy, but for those who have trouble trusting, that is a challenge.

moonNstars: When you have two disorders that are somewhat similar, for example Bipolar and BPD, which one is treated first, or can they be treated together?

Dr. Mihura: They can be treated together, but are treated with different methods (although one may also help the other). For bipolar disorder, it is the general consensus and based on research, that this needs to be treated with bipolar medications, and the person needs to stay on that medication so they will not relapse. The BPD can be helped with medication, but it is recommended the person seek psychotherapy also. Additionally, treating bipolar disorder will help the BPD symptoms not be as unstable (mood swings, for example).

Any approach that helps the person address their stress/anxiety points, whether internal or external sources, can help reduce the occurrence of the symptoms of a disorder. So, the psychotherapy could also help the person learn how to notice when their mood is shifting and how to modulate it, and when to increase their meds, but the bipolar part does need the medication. So, yes, they can be treated at the same time in one's life.

David: For those in the audience, you can read more about Bipolar Disorder and Borderline Personality Disorder, as well as all psychological disorders, here.

cathygo: Dr. Mihura, I have a very close friend who I know has BPD, but his Dr's will not recognize it. He uses prescription drugs, is a cutter, and he has a little boy who is being exposed to this behavior and a wife who thinks he's just a drug addict. What can I do to help him?

Dr. Mihura: That sounds like a very tough situation for you to be in. I am not sure exactly what you mean by his doctor will not recognize it. If your friend recognizes the problems, he can tell his doctor what the problems are. He will need to tell his doctor what his symptoms are, the ones you refer to as BPD. If the doctor still will not address them, then he should seek out the help of someone else. I would be sure that it is the doctor that is not recognizing them first and that your friend has talked about these problems.

It sounds like you care very much about your friend. As a note, I can only give feedback based on little information here, but I would try not to feel too much responsibility. Sometimes, one can feel very caught up in a person's life and problems when they have borderline features. Sometimes a spouse, for example, can describe these behaviors to a doctor but it is up to the patient what they want to do. Good luck in whatever you do, and to your friend and his family.

David: I have one question. Can personality disorders be diagnosed in young children and adolescents?

Dr. Mihura: Yes, they can, although this is less common. The patterns of behavior and problems need to be problematic and enduring, however. For example, sometimes adolescents may have what look like borderline features, in problems with identity and some anger control, but it may change over time with maturation. Sometimes, as in adults too, the symptoms may be more confined to an 'Axis I' disorder, like emerging bipolar in an adolescent that looks like the anger, depression, liability of a borderline personality, but it is due to an 'episodic' disorder, not a long-lasting pattern as in a personality disorder.

David: Thank you, Dr. Mihura, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. You will always find people in the chatrooms and interacting with various sites. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com/

Thank you again, Dr. Mihura, for coming tonight and for staying late to answer everyone's questions. You were an excellent guest and we appreciate your coming here.

Dr. Mihura: You're very welcome, David. And thank you for having me here. I enjoyed talking to the participants, and I wish all of them luck in the problems they posted, and also for those who didn't post.

David: Good night everyone and I hope you have a pleasant weekend.

---

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Online Conference Transcript

What's it like living day-to-day with DID/MPD (Dissociative Identity Disorder, Multiple Personality Disorder)? There are many issues for DID patients.

Psychologist, Randy Noblitt, Ph.D. specializes in the treatment of DID patients. He says because of the experience of abuse in childhood (child abuse), many are suffering from disturbing flashbacks, dissociative switching (switching alters), and losing time. Then there's the depression and mood swings, thoughts of suicide, and loneliness that accompanies many serious mental illnesses.

Along with the above subjects, we discussed managing dissociation and getting your alters to work together, treatment for DID and integration (integrate your alters), what is life like after integration, hypnosis and EMDR treatment for DID, how to get your partner to understand MPD and how a significant other can help their DID partner.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

---

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Living Day-to-Day with DID, MPD (Dissociative Identity Disorder, Multiple Personality Disorder)." Our guest is Randy Noblitt, Ph.D. In private practice in Dallas, Texas USA, Dr. Noblitt specializes in the treatment of individuals who suffer from the psychological aftermath of childhood trauma with a special interest in dissociative disorders, PTSD, and reports of ritual abuse.

Over the past 15 years, Dr. Noblitt has evaluated, treated or supervised the treatment of more than 400 MPD/DID patients. He also co-authored the book Recovery from Dissociative Identity Disorder, a consumer's manual for finding and obtaining competent therapy, social services, and legal assistance.

Dr. Noblitt lectures widely on the existence of ritual cults and mind-control techniques and has served as an expert witness in a number of child abuse cases. He is also a founding member of The Society for the Investigation, Treatment and Prevention of Ritual and Cult Abuse.

Good evening, Dr. Noblitt, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Is it difficult for people with DID to find competent treatment for their disorder?

Dr. Noblitt: Hello, David. Thanks for inviting me. Yes, it is difficult and getting more so all the time.

David: Why is that?

Dr. Noblitt: Managed care is increasingly limiting funding for adequate treatment. Additionally, the very real threat of litigation has caused many excellent therapists to leave this field.

David: I'm also wondering if there is an abundance of skilled therapists to treat Dissociative Identity Disorder or are there relatively few?

Dr. Noblitt: There are fewer therapists than needed. As you probably know, there is a prejudice in the mental health field regarding DID (MPD) so fewer people are going into this area. This is extremely unfortunate since individuals with DID have significant needs. They are often known to fall between the cracks not only in the realm of mental health but in the social services arena as well.

David: In my introduction, I had mentioned that you have treated, or supervised the treatment of, some 400 DID (MPD) patients. In your experience, what are the most difficult issues for DID patients to cope with on a day-to-day basis?

Dr. Noblitt: The difficulties experienced by DID/MPD patients vary. One significant problem is suicidal and self-destructive impulses. Many individuals with DID/MPD also experience clinical depression, mood swings, and disability causing unemployment and poverty which further restricts their quality of life.

David: The depression and the mood swings are very difficult to cope with. What are your suggestions for dealing with that?

Dr. Noblitt: Individuals with depression often rely on psychoactive medications, although a high percentage with Dissociative Identity Disorder (Multiple Personality Disorder) do not get adequate relief from medications alone. The development of caring and supportive relationships and psychotherapy is often helpful.

David: Many with DID, and this is from email that I receive, live a pretty lonely life, in that they find it difficult to share their DID with others.

Dr. Noblitt: Yes, this is common. Isolation tends to increase a sense of hopelessness and depression. Taking the risk to develop caring relationships can go a long way in reducing one's depression and sense of isolation.

The reason that many DID patients experience loneliness and isolation stems from their experience of abuse in childhood by family members or other trusted individuals. This early betrayal of trust is devastating.

---

David: We have a lot of audience questions, Dr. Noblitt. Let's get to a few and then I want to talk about coping with flashbacks and other day-to-day issues.

teesee: Why the prejudice within the mental health field?

Dr. Noblitt: This prejudice goes back to a time even before mental health was considered an independent profession and has to do with the prejudices associated with trance states and other states of mind that resemble "possession." Additionally, there has been prejudice against dealing with child abuse and even now, I would say that the greatest part of our society is in denial about the magnitude of this problem.

David: We have a lot of questions regarding treatment for DID and integration:

lovey: Is it important to integrate your alters, in your opinion?

Dr. Noblitt: Not all individuals with DID/MPD are motivated to achieve complete integration. I believe the patient has the right to make this decision without coercion on the part of the therapist. If the patient asks me, "is it healthy to integrate?" I would say yes.

More important than integration is improving the level of functioning and the quality of life.

David: Why would you say "it's healthy to integrate?"

Dr. Noblitt: I view integration as a process with many levels and steps to it. Before the alternates "go away," the individual with DID learns to integrate experience and behavior, reducing inner conflict and becoming more functional.

colbe: Do you still think the number 1 treatment for MPD is hypnosis?

Dr. Noblitt: Let me qualify my response by saying that I think it is important to work in trance states and hypnotherapy may be a good way to accomplish this. Hypnotherapy in the traditional sense may not always work with this diagnosis.

maranatha: I just found out in January that I have DID. My alters fight and tease each other all the time. There is much confusion and mistrust among them. My doctor wants me to try to get them to talk to each other, but I can't even get them in the same "room," so to speak, or to sit with everyone. Any suggestions on how to start building that trust and communication between them? I can't hold a job down 'cause of so much confusion in them. Is it still possible to integrate them?

Dr. Noblitt: There are a variety of ways to increase communication: journaling, music therapy, art therapy, hypnotherapy. Why not ask your therapist what he or she recommends since he or she knows you? Integration is definitely possible and is a realistic goal. Not all individuals with DID achieve this goal.

David: Also Maranatha, we had an excellent conference on getting your alters to work together. I hope you'll take a look at the transcript.

Maera: Can you touch on how to break the self-destructiveness or alters inside who will not cooperate and only sabotage?

Dr. Noblitt: Increase inner communication and learn why the self-destructive motives are there. Usually, these self-destructive motives are related to traumatic experiences that need resolution through therapy.

7claire7: Why do you like to use trance and hypnosis?

Dr. Noblitt: Dissociative Identity Disorder is a trance disorder. Unlike the other various diagnoses, DID involves trance states. I have observed that patients who do not work in trance states in therapy are often more unaware of the functioning of their entire dissociative system. Developing this awareness is healthy and increases the patient's control over the disorder.

David: There are two things I wanted to address tonight and both deal with memory. Because DID is the result of trauma or abuse, many with DID suffer from flashbacks on a fairly frequent basis. How does one cope with them and then reduce the number and frequency?

Dr. Noblitt: This is a complex question. Ultimately, flashbacks reduce over time after the trauma associated with the flashback has been worked through in therapy or independently. However, before that time, many individuals want to reduce these flashbacks and are able to do so by learning to "shut down" the system.

I encourage my own patients to "open up" when they are in therapy and "shut down" when they are not in therapy. Also, some medications can help with the frequency and intensity of flashbacks. Anti-psychotics tend to reduce some particularly disturbing flashbacks and some anti-anxiety medications will reduce the anxiety that accompanies them. This varies from person to person. As I mentioned before, people with DID sometimes have unusual reactions to medications.

David: When you say "shut down" the system, what do you mean by that and how is that accomplished?

Dr. Noblitt: Individuals with DID sometimes experience trance states that may be spontaneous or triggered by particular stimuli. When this happens, there is likely to be more dissociative "switching" and "losing time." Shutting down is like the reverse of being in such a trance state. This can be accomplished in different ways by different individuals with DID. Sometimes it takes trial and error to find what works with a particular individual. Some individuals respond to "self-talk" and particular cues that may cause them to shut down. For some individuals, particular pieces of music may serve this function.

---

David: The other memory question I had was how to deal with "losing time" caused by switching alters or dissociating. This can be very frustrating and confusing for those with DID. Do you have any suggestions for helping with that?

Dr. Noblitt: Improving inner communication and increasing the degree of integration tends to reduce the loss of time. Further, when the various alternates are working well together, they can contract to prevent or reduce loss of time.

David: By the way, Dr. Noblitt, where can one purchase your book?

Dr. Noblitt: Initially, my assistant, Pam and I put this together for the benefit of my patients who were experiencing problems obtaining appropriate services. I would be happy to make a copy available over the internet if individuals are interested and can receive attachments.

David: We will post more info on that in the transcript when it goes up on Friday evening. A few site notes, then we'll go right to the audience questions:

Here's the link to the HealthyPlace.com Personality Disorders Community. You can sign up for the mail list and receive our newsletter, so you can keep up with events like this.

Here's the next audience question:

asilencedangel: When you have a protector who is extremely angry and has been recently betrayed by a spouse, how would you suggest she learn to trust again?

Dr. Noblitt: It may be necessary to resolve the betrayal of trust in a joint therapy session with the spouse and that particular alternate present.

Hannah Cohen: Dr Noblitt, what do you do when the spinning starts and the motion carries the time wild and you cannot stop to see one thing to grab on to and stop yourself? You stand still the best you can and say strong and loud for the circle of spinning to stop so you can walk away from the noise! Dr Noblitt, I'm having difficulty getting away from the noise. Any suggestions would be appreciated. Thanks.

Dr. Noblitt: When spinning occurs, the individual may be in great distress and often is motivated to learn how to stop the spinning. This may be accomplished in several ways. The most permanent solution is to work through the trauma associated with the spinning. A more temporary solution is to learn how to trigger a "shut down" response. Some individuals are able to reduce the effects of these experiences with medication. Many individuals spin as a consequence of "telling the secrets." However, telling the secrets eventually wears down the spinning response.

AngelaPalmer27: How much luck have you had dealing with alters that self-injure other alters?

Dr. Noblitt: This varies from individual to individual. Self-injury is more common early in therapy and less common later in therapy when the individual has worked through the various issues around experiences of trauma.

Some individuals can learn through imagery to stop or block self-injurious behaviors. In response to your question, I have had some patients who can learn to stop this experience and others who do not learn to until they have worked through the trauma.

Bucs: I was recently diagnosed with MPD. My alters don't talk to me or talk out loud, as other peoples alters do. I have noticed that my handwriting styles change day to day, and I still have what I refer to as "mood swings." Will they ever talk to me? And should I even worry about it if they don't?

Dr. Noblitt: This is a common experience, particularly in the early stages of therapy. As you work on opening up your system in therapy and increase inner communication, this will become less of a problem for you.

sryope77: My question is this (and I will try to be appropriate and not offend)... I lead a BDSM alternative lifestyle and I was wondering how to keep the babies and kids and others who don't want/need to be involved out of it. Please don't judge me, this is a common lifestyle among many DID survivors and a lot of us led this life LONG before the net, but we are having trouble keeping it "healthy" for all of us.

Dr. Noblitt: I know that this is a common experience among individuals with DID and I do not judge anyone's sexual lifestyle. But, I recommend that individuals who have been abused not participate in any activities that may be interpreted as retraumatization by the alternates. This is not because this particular lifestyle is "bad," but for many, it resembles too much the original trauma.

sryope77: I hope I can get some help with this. My former therapist "dropped" me because she says she is a Christian and we are not to discuss that, but how can we heal or get better if we are "censored" in therapy?????

David: Sryope, I want to add here that if you are not finding your therapist helpful, then it's time to get another therapist. 

Dr. Noblitt: David is right. You need to find a therapist who is willing to work with you and your needs, not have you conform to hers.

sryope77: That's what my former therapist says, but we use our lifestyle sometimes to work THROUGH the past traumas and it is about the only way we ever get any "GOOD" touches like hugging and holding.

Dr. Noblitt: This is exactly how a traumatized child feels.

David: Here's the next question:

Snowmane: Have you heard of using energy work along with containment exercises to control and clear memories?

Dr. Noblitt: Yes, I have heard of it, but I don't know of anyone who is having success with this approach. Some have claimed that this can be effective, but whenever I have investigated this further, I have not found it to be helpful.

Containment exercises are very helpful but one can never "clear" past experiences. The best one can do is desensitize them and reduce inner conflict and keep self-sabotage to a minimum. As a word of clarification, I should state that I am not from the "energy" school and may be biased against it.

---

lovey: How long is the treatment of Multiple Personality Disorder, Dissociative Identity Disorder?

Dr. Noblitt: Unfortunately, DID/MPD requires lengthy treatment. The briefest case I had took six months. Most individuals, however, are in therapy for years. It should be pointed out, however, that many individuals will develop some skills in managing dissociation within the first few months of treatment. Others may have the symptoms of depression and PTSD (Post-Traumatic Stress Disorder) reduce sometime later in therapy.

Treatment for DID seems to progress in steps and stages. Individuals with more severe symptoms usually take longer than individuals with milder symptoms.

wlaura: In your treatment of DID patients, what is their life like after integration? Are there residual problems related to the abuse?

Dr. Noblitt: Some individuals are disabled prior to treatment and periodically hospitalized to address their disabling condition. Many of these individuals are able to obtain employment and experience significant improvements in their functioning such that they no longer require hospitalization. However, in my experience, patients who have successfully completed treatment still have some residual problems. Treatment for DID does not completely wipe clean the effects of trauma.

luckysurvivor:I suffer from DID and bipolar disorder and work and manage to survive, although I am suicidal a lot. My biggest emotional pain is an alter that is destroying relationships I have with people. Now I have no friends. I don't know how to reason with her anymore. Any suggestions?

Dr. Noblitt: It would be helpful to understand the alter's motivation. Some alters destroy relationships because they fear closeness with others, sometimes because they were betrayed in a close relationship. That particular alter will need to work in therapy to resolve her fear of vulnerability and to develop better interpersonal skills.

jjjamms: I am highly functional when it comes to working - it's the interpersonal relationships that are hard. How does one reach out with DID? It's very isolating.

Dr. Noblitt: There is no easy answer to this dilemma. It takes much effort and work to overcome. I would encourage you to bring this up with your therapist. Together, you may be able to formulate a specific plan for expanding your social life.

Different approaches seem to work for different people. Some individuals develop a sense of closeness with others in a support group (although this does not work for everyone). Some people can make social contacts through a church or synagogue. Sometimes it is possible to develop social relationships at work.

This is a very important goal and I wish you luck in achieving it. Most individuals with DID who expand their social network soon notice improvements in their mood and quality of life. It is difficult to change one's lifestyle when one has been living like a recluse for years, but I have known people who have succeeded through their perseverance.

eveinaustralia:I live in Australia and I have been refused talk therapy because I stopped taking the Psychiatrist's drugs (my significant other and I thought they were making me worse). Do you believe that MPD people have to take drugs and that it's okay to refuse therapy without them? Also, why are the drugs so important to MPD people?

Dr. Noblitt: I believe in the patient's right to choose aspects of therapy that are helpful and reject those that they feel are not helpful. I do not think that therapists should require that their patients take medications unless such medications treat a life-threatening condition (such as HIV).

I believe no patient, DID or otherwise, should be forced to take psychoactive medications without their consent.

David: If you haven't been on the main HealthyPlace.com site yet, I invite you to take a look. There are over 9000 pages of content. http://www.healthyplace.com

HealthyPlace.com is broken down into different communities. And so some of the questions about depression, for instance, can be answered by the reading through the sites and "conf. transcripts" in the Depression Community.

We also have a very large self-injury community.

Between the sites and the "conf. transcripts," you will find a lot of information on almost every mental health topic.

We have a few more questions, then we'll call it a night.

katerinathepoet: Hello Dr. Noblitt, I have had Multiple Personality Disorder most of my life. I was wondering how I can get my husband to understand MPD. He is not comfortable with me and doesn't understand it all. We do not have enough money for therapy, so any suggestions on how to get him to understand my MPD?

Dr. Noblitt: You might consider contacting the Sidran Foundation for literature that can explain your condition to him. You might also want to explore the possibilities of obtaining Medicaid, Medicare, or some other form of subsidized funding for treatment. You can also consider pastoral counseling with a therapist skilled in DID issues.

sherry09: What do you do when the children are screaming in your head because they are still in the past?

Dr. Noblitt: This problem falls within the realm of developing self-soothing and grounding skills. Sometimes self-talk can be helpful, reminding them that they are not in any danger at the present time, letting them observe their present environment. Other soothing and calming strategies can be helpful as well.

---

David: Here's the flip side to katherinathepoet's question about getting her SO to understand her DID:

Temper: I am a SO (significant other), and on one of my support lists we have been talking about the role of a SO. What role do you see a SO having in therapy and outside? What can a significant other do to help their DID partner (specifically, they were talking about messing with internal politics, rescuing alters, and instigating system changes)?

Dr. Noblitt: The role of the significant other is probably the primary social support for the individual with DID. The most important thing about this role is maintaining a healthy relationship where the individual with DID can learn to trust and to give and accept unconditional love.

The significant other can help the individual with DID by being supportive and responsive. He or she should never take advantage of the relationship or use the DID's vulnerability to jockey for a power position. There should be boundaries established in the relationship to distinguish between a healthy partnership and a therapeutic relationship.

Maera: What do you think about EMDR treatment for DID?

Dr. Noblitt: I believe that EMDR methods effectively access dissociated mental states, for some individuals, not all. I think we should learn more about how and why EMDR causes these particular effects. Hopefully, all of us are interested in the effectiveness of the method, not the particular theory behind it.

MomofPhive: Why don't all individuals with DID achieve the goal of integration? Is it that some aren't able to or choose to and why not?

Dr. Noblitt: I don't think that anyone really knows the answer to this question. Many therapists assume that the individual has not been able to heal the effects of trauma or that the individual does not want to say goodbye to their alternates.

SoulWind: Is it possible to recover and function in a normal way without dealing with ALL of the repressed memories and the accompanying flashbacks?

Dr. Noblitt: Again, I don't think anyone knows for sure. However, I assume that patients need to deal with the flashbacks but do not necessarily have to deal with every memory that may be hidden from their conscious awareness. Individuals with DID need to have enough insight into these memories, however, to understand the gist of what happened to them, why they have alternates, and why their alternates behave and feel as they do.

David: Thank you, Dr. Noblitt, for being our guest tonight and for sharing this information with us. We especially appreciate that you stayed late to answer many of the audience questions. And to those in the audience, thank you for coming and participating. I hope you found it helpful. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Thanks again, Dr. Noblitt.

Dr. Noblitt: My pleasure, David.

David: Good night everyone.

---

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Online Conference Transcript

Dr. Sam Vaknin: is our guest. He is a narcissist and is the author of the book Malignant Self Love - Narcissism Revisited.

Dr. Vaknin defined the abusive narcissist, the criteria of NPD, and explained the behaviour of narcissists. We also discussed the types of abuse narcissists inflict upon their victims, the types of people who are attracted to the narcissist, the life a victim of the narcissist can look forward to, and what it takes to get out of a relationship with a narcissist.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

---

David: Welcome to HealthyPlace.com and our chat conference on "Relationships with Abusive Narcissists." For those of you who may be new to the subject, here is the definition of narcissism.

Our guest is Dr. Sam Vaknin. Dr. Vaknin has Ph.D. in philosophy and is the author of Malignant Self Love - Narcissism Revisited. He also hosts a very extensive site on Narcissism and Narcissistic Personality Disorder (NPD) in the HealthyPlace.com Personality Disorders Community. Almost everything you would want to know about Narcissism is included there and in his book. Dr. Vaknin, himself, is an admitted narcissist.

Good evening, Dr. Vaknin and welcome to HealthyPlace.com. I'm wondering, when we speak of "abusive narcissists," is this a special sub-class of narcissists or is being abusive a part of narcissism itself?

Dr. Vaknin: Good evening, David, everyone. The DSM IV-TR, the bible of mental health disorders, does not regard abusive behaviours as one of the criteria of NPD. It does, however, mention the precursors of abuse: exploitativeness, an exaggerated sense of entitlement and, above all, a lack of empathy. So, I think it is safe to say that abuse does characterise the behaviour of narcissists. Narcissists are terrified of intimacy because they are afraid of being exposed as frauds (the False Self) or of being hurt (especially the borderline narcissists). So, they cope either by exerting minute control over their nearest and dearest - or by being emotionally absent. There are numerous abuse strategies and they are detailed here.

David: Many of the visitors to HealthyPlace.com are, unfortunately, very familiar with "abuse." Sexual abuse - rape and incest and physical abuse, including domestic violence. Are these the types of acts you're referring to when you use the term "abusive narcissist?"

Dr. Vaknin: Sexual and psychological abuse are subsumed by narcissistic abuse. The narcissist abuses his spouse, children, friends, colleagues, and just about everyone else in whichever way possible. There are three important categories of abuse:

1. Overt Abuse - The open and explicit abuse of another person.
2. Covert or Controlling Abuse
3. Abuse in response to perceived loss of control

There are many types of abuse: Unpredictability, Disproportional Reactions, Dehumanization and Objectification, Abuse of Information, Impossible Situations, Control by Proxy, Ambient Abuse.

David: What, then, can the other person in this relationship expect from the narcissist?

Dr. Vaknin: The narcissist regards the "significant other" as one would regard an instrument or implement. It is the source of his narcissistic supply, his extension, a mirror, an echo chamber, the symbiont. In short, the narcissist is never complete without his spouse or mate.

David: I'm assuming that there is something the narcissist looks for personality-wise in his/her victims. Can you go into that a bit please?

Dr. Vaknin: The narcissist is a drug addict. The name of the drug is Narcissistic Supply (NS). The spouse (or mate, or love, or friend, or child, or colleague) of the narcissist is supposed to supply the narcissist with his drug by adoring him, admiring him, paying attention to him, providing him with adulation, or affirmation and so on. This often requires self-denial as well as a denial of reality. It is a dance macabre in which both parties collaborate in a kind of mass psychosis. The narcissist's partner is also expected to accumulate past narcissistic supply by serving as a passive and fawning witness to the narcissist's (often imaginary) achievements.

David: So, if you are the victim of the narcissist, what kind of life can you look forward to?

Dr. Vaknin: You will be required to deny your self: your hopes, your dreams, your fears, your aspirations, your sexual needs, your emotional needs, and sometimes your material needs. You will be asked to deny reality and ignore it. It is very disorientating. Most victims feel that they are going crazy or that they are guilty of something obscure, opaque, and ominous. It is Kafkaesque: an endless, on-going trial without clear laws, known procedures, and identified judges. It is nightmarish.

David: Here's an audience comment on what life is like with an abusive narcissist:

bunnie-41: miserable and very unrewarding.

David: Before we get to some audience questions, what is it in the victim's personality that they find themselves attracted to the narcissist?

Dr. Vaknin: It is a very complicated situation. Generally speaking, there are two broad categories of partners of narcissists. One category consists of healthy people, with a stable sense of self worth, with self-esteem, professional and emotional independence, and a life, even without the narcissist. The second category consists of co-dependendents of a specific type, which I call "Inverted Narcissists" (FAQ 66). These are people who derive their sense of self worth from the narcissist, vicariously, by proxy as it were. They maintain a symbiotic relationship with the narcissist and mirror him by negation - by being submissive, sacrificial, caring, empathic, dependent, available, self-negation (in order to aggrandize him)

David: Here's the first audience question, Dr. Vaknin.

marymia916: How can you help someone who is with a narcissist and is not strong enough to leave?

Dr. Vaknin: It depends what is the source of the weakness. If it is objective - money matters, for instance - it is relatively easy to solve. But if the dependence is emotional, it is very difficult because the relationship with the narcissist caters to very deep-set, imprinted, emotional needs and landscape of the partner. The partner perceives the relationship as gratifying, colourful, fascinating, unique, promising. It is a combination of adrenaline-rush and Land of Oz fantasy. It is very difficult to beat. Only professional intervention can tackle real co-dependence. Having said that, the most important thing is to provide an emotional alternative by being a real friend: understanding, supportive, insightful, and non-addictive (i.e., do not encourage co-dependence on you instead of on the narcissist). It is a long, arduous process with uncertain outcomes.

David: Your answer then brings us to this question:

kodibear: If the abuser is a narcissist, how do we get away permanently?

Dr. Vaknin: Please clarify the question. Do you mean how do YOU get away or how do you get rid of the narcissist's unwelcome attentions?

kodibear: Both.

Dr. Vaknin: You get away by getting away. Get up, pack, hire a lawyer and go. It is far more difficult to get rid of the narcissist. There are two types: the vindictive narcissist and the unstable narcissist. The vindictive narcissist regards you as an extension of himself. Your express wish to leave is a major narcissistic injury. Such narcissists at first devalue the sources of their pain ("sour grapes" syndrome) - "She is no good, anyhow. I wanted to get rid of her. Now I can do what I really wanted and be who I really am, and so on. But then the vindictive narcissist "flip-flops". If you are such defective merchandise - how do you dare desert him? Your devalued image now reflects on him! So, he sets out to "fix" the situation but trying to "amend" the relationship (often by stalking, harrassing) or by trying to "punish" you for having humiliated him (thus restoring his sense of omnipotence).

The second type, the unstable narcissist, is much more benign. He simply moves on once he is convinced that you will never provide him with narcissistic supply. He "deletes" you and hops on to the next relationship. My advice: be firm, unequivocal, unambiguous. Most of the problems with narcissists arise from a message that is neither here nor there (having sex just one last time, letting him visit and sleep over, keeping his stuff for him, talking and corresponding with him, helping him with his new relationships, remaining his best friend).

David: What you're saying, Dr. Vaknin, is that to get rid of the abusive or vindictive narcissist, a simple "no" or "our relationship is over" is usually not enough.

Dr. Vaknin: No, it is not enough. The vindictive narcissist must eliminate the source of his frustration either by subsuming it (re-establishing the relationship) or by punishing and humilating it and thus establishing an imaginary symmetry and restoring the narcissist's sense of omnipotence. Vindictive narcissists are addicted to power and fear as sources of narcissistic supply. Unstable ("normal") narcissists are addicted to attention and their sources of supply are interchangeable.

David: For those asking, here the link to purchase Dr. Vaknin's book: Malignant Self-Love: Narcissism Revisited. And I'm not hawking the book, but if you are interested in the subject of narcissism, it's a great read and almost everything you would want to know about narcissism is in there.

Dr. Vaknin: Why, thank you. I may decide to finally read it myself ..:o). My turn to compliment. It is a must.

David: Thank you, Dr. Vaknin. This Saturday night, we'll be talking about Bipolar Disorder and ECT, electroshock therapy. About 4000 people listen to the show through our site. I hope you'll join us and become a regular listener.

One thing I'd like to touch on and then we'll continue with audience questions -- are there female abusive narcissists?

Dr. Vaknin: Over 75% of all narcissists (i.e., people diagnosed as suffering from the Narcissistic Personality Disorder as a primary Axis II diagnosis) are male. But, of course, there are female narcissists.

David: Are the behaviors exhibited by females the same or similar to those of male narcissists?

Dr. Vaknin: Largely, yes. The behaviours are identical - the targets are different. Women narcissists will tend to abuse "outside the family" (neighbours, friends, colleagues, employees). Male narcissists tend to abuse "inside the family" (mainly their spouse) and at work. But this is a very weak distinction. Narcissism is such an all-pervasive personality disorder that it characterizes the narcissist more than his gender, race, ethnic affiliation, socio-economic stratum, sexual orientation, or any other single determinant does.

David: Here are some audience comments about what's been said so far and then we'll get to the next question:

coping: I never knew that narcissim was a personality disorder until I read your writing and after I dated my last boyfriend. The relationship ended 6 months ago and I still feel hurt.

Dr. Vaknin: The aftermath of a relationship with a narcissist is often characterized by Post Traumatic Stress Disorder (PTSD).

garwen2: Hello, Dr. I am 53 and living with my elderly NPD mother...with my saint of a husband also. I have just learned, this last year, of her problem through your website and now reading your book. The main advice I saw for dealing with her is avoidance. And for almost a year, I have been more like a maid-in-waiting with not much social contact. The response I have recieved from this non-action is that she does not even notice. It is like OUtta sight, outta mind. This is really strange to me.

bunnie-41: A narcissist regards the person he is with as a source to accomplish his goals. I know, I was involved with one. They do not know how to feel real love or compassion.

kodibear: I am in intensive therapy for lack of self-worth from the abuse which started when I was a baby and I still am controlled by him, sorry to say. It makes it a little easier to understand what is going on and why he won't leave me alone after listening to you.

Neevis: My husband is totally lacking in empathy. I married a narcissist and the worse he is to me, the more I seem to want to be with him. What does that say about me?

KKQ: I have found that narcissists believe that they are GOD and all must bow to their desires or be punished.

LdyBIu: I have been married to a narcissist for 26 years and we are separated now.

David: Here's the next question:

kchurch: If a narcissist needs his spouse, what has to happen in order for the narcissist to leave a mate?

Dr. Vaknin: Before I respond, I wish to re-iterate what I said before: Living with a narcissist is a total experience. The narcissist takes over the partner, objectifies her (turns her to an object) and uses (and abuses) her. The result is Post Traumatic Stress Disorder (PTSD) - a shock mixed with breavement.

To the question: If the spouse is an outstanding source of narcissistic supply (very rich, very beautiful, very admiring very accepting, etc.) - the narcissist will do everything in his power to stick around. The only way to get rid of the narcissist is to make him realize that it is over. That no matter what he does or does not do to receive narcissistic supply, he is unlikely ever again to receive it from this source. But such a message must be incisive (though not hurtful or humilating). It must be clear, unequivocal, unambiguous, and consistent. Once he digests the message and internalizes it - the narcissist vanishes. To the narcissist, all sources of narcissistic supply are the same, interchangeable, and indistinguishable.

Checky: Hi, Dr. Vaknin. You're up late! What is your opinion on this: Can an abusive narcissist ever become a tolerable narcissist while in a marriage and when the abuse has taken place over many years?

David: I'll add to that question. Can the narcissist ever make a "real" change in his abusive behavior or is this ingrained in his personality?

Dr. Vaknin: Whether the narcissist is tolerable or not is up to the spouse or partner to decide. If you are asking whther the narcissist can ameliorate, tone down, be mollified, reduce his intensity, refrain from abuse and modify his behaviour - sure, he can. It depends what is in it for him. Narcissists are the consummate and ultimate actors. They maintain emotional resonance tables. They monitor other people's reactions and behaviour - and they are mimetic (imitators). But it is not a real and profound change. It is merely behaviour modification and it is reversible. I hasten to say that certain schools of psychotherapy claim success in treating pathological narcissism, notably the Cognitive-Behavioral Therapies and psychodynamic therapies - as well as more exotic, Eastern, therapies.

David: A few audience reaction comments here:

garwen2: So you respond by not having reactions? I call it emotional divorce...and it works

dolly: Oh! The ole "I treat you like you treat me" syndrome.

mcbarber: Dr. Vaknin, after being married to and abandoned by my narcissistic husband three times I am so angry, but deep down I somehow still crave him. How do I get over it?

Dr. Vaknin: You should talk to yourself. Ask yourself, in this dialog, why are you so atttracted to him? He probably fulfills very deep emotional (or maybe sexual or financial) needs. Prioritize your inner life. What is most important to you and what is the price you are willing to pay for it. Life is a trade off. Living with a narcissist - even with an abusive narcissist - is wrong only if it bothers you, hurts you, and prevents you from functioning properly. If you thrive in his company and take his abuse in stride - I say, why not?

moyadusha: Does the narcissist have a conscience?

Dr. Vaknin: No. Conscience is predicated on empathy. One puts oneself in other people's "shoes" and feels the way they do. Without empathy, there can be no love or conscience. Indeed, the narcissist has neither. To him, people are sillhuettes, penumbral projections on the walls of his inflated sense of self, figments of his fantasies. How can one regret anything if one is a solipsist (i.e., recognizes only his reality and no one else's)?

pkindheart: I was involved with a woman who is a narcissist. Her narcissistic supply was sex. She got a real high from it both during and especially afterwards. This high was intoxicating and addictive to me as well. Is this a common thing to happen with a woman who is a narcissist? I have had a very hard time dealing with the loss of this.

Dr. Vaknin: Pathological narcissism (rather NPD) is a clinical condition. Only a qualified mental health diagnostician can determine whether someone suffers from NPD and this, following lengthy tests and personal interviews. But there is something called addiction to sex. Like every addiction, it is connected to predominant narcissistic traits in the addict's personality.

David: You mentioned earlier that victims of abusive narrcissists "deny reality." Here's a followup question:

Mari438: Please give me an example of being asked to deny reality.

Dr. Vaknin: The partner is asked to accept, unconditionally and uncritically that she is inferior to the narcissist, that he is superior to her and to all others, that he is accomplished (even when he is not), that he is victimized (if he is somewhat paranoid) and so on. The partner replaces her judgement and critical faculties with those of the narcissist. This is suspended individuality. The partner is further destablized by the narcissist's tendency to idealize and, very rapidly, devalue; to change his mind often; to act unpredictably and capriciously; to form and abandon plans and so on. This disorientation leads to an overpowering and surrealistic sense of unreality.

David: Here are some more audience comments on what's being said tonight:

estrella: I was able to dump my narcissist after I began to develop traits within myself that I thought he had and thought I lacked.

bboop13: I can so relate to suspended individuality. I am finally divorced and am back to myself.

kodibear: I know as a victim for many years, as a child, I denied reality because he made me believe it was what I wanted from him.

garwen2: It really helps to understand this "no conscience, no love". It lets you know where you stand and gives you the strength to break away.

Checky: I tried to get my husband to change the abuse but he decided to seduce another supply.

jlc7197: My NPD husband never apologized once in 25 years. Not once!

Mari438: My husband was the most sensitive caring, considerate man I ever met. Actually too sensitive. Almost seemed to be child-like.

bunnie-41: I was married to a narcissist for 4 years and as long as I gave him all my attention, told him everyday how wonderful and handsome he was, gave him every material thing he wanted, did everything he wanted to do, ask him no questions or confronted him about anything, he was happy. When I started saying "no" is when he would sulk and get upset. Then I found out that he was already married when he married me. I could write a book of the abuse I have experienced with him.

Zette: Are narcissits usually big liars?

Dr. Vaknin: Narcissists are pathological liars (except I...:o)) This means that they lie even when they do not have to, when they achieve nothing by lying and when telling the truth would have achieved the same (or better) result. Pathological narcissism is the development of a FALSE self based on fantasies, grandiosity, and deceit. So, the very foundation of the narcissist is falsehood. Narcissists lie for two reasons: Either to obtain narcissistic supply or secure it Or because they prefer fantasy (or eternal love, brilliance, wealth, might) to (drab and disappointing) reality. Their propensity to fantasize often deteriorates to outright lying.

bboop13: They are the biggest liars and sooo good at it.

Neevis: I can answer that they are the biggest and best liars.

David: Just so everyone knows, you can sign up for our mail list so you can be notified of other events going on at HealthyPlace.com. A few more audience comments:

femfree: May I suggest that some victims wish to be deluded because their reality is just "too hard."

marymia916: I just want to thank you for changing my life Dr. Vaknin.

KKQ: I can sniff out a narcissist a mile away and no longer will put myself in that kind of a sick role.

kodibear: Having PTSD because of this, I can tell you I have no desire to delude myself, just survive.

jlc7197: My children were damaged severely by his abuse.

David: Dr. Vaknin, we have a few similar audience questions of a personal nature referring to you being an admitted narcissist.

Dr. Vaknin: Yes?

Neevis: Dr. Vaknin, you know that you are a narcissist. Do most narcissists have the same self-realization or do they think that something is wrong with everyone else but themselves?

Dr. Vaknin: Exceedingly few narcissists are self-aware. Actually, you might say that self-awareness is the antonym of narcissism. Most narcissists go through life convinced that something is wrong with everyone; that they are victimized, misunderstood, underestimated by intellectual midgets, abused (yes, abused!) by envious others and so on. In essence, the narcissist projects his own emotional barren and vitriolic landscape onto his environment. He sometimes forces people around him to behave in a way that justifies his expectations of them. This is called Projective Identification.

merelybecky: You do not seem to be like any Narcissist I know.

Dr. Vaknin: I am not sure if that's a compliment (laughing).

marymia916: Do you feel satisfied with your life?

Dr. Vaknin: Not at all. I suffer from a "grandiosity gap". It is the abyss between the narcissist's inflated, fantastic and grandiose image of himself - and reality. My self image, my expectations from myself and from people around me (for instance, my sense of entitlement). My unrealistic appraisal of my talents and skills (totally incommensurate with my rather mediocre achievements) - this hurts and transforms life into a frenetic, obsessed, sick, and sickening search of affirmation from the outside. Narcissistic supply is a drug and I am a drug addict.

David: Here's an audience comment:

dolly: If I heard my narcissist husband talk like this, I would pass out.

Zette: Hey, don't you know - the narcissist is ALWAYS right! Given that mindset, their lives must be almost as miserable as those they feed off of.

mldavi5: When I first read your site, you said that you had had no healing. However, you seem mellower and SEEM to show compassion. So has there now been some improvement for you in your condition?

David: Please respond to that.

Dr. Vaknin: I thought this chat was about relationships with abusive narcissists - but I will not evade the question...:o) There has been a marked deterioration in my condition in the last few years. As the narcissist ages, the grandiosity gap expands. He is no longer young, healthy, fit, agile, competitive. The narcissist feels "eroded," without an "edge," rusting away, wasted. The narcissist then reacts in one of three ways. He becomes

1. paranoid (suspects a conspiracy of the whole world against him) or;
2. schizoid (retreats from the world, mainly in order to avoid nacissistic injury), or;
3. psychotic (renounces reality altogether and lives in fantasyland ever after).

Most narcissists - myself included - react with a blend of all three to the painful decline in their prowess, clout, faculties, abilities, skills, and charm. But I am mostly schizoid and paranoid.

David: It is about 4:40 a.m. in Macedonia, where Dr. Vaknin is located. We appreciate you being here tonight, Dr. Vaknin, and for staying up so late and sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. You will always find people interacting with various sites. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Dr Vaknin: I want to thank all of you, moderator and audience alike, for being here and for your kind words. Be strong and do the right thing! Sam

David: Here's the link to the HealthyPlace.com Personality Disorders Community. Sign up for the newsletter mail list to keep up on events and happenings here at HealthyPlace.com.

Thanks again, Dr. Vaknin and good night everyone.

---

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

1. Coping With Feelings and Thoughts of Suicide
   Guest: Dr. Alan Lewis

2. Diagnosing Borderline Personality Disorder, and finding treatment that works.
   Guest: Dr. Leland Heller

3. Living With and Recovering From Borderline Personality Disorder (BPD)
   Guest: Melissa Ford Thornton

4. Narcissism in the Workplace
   Guest: Sam Vaknin

5. Narcissistic Personality Disorder
   Guest: Sam Vaknin

6. Relationships with Abusive Narcissists
   Guest: Sam Vaknin

7. The Development and Treatment of Personality Disorders
   Guest: Joni Mihura, Ph.D.

8. Transforming Borderline Personality Disorder Into A Healing Experience
   Guest: Laura Paxton

9. Treating Self-Injury
   Guest: Michelle Seliner

 

---

---

back to:   Personality Disorders Community Homepage ~ Other Conference Transcripts on Mental Health

Michelle Seliner LCSW, Chief Operating Officer for S.A.F.E. Alternatives, discusses the treatment of self-injury, self-harm, including:

• how to determine whether one needs professional help or not when it comes to self-abuse.
• the difficulty in stopping repetitive self-injurious behavior.
• the recognized standard for treating self-injury.
• the S.A.F.E Alternatives (Self-Abuse Finally Ends) method of treatment.
• can self-injury really be stopped altogether or just really managed?

Self-Injury Chat Transcript

Natalie: is the HealthyPlace.com moderator.

The people in blue are audience members.

---

Natalie: Good evening. I'm Natalie, your moderator for tonight's "Treating Self-Injury chat conference. I want to welcome everyone to HealthyPlace.com.

Tonight's conference topic is "Treating Self-Injury."

We receive a dozen or more emails every month from people inquiring about self-injury/self-mutilation and when you get to the bottom line, they all have one question in common:

How do I quit hurting myself?

Our guest tonight is Michelle Seliner LCSW, Chief Operating Officer for S.A.F.E. Alternatives, the nationally recognized treatment approach for self-injurious behavior.

S.A.F.E. Alternatives' (Self-Abuse Finally Ends) approach is designed to help people end self-injurious behavior. The website for S.A.F.E is www.selfinjury.com. The phone number 1-800-DONTCUT (1-800-366-8288).

To be clear, self-injury is not a psychiatric disorder, but rather it's a symptom of a more serious psychiatric problem; a personality disorder, a mood disorder like bipolar or depression, or possibly OCD (obsessive-compulsive disorder).

Good evening, Michelle, and thank you for joining us tonight. How does one determine whether they need professional help or not when it comes to self-abuse?

Michelle Seliner: Thank you for inviting me.

It is our opinion at S.A.F.E. that anyone who is injuring could benefit from a professional evaluation. Research shows that even those who have injured only once have a higher level of emotional distress. A professional can help the client to identify the source of that stress and learn to cope in healthier ways. It is our belief that self-injury doesn't "work" for healthy people: That is, rather than providing a sense of relief, it merely hurts.

Natalie: How difficult is it for someone to stop repetitive self-injurious behavior? And why?

Michelle Seliner: Although people can and do get better on their own, many find it incredibly difficult to stop the behavior as it provides an immediate sense of relief. In addition, self-injury is not the actual problem, but rather an attempt to soothe uncomfortable emotional states that underlie the behavior.

Natalie: What is the recognized standard for treating self-injury?

Michelle Seliner: The standard treatment for self-injury involves focusing on emotional regulation through skills training. Clients are taught to pay attention to the irrational thoughts that might serve to fuel intensive feeling states. They are also taught to focus on the present rather than the past.

Natalie: So there's therapy. Are there medications that can help?

Michelle Seliner: Yes, there are medications used to treat the psychiatric diagnosis that accompany the symptoms of self injury.

Natalie: So for instance, if you suffer from bipolar or depression, you might be on an antipsychotic or antidepressant. Do these medications also relieve self-injury behaviors or the urge to commit self-harm?

Michelle Seliner: No, there is no medication used to treat self-injury.

Natalie: Besides the recognized standard, are there any other alternative methods of treatment?

Michelle Seliner: Yes, for example, while the S.A.F.E. Alternatives model also focuses on irrational thinking, we do look at early childhood experiences as well as family systems and relational difficulties.

---

Natalie: Michelle, when you speak of "treating" self-harm, are you talking about "curing" it, ending it forever? Or is it more like an addiction or many of the psychiatric illnesses, where the patient "manages" the behavior over the long-term?

Michelle Seliner: While some of our clients have been diagnosed with psychiatric disorders which may need to be managed over their lifetime, we do not view the behavior of self-injury as an addiction. It is our belief that once a client resolves underlying issues and learns to tolerate uncomfortable feelings rather than attempting to "stuff" them, self-injury becomes unnecessary. It is also our experience that when a client gets healthier, self-injury becomes painful rather than helpful.

Natalie: Is self-help, alone, a realistically effective tool in recovering from self-injury?

Michelle Seliner: Some people have gotten better with self-help. This means that they stopped injuring on their own and it doesn't necessarily mean that they have resolved the issues that underlie the behavior. Sometimes, these people are at risk for switching to another coping strategy such as drugs, alcohol or eating disorder.

Natalie: S.A.F.E. Alternatives opened its doors in 1985. That's over 20 years ago. Yet there are still relatively few therapists in the U.S. who know how to treat it. Why is that?

Michelle Seliner: Self-injury used to be an obscure psychiatric symptom. Most therapists didn't ever think they would be treating clients who engaged in these behaviors. The escalation of these behaviors has been so rapid that school, hospital, criminal justice, and mental health professionals have been caught off-guard.

Natalie: So are you saying that self-injury is no longer "out of the norm" when it comes to psychiatric symptoms? That a lot of people are engaging in that kind of behavior?

Michelle Seliner: Yes, the most current research shows that 1 in 5 college students engage in the behavior. This study came from Cornell. Similar studies have found similar statistics for middle and high school age students.

Natalie: So how does one go about finding a therapist who specializes in treating self-injury? And what credentials should a prospective patient be asking about?

Michelle Seliner: We have a list of therapists from a variety of states who have expressed an interest in working with self-injurers. In general, they have also received some training in working with this population. While we cannot endorse each of these therapists, it is a place for some clients to start their recovery or evaluation. We welcome any feedback regarding client experiences with the therapists listed on the website.

Natalie: Tell us a bit more about the S.A.F.E. Alternatives program. How does a patient get admitted? How long do they stay? And what should they expect?

Michelle Seliner: We would suggest finding a psychiatric professional who is at least masters prepared as either a psychologist, social worker, or counselor and is licensed in your state. Psychiatrists can help with medication evaluations. Some psychiatrists also do therapy.

The SAFE Alternatives philosophy is based upon the book, Bodily Harm: The Breakthrough Healing Program for Self Injurers. We believe that self-injury is a choice; that there is only pain, not relief in self-injury.

Self-injury negatively affects all portions of a person's life-physical, mental and social. The goal is complete abstinence. The S.A.F.E. program offers a continuum of care for the self-injuring client.

We have an intensive 30-day program, early intervention partial hospitalization program and weekly group psychotherapy. In addition, for professionals, we offer clinical consultation, program development, and training. We have several educational materials available. For more information please visit our website, www.selfinjury.com or call 1-800-DONTCUT.

Natalie: What is the average cost of the program? Does insurance partially or fully cover it?

Michelle Seliner: Yes, insurance typically covers the cost of the program. We have financial counselors available to discuss individual plans.

Natalie: What is the rate of relapse; recurrence of self-injury behaviors after going through the S.A.F.E. Alternatives program?

Michelle Seliner: We find that relapse upon leaving the program is not that unusual. However, the majority of clients find that SI no longer works for them as a soothing strategy as it did in the past. It is our experience that most clients stop the behavior after "testing" it upon leaving the program. In one study, we found that 75% were injury-free two years post-discharge.

Natalie: We have a lot of audience members with questions. Let's get to a few Michelle and then we'll continue on with the interview. Here's the first question:

Andrea484: What type of alternatives does your program suggest to those who come in?

Michelle Seliner: One of the first exercises our clients do is come up with a list of alternatives. When developing your list of alternatives, be sure to choose things that are healthy. For example, you would not want to have an alternative be something that could develop into another issue, like over-exercising. Some good alternatives may be journaling, calling a supportive person, nurturing yourself, going for a walk, reading, etc.

blackswan: What is the one thing you would recommend most to someone who's trying to overcome self-injury?

Michelle Seliner: First, I would recommend that they consider an evaluation from a professional so that together an appropriate plan of treatment can be developed. From there, I would develop a list of alternatives. It is important that you and your therapist agree on a plan of treatment.

aynaelynne: What should a therapist do to stop this behavior? I've heard of contracting, but if the client is unwilling what else and how pressing should the therapist be?

Michelle Seliner: First of all, the only person who can stop the behavior is the client. Contracting will only work if the client is motivated to stop injuring. If the client is unwilling, then alternative treatment should be pursued.

Natalie: So the audience understands, by contracting, I believe the term refers to where the patient signs an agreement not to self-harm.

Michelle Seliner: Yes, SAFE refers to this as the SAFETY Contract.

Natalie: Where is SAFE Alternatives based out of? And is the program open to people from across the U.S.?

Michelle Seliner: SAFE is based out of the Chicagoland area. We take clients from all over the world.

Natalie: Here's an audience comment and more questions:

saab32d: I am a recovering cutter. I did it for 9 years haven't done it for 16.

Michelle Seliner: Congratulations. Best wishes on your road in recovery.

---

motochik78: How can those with dissociative disorders work on ending self-injury that is done while in a dissociative state, especially when the "alter" that is "out" enjoys the self-injury so much that they purposefully hurt the person, that they can't overcome it?

Michelle Seliner: This is a difficult question. As you may know, there is controversy surrounding the diagnosis of DID. When we encounter someone who comes to us with a DID diagnosis we first work on grounding techniques, in hopes to prevent the "alters" from taking over. We treat dissociation the same way we do self-injury, in that we see it as a coping strategy to avoid uncomfortable feeling states. We ask clients to pay attention to their dissociation and to pair it with feeling states. If someone is DID, and can't sign our No-Harm contract, it may be that they need to do some more individual and integrative work before they would be ready for our program.

mousey!!: If a person enjoys self-injury, like doing it, I don't know, because it feels good, is there any way to get them to agree to get help?

Michelle Seliner: You can offer them support and information. Self-injury does serve a soothing purpose for someone who is struggling. Bodily Harm is a good resource for persons who self-injure, their families and professionals.

KrazyKelz89: What is the relapse rate of someone who self-injures and stops?

Michelle Seliner: We have found that post-treatment in the SAFE program that 75% of clients are self-injury free 2 years post-treatment. I cannot speak for the general population, as many self-injurers, prior to treatment, start and stop injuring. Typically a psychiatrist is used to manage medication for an accompanying diagnosis.

Psychiatrists usually do not do psychotherapy. Some clients have found a support group to be helpful.

Natalie: Michelle, do you think more people are self-injuring because it's glorified on tv or other media?

Michelle Seliner: Certainly that is a contributing factor but there are also others. It is a common coping strategy used by those struggling. We do not subscribe to the contagion effect, as healthy people do not self-injure.

miked123lf: What about the PEM program, the Psycho-Educational Model program where rewards are given for positive behavior? Could that work for cutters and people who self-injure? Or is this used for behavioral problems only?

Michelle Seliner: I am not familiar with this program being used for self-injurers. Applying what I know about self-injury, it is so important to remember that self-injury is a choice. Regardless of the rewards or who is asking you to give up the behavior, ultimately it is only you that can keep yourself safe.

Natalie: What are the characteristics of someone who is likely to be more successful when it comes to achieving a positive outcome from treatment?

Michelle Seliner: We have found it very difficult to predict who will do well. However, clients who seem to do best are those that honestly engage in the treatment process and recognize that treatment is for their own well-being and not for the treatment staff or parents.

Natalie: Is there an age limit to get into the SAFE program?

Michelle Seliner: We accept clients 12 and up. To date, our most senior client was 77 years old.

thelostone: Can the S.A.F.E program also help someone my age (43) recover from years of self-harm and not dealing with my feelings for years?

Michelle Seliner: Yes, often times we are a client's last resort. Some of our clients have been hospitalized hundreds of times. For some, it is their first hospitalization.

Natalie: I'm assuming since there are very few self-injury treatment programs, your program is very busy. How long does it take to get in? Is there a waitlist?

Michelle Seliner: Yes, there is a waiting list. It can take 2 weeks to 1 month.

NobodyKnows: How would somebody go about seeking admission to the program?

Michelle Seliner: To seek admission to the program, please contact us through the website or call 1.800 DONTCUT (1-800-366-8288).

Natalie: Is there a group of people who self-injure who are treatment-resistant; who despite trying various methods of treatment won't be able to control their behavior?

Michelle Seliner: Unless there is significant neurological damage, we don't believe that people can't control learning to stop self-injury. As stated before, some clients will continue to deal with disorders such as depression, anxiety, thought disorders, bipolar, etc. They may still experience intense emotional states, but they can learn to respond in a healthier, more productive way.

Natalie: We also have parents of children who self-injure, along with family members and loved ones, in the audience tonight. For these individuals, discovering and seeing that someone they care about is hurting themselves it can be very scary, alarming, distressing. What would you say to these people? And what can they do to help the self-injurer?

Michelle Seliner: The first thing to recognize is that they are not "crazy." They are instead trying to cope and survive in the best way they know how. The good news is that people can and do get better all the time and go on to live healthy, happy and productive lives. It is important for the family to take the behavior seriously, but anger and hysterics are counter-productive.

It's important to keep the lines of communication open. Parents and friends should not be the therapist, it is helpful for self-injurers to have someone to talk to who can truly help them to identify the problem and learn healthier ways of responding.

Natalie: Our time is up tonight. Thank you, Michelle, for being our guest, for sharing this valuable information on self-injury treatment and for answering audience questions. We appreciate you being here.

Michelle Seliner: Again, thank you for the opportunity to share our approach to the treatment of self-injury.

Natalie: Thank you, everybody, for coming. I hope you found the chat interesting and helpful. Good night everyone.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Getting help for self-harm and the relationship between eating disorders and self-injury

Dr. Sharon Farber, the author of When The Body Is The Target: Self-Harm, Pain and Traumatic Attachments and therapist, believes self-injury is addictive and counsels people on self-injurious behavior ranging from cutting, burning, and general self-mutilation to eating disorders, including bulimia (binging and purging). She discussed the trauma that can lead to self-harm and how to recover from a lifetime of self-injury

David: HealthyPlace.com moderator.

The people in blue are audience members.

---

Self-Injury Conference Transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Getting Help For Self-Harm." Our guest is author and therapist, Dr. Sharon Farber.

Our topic tonight is "Getting Help For Self-Harm." Our guest is author and therapist, Dr. Sharon Farber. Dr. Farber is a board-certified clinical social worker and author of the book: When The Body Is The Target: Self-Harm, Pain and Traumatic Attachments.

Dr. Farber maintains that there's an addictive-like nature to self-injury. We're going to be talking about that along with the role that childhood neglect, abuse, and other trauma play in self-harm, along with why it's still difficult to find qualified therapists to treat this problem and where you can get help.

Good Evening, Dr. Farber, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Could you please tell us a little more about yourself and your experience in the area of self-harm?

Dr. Farber: I have been in practice for around thirty years. My interest in self-harm came about when I developed a specialty in treating people with eating problems. (Detailed information on different types of eating disorders.)

I came to understand that a lot of people with eating problems, especially those who binge and purge, have problems with self-injury (especially picking their skin or scratching themselves, sometimes even more obtrusively through burning). Then I went on to do some original research. I wanted to understand why people who injure themselves may also have some kind of disordered eating, or why people who have disordered eating may injure themselves.

I did research where I compared bulimic behavior with self-mutilating behavior for similarities and differences. The similarities were extraordinary. Very powerful. I became fascinated and began treating more patients who self-injured. (Symptoms of Bulimia Nervosa)

I should also tell you, when I use the word self-injury or self-mutilation, I am also talking about a passive form of self-mutilation, and that includes people who compulsively get their bodies pierced or tattooed or branded.

David: What were the similarities between those with bulimia and those who self-mutilated?

Dr. Farber: Well there were quite a lot of similarities. Both of them seemed to be an individual's attempt to solve emotional problems, to make himself or herself feel better. They really served as a form of self-medication. Just as drug addicts and alcoholics use drugs or alcohol in order to medicate themselves, in order to calm themselves down or to rev themselves up, they use self-mutilation to make themselves feel better.

I came to regard both the binging and purging and the self-injury as functioning as someone's drug of choice. I found that the self-injurious behavior and the bulimic behavior, especially the purging (which is the most painful part of that experience), were being used as an attempt to release tension or to interrupt or end a feeling of depression or extreme anxiety.

David: In the introduction, I mentioned that you believe there's an addictive nature to self-harm. Can you elaborate on that, please?

Dr. Farber: Sure, what happens is that a person may start out scratching at their skin or pulling off scabs. It starts out, usually, in a milder form, possibly in childhood, and tends to, for the time being, make the person feel better. The problem is that it doesn't last - the feeling better. So what happens is then they have to do it again and again; just as an alcoholic becomes an alcoholic (what is an alcoholic?). He develops a tolerance for alcohol, so he has to drink a greater quantity and much more frequently. The same thing happens with self-injurious behavior. So someone who starts as picking at the skin then turns to mild cutting, which then becomes more wild and severe. In other words, they develop a tolerance for the self-injury, so they have to up the ante and do it more severely.

One of the things that I have found that was very interesting has to do with symptom substitution. That is if somebody tries to give up their self-injury but they are not psychologically ready, but they are doing it to please somebody (a boyfriend, parent, therapist), what will happen is another self-destructive symptom will crop up in its place.

One of the things that I have found in my study that was very, very interesting is that both the cutting and the purging (very, very painful and violent) seem to have the same kind of strength as a form of self-medication. Both are extremely powerful, and so often people will react as if they took instant or immediate-acting Prozac. It's that powerful as a form of self-medication and that is why it tends to be so addictive. Of course, it means that if they need something so powerful to make themselves feel better, getting into treatment with a therapist that is knowledgeable and understands how the self-harm behavior works is very, very important. The right kind of treatment can help enormously.

David: We have several audience questions on what we've discussed so far. Let's get to those and then we'll continue with our conversation.

---

Detached9: Why do you think self-injury is so common in people with anorexia or bulimia? possibly punishment?

Dr. Farber: Well the fascinating thing is that punishment is one of the functions it can serve, but for many people, it's a form of their body's speaking for them. In other words, the body says for the person what they cannot allow themselves to say or know in words. It's about speaking about the emotional pain that they cannot put into words, so their body speaks for them. If you want to think of the bleeding as a form of tears that they couldn't cry, I think that's a good metaphor.

It can be about punishment. Punishing one's self or punishing another. It can be about ridding themselves of something bad or evil inside. A form of cleansing or purifying themselves, except, of course, it doesn't work. If it did work, they would only do it once and they would be sufficiently cleansed or purified.

It starts as someone's solution to an emotional problem, but the solution can become more problematic than the original problem. The solution can take on a life of its own, and become like a runaway train. One of the psychological problems with self-harm is that it creates, for the person, a sense of being in control but then it becomes very out of control.

Cissie_4233: But anorexics and bulimics deal with a certain amount of vanity, therefore why are they now concerned with the scarring?

Dr. Farber: Well because anorexia and bulimia are not always about vanity. It's not always about wanting to look thin. For many people, it is more about emotional pain. And for many people who have a problem with eating they have difficulty with using words to express their emotional pain. So when someone says "I feel fat," they really mean "I feel anxious" or "I feel depressed" or "I feel lonely." For many people with eating problems, the obsession with their physical appearance is just a cover for much deeper emotional pain.

David: I just want to clarify one thing. You are saying that there's a link between eating disorders and self-injury. But, of course, there are people who self-injure who don't have an eating disorder. What about them? Why have they turned to self-injury to cope with their emotions?

Dr. Farber: What I have found in my study is that the people who have suffered the most trauma in their lives, especially childhood trauma (and that trauma can be the trauma of physical or sexual abuse, or children who suffer through various medical or surgical procedures), may need to use more than one form of self-harm.

Sometimes trauma is not the dramatic kind of trauma that I have just mentioned. It can be a loss, like a child suffering the loss of a parent or grandparent in childhood. Children can be traumatized by being constantly or chronically neglected (either emotionally or physically or both).

Abi: How/why, as you say, is body piercing, tattooing or branding described as a 'passive' form of self-mutilation when there are obviously so many people that have such things done and yet do not self-harm as in cutting or burning, etc?

Dr. Farber: Because they are having someone else mutilate their skin, their body tissue, you know? With people who get themselves tattooed constantly, many of them do it not only for the way it looks but for the experience of the pain. Some people will get a buzz from the tattooing. Some people even experience this erotically and get turned on by it. And the same thing goes for the people who purge.

About the piercing and tattooing, I am not talking about someone who just gets a tattoo in order to look cool or because their friends are doing it. I am not talking about that. I am talking about people who feel a "need" to do this to their bodies and have this kind of physical experience. What it does for them is what cutting or burning does for others. It distracts them from the pain that is inside; the internal pain. In other words, they'll have pain inflicted on themselves in order to divert the emotional pain that is inside.

TheEndIsNow: Many people talk about cutting, or other forms of self-injury prevalent among the abused. Are there other common reasons as to why a person might turn to self-injury?

Dr. Farber: Yeah. As I have said before, it usually comes from experience in childhood of trauma, but the trauma doesn't have to be the trauma of physical or sexual abuse; it certainly can be. It can be the trauma of losing a parent or grandparent. They may have no one in their lives that can help them express their pain so they may turn to doing something to their body.

lra20: What about the people who don't know why they do it? I have never been physically or sexually abused.

Dr. Farber: You don't have to be physically or sexually abused. People experience events very very differently. Trauma can be parents splitting up and all of a sudden the child no longer sees his or her father or mother, and that is a terrible trauma for a child, and that is terribly painful, and that child may start to express that pain through scratching himself or throwing up.

The trauma of physical or sexual abuse is certainly one of the major factors in self-harm, but there are many people that have been traumatized but not through physical or sexual abuse. Trauma comes in many different forms.

David: Here's the link to the HealthyPlace.com Self-Injury Community.

David: I want to address the treatment of self-injury, Dr. Farber. What does it take to recover from self-harm?

Dr. Farber: Well, first of all I think it takes a lot of courage. I think it also takes a relationship with a therapist in which you feel really safe -- And this feeling of safety doesn't have to start right from the beginning of therapy.

Most people who harm themselves come into therapy feeling very suspicious or wary of the therapist, but over time a sense of trust develops and the patient feels the therapist is not trying to control her (but when I say her, I am speaking of my own experiences, where most people who do this are female. Please understand when I say her, I mean her or him). I think when you are in therapy, you need to feel in control of yourself and that your therapist isn't trying to control you or insisting you stop hurting yourself. That is a good start. What can be very helpful is if a therapist can try to help you make it less dangerous (through medical help).

Also, it helps if a therapist can let someone know, right from the beginning, that even if you can't articulate in words why you are doing what you are doing, you must have good reasons for doing it. I think in good therapy, the patient and therapist work together to try to understand how and why self-injury became necessary in your life. When you do that, you can try to find other ways to make yourself feel better that are not so harmful - ways that can make you feel better about yourself, ways that you don't have to hide. And I think while all of this is going on, you start to have more control over yourself than you thought, and you find you are more able to speak about the pain that you are feeling inside than you thought, and you don't need to cut yourself or burn yourself so much in order to express that.

---

David: Are you saying that one method of treating self-injurious behavior is to taper off; sort of like quitting smoking cigarettes, where you smoke lower nicotine cigarettes or use nicotine substitutes until you finally quit?

Dr. Farber: I am not suggesting anything about how they do it. I think when people feel understood, they start to understand the how and why of why they felt the need to hurt themselves and they'll find other ways to make themselves feel better and the self-injury quite naturally diminishes.

You see, when I talk about treatment, I am not talking about treatment of just the symptom (the self-injury), I am talking about treatment of the person who has that symptom.

I think, very often, that people who hurt themselves tend to have relationships with others that are very painful, where they really cannot trust other people and I think that when someone can start to feel really safe in a therapeutic relationship, really safe with the therapist, that this attachment with the therapist, this relationship, can even become stronger than the relationship to self-harm, than the relationship to pain and to suffering.

David: Then what you are saying is: that until the person can work through their psychological issues, it is very difficult to control the self-injury.

Dr. Farber: I am saying that people need to do both at the same time. They kind of work together, both understanding how and why the need for self-injury arose. Therapists can help their patients find ways to control the self-harm behavior. One way I find extremely effective is when they are feeling the impulse to hurt themselves if they can try just to delay it for five or ten minutes. During those five or ten minutes, pick up a pencil and start to write. Try to put into words what you are feeling. In the process of doing that, in the process of using words to put shape or form into the pain you are feeling inside, the pain inside starts to diminish and by the time you finish writing, the urge to hurt yourself may well be much, much less. It's a way of starting to use your mind to deal with the pain rather than to use your body to deal with the internal pain, and that's the key to recovering from a life of self-injury.

David: We have many audience questions and I want to get to those. I have one last question for the moment. I know that you teach therapists how to treat self-injurers. In your estimation, are there many qualified therapists out there right now to provide proper self-injury treatment?

Dr. Farber: Not many at all, unfortunately. There are a number of reasons for this. One is that therapists become very anxious around people who hurt themselves, and really, there is nothing much in our training that teaches us how to handle people who do this to themselves.

One of the things I have become very interested in doing, and have begun doing, is teaching other mental health professionals how to understand and how to treat people who harm themselves. I want to make therapists less frightened. One of the ways that I am doing this is this summer I will be teaching a seminar at the Cape Cod Institute in July on the treatment of people who harm themselves, and anyone who is interested can go to the Cape Cod Institute website. I also have a toll-free phone number (888-394-9293) for information about the program this summer. You will receive a catalog with the registration information.

David: I ask that because I know that self-injury is still not understood, or is misunderstood, by many. So where does one go for qualified treatment? How do you find the proper treatment for self-injury?

Dr. Farber: I wish I could answer that, really. It can be difficult. First, find a therapist who is willing to learn about self-injury, if they don't already know about it. Then, you really need to search for qualified professionals. I know there are a number of websites about self-injury that have names and addresses of different clinics or therapists that are interested in working with patients who self injure, so that may be a good way to do it. Also, there are some therapists that are learning to do DBT (Dialectical Behavioral Therapy) and this is often a group treatment for people who harm themselves in different ways, who have various kinds of self-destructive behavior.

David: So, for those in the audience, that means if you are looking for treatment, you need to interview the therapists before starting treatment with them. Make sure they have an understanding of self-injury, or at the very least, they are willing to find out more about it. Here are some audience questions:

shattered_innocents: Hi Dr. Farber. Do you recommend any kind of art therapy for dealing with self-injury?

Dr. Farber: I think that anything that can help you express your emotional pain can be helpful - art therapy, poetry, music. Anything to help you express what you are feeling inside, so you don't have to use your body to express it, is wonderful.

Crissy279: Are there any alternatives to cutting or burning that you find have a high success ratio?

Dr. Farber: As I have already said, I think if people can get themselves to sit down and write what they are feeling inside, that can be enormously successful. Often people are afraid to write. You are not writing for publication, so forget about grammar and spelling. Just write what is in your heart. Just as you could use art or poetry or music or dance to express what is feeling inside - these are all much healthier, much more constructive ways of dealing with your emotional pain than using your body to express your pain. You deserve better than to hurt yourself in that way.

angels0ul: Am I just crazy, because my parents are together, my family is supportive and functional, I'm a straight-A student, busy in my community, and have never been through what you could really call "trauma" - not even the death of relatives or friends, and I still SI and struggle with anorexia?

Dr. Farber: As I have said before, trauma comes in all different forms and sometimes it is not nearly so obvious. If you can sit down with a therapist who wants to understand, you may be able to piece together why self-injury came about in your life and why it is something you need to use. You may not be able to know this now or articulate this now, but in time you may be able to.

jjjamms: I really would like to know why I cannot have feelings - good or bad ones. I have anorexia, MPD and self-injurious behavior. I try so hard to get through the feelings, but they are intolerable. How do I HAVE feelings?

Dr. Farber: Well, to be able to feel your feelings, I think first you need to be able to try to express them to somebody. Often that can be a therapist, and often at the beginning, it doesn't come out as something understandable or intelligible. For most people, to go from the experience of inflicting pain on your body to the experience of articulating your pain into words is a long process that doesn't happen overnight. It is also one of the reasons that short-term therapies are not that effective.

---

peanuts: How often is self-injury found in those with high abilities to dissociate?

Dr. Farber: Most people who self-injure dissociate either when they are self-injuring or right before. What the self-injury does is, if you are in a dissociated state that starts to feel intolerable, the SI can help bring you out of that state.

For some people, they can be in a state of extreme anxiety (hyper-arousal). Sometimes, when they self injure, the self-injury ends that state of hyper-arousal and brings about a dissociative state which may be more desirable. So self-injury can be used to interrupt a dissociated state or a state of hyper-arousal or a state of depression or a state of anxiety.

aurora23: I self injure and sometimes I feel suicidal and wonder: if I just went a little bit further or I cut a little bit deeper this time, what would happen. But my self-injury is not a suicide attempt. Are these feelings normal or should I have some concerns about these thoughts?
(note: Extensive information here on suicide,suicidal thoughts)

Dr. Farber: You should have some concerns about these feelings because there are some people who do not have the intention to end their lives but they like to flirt with the idea of going a little further and die in the process, although that was not the intention.

David: Earlier, you mentioned substituting one self-injurious behavior for another. Here's a question about that:

asilencedangel: If a person should turn their razors over to a therapist as the beginning of giving up self-injury and then starts abusing their body sexually and physically, could this be symptom substitution and how do I stop before it too gets out of hand?

Dr. Farber: I think if the person gives up the cutting before they are ready to do it, psychologically, they will find some other ways to hurt themselves or find other people to do it. So before someone gives up their cutting implements they need to think about whether they are ready to do this or not. You really need to be honest with yourself about it.

Asilencedangel, why did you turn your razors over to your therapist?

asilencedangel: I thought that I wanted to stop cutting, but now I am starting to question that.

Dr. Farber: I would say that if you turned over your razors to your therapist because the therapist requested it, and you did it for your therapist and not for yourself, then it is not going to work.

mucky: I think that turning razors over just makes it worse, makes me crave it more. At least if I have the razors, I can talk myself down or write a lot of times. Is this ok?

Dr. Farber: Of course it is okay. I think a lot of people who give up their self-injury do it knowing that if they really need to do it (self injure), they can (it's like having an ace up the sleeve). Making the decision to give it up makes someone feel more desperate - forbidden fruit always tastes sweeter. When you give something up, it makes you yearn for it more. I think getting beyond self-injury is more than giving up a certain behavior. It's about giving up a way of life that is attached to pain and suffering, emotional pain and emotional suffering, and when this happens, the self-injury falls by the wayside because it is not needed.

David: Here are a few more audience comments on this subject, then we'll go to the next question.

Jus: That was kind of my question too because someone told me that you should be SI free for 7 months before getting rid of your blades, etc.

2nice: My therapist said she couldn't see me anymore if I didn't stop and it scared me. I couldn't imagine starting all over again with a new person. So I gave everything to my shrink.

cassiana1975: My question is, how do you let everyone know about the self-injury? No one knows I do it. I know that I need help. I want help from friends and family, but I am afraid they will call me crazy.

Dr. Farber: I think you need to be able to talk about it with someone that is not your family or friends. Someone that will help you find a way to tell your family or friends. SI thrives in an atmosphere of secrecy and that promotes the shame. When you can come out to family or friends about it you are taking the behavior that seemed shameful and you're turning it into something else. You are starting to connect more with the other people in your life and that can only be good. Sometimes a therapist can help you to tell your friends or your family about what it is that you are doing, if you feel that you can't do this all by yourself.

David: Here are a few audience suggestions on where you might consider finding someone to talk to:

Trina: Teachers, GP (General Practitioner), guidance counselors, a walk-in clinic are all places teens can go to talk.

peanuts: My GP was supportive - admitting not knowing much about it, not being able to do therapy, but he was willing to listen anytime I needed to talk. It was a start and got me to therapy and other help.

Silent Night: How can I help my mom better understand self-injury?

Dr. Farber: Your mom may want to look at some of the websites about self-injury. There are a number of books out there. And try talking with your mom in an honest way; that would be a good place to start.

David: I know it's getting very late. Thank you, Dr. Farber, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful.

Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others: http://www.healthyplace.com.

Dr. Farber: It was a pleasure being here and I thank you for inviting me, and I hope this has been helpful to the people that have tuned in. And to everyone, I wish you all health and hope and healing.

David: Thank you, again, Dr. Farber. I hope everyone has a pleasant weekend. Good night.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

How to Stop Self-Injuring

Dr. Wendy Lader, our guest speaker, is an expert on the treatment of self-injury. She is the clinical director of SAFE (Self Abuse Finally Ends) Alternatives. She is the author of the book "Bodily Harm: The Breakthrough Healing Program for Self-Injurers".

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

Self-Injury Chat Transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. I hope everyone's day has gone well. Our conference tonight is on "Treatment for Self-Injury. How To Stop Self-Injuring".

Our guest is Wendy Lader, Ph.D., clinical director of the SAFE (Self-Abuse Finally Ends) Alternatives Program.

Dr. Lader is an internationally recognized expert on the treatment of the self-injurer. She is co-developer and clinical director of S.A.F.E. (Self Abuse Finally Ends) Alternatives, currently housed at MacNeal Hospital in Berwyn, Illinois. Developed in 1985, S.A.F.E. remains the only inpatient and partial hospitalization program designed exclusively for the self-injury patient.

She is the co-author of the book, "Bodily Harm: The Breakthrough Healing Program for Self-Injurers" and has published journal articles and lectured extensively on the subject.

Good evening Dr. Lader and welcome to HealthyPlace.com. We appreciate you being here tonight. Just so everyone is on the same page here, please give us your definition of self-injury, what is it and what it isn't.

Dr. Lader: Self-injury is the deliberate harming of one's body in a non-lethal way, with the purpose of managing uncomfortable emotions. It isn't a suicide attempt.

David: Please correct me if I am wrong about this, but people are not "born" being self-injurers. In other words, there's no genetic predisposition to self-injury. What is it then that pushes someone into this type of behavior?

Dr. Lader: You're correct. There is no gene for self-injury. However, there may be some predisposition for lower tolerance for frustration. In general though, we find most of our clients come from homes in which communication is indirect or at times violent.

David: I have heard people who are self-injurers say that by cutting themselves, they actually feel better. I think that's difficult for some people to understand. Can you elaborate on that?

Dr. Lader: Self-injury is a form of numbing, similar to drugs or alcohol. It may even release naturally occurring opiates that make people feel better.

David: And when you say that people come from homes where communication is indirect, can you explain that to us, please? And why would that result in self-injurious behavior?

Dr Lader: The answer to this question is complicated. In general, families have difficulty expressing feelings through words. Instead, sometimes these feelings are expressed through action or just not talked about at all. So, people may learn the only way to get attended to is through action or it "turns up the volume" so that people notice that something is wrong.

David: So, are you saying that in some instances, this may be an attention-getting mechanism?

Dr. Lader: That's minimizing the problem. When people need to express themselves in this way, it's because other avenues have not been responded to. This creates tremendous frustration and anger without an outlet.

David: You also mentioned the numbing sensation, similar to drugs and alcohol. Would you say that self-injurious behavior is addictive or similar to having an addiction?

Dr. Lader: We don't believe it's an addiction, because we do believe that people can fully recover. However, it's addictive-like in that it helps people feel better, though temporary, and it often increases in severity and intensity over time.

David: Here are some audience questions, Dr. Lader:

siouxsie: I know a lot of self-injurers have been abused but I have never been abused in any way and I am a Self-Injurer. Is this common?

Dr. Lader: Yes. While many self-injurers have experienced physical abuse or sexual abuse, a large number have not.

Exfear: Why do most self-injurers like myself, find that we have to self injure in order to get the help?

Dr. Lader: Many people come from families that do not respond to more subtle cries for help.

daybydaymomof2: Is self-injuring in any way hereditary?

Dr. Lader: Self-injury itself is not hereditary. However, family histories of mood disorders, low tolerance for frustration and other forms of addiction are common.

Silkyfire: I have felt that the feeling of the blood running down my arm is a symbol of the stress leaving. Is that average?

Dr. Lader: We hear that very frequently and bloodletting has a long history in our culture as a release of "toxins." And maybe, in this case, it's toxic feelings.

savanah: Is there such a thing as healthy self-injury?

Dr. Lader: We don't believe there is. We view self-injury as an escape from dealing with the "real" problem which is facing uncomfortable events and feelings.

wonder: I run the website Self-Harm Links. I receive emails weekly asking for help for self-harm. I am not a doctor. I have only my personal experience. Given the lack of professionals who deal with self-injury, what do you think a good response would be to refer people who need more help than I can offer?

Dr. Lader: Tell them to call the informational line - 1 800 DON'T CUT or they can read our book, "Bodily Harm: The Breakthrough Healing Program for Self-Injurers".

David: I want to get into the treatment aspect of self-injury. First, can you give us some details about the SAFE Alternatives Program-- how it works, what the goals are, what the costs are. Then we'll get into other aspects of treatment for self-injury.

Dr. Lader: We forgot to mention that we have a website - www.safe-alternatives.com. On our website, we also answer some of those questions. In general, we're a thirty-day inpatient/day hospital program that uses a combination of impulse control logs, writing assignments, individual and group therapies. The cost depends on the number of inpatient days versus partial, and many insurance companies cover much of these costs.

David: Does insurance cover the costs or most of the costs?

Dr. Lader: It really depends on the insurance company and each individual's benefit plan.

David: And just to give people in the audience an idea of the costs involved, can you give us a range, please?

Dr. Lader:Approximately $20,000 for 30 days.

David: Before I get into the treatment details, I'm wondering if a person with self-injury can be completely "cured" or is it like an addiction, where they live with it day-to-day and manage it day-to-day?

Dr. Lader: We believe that people can be completely cured.

David: Regarding treatment for self-injury, what are the various treatments available and how effective are they?

Dr. Lader: I can only speak for the effectiveness of our program. Our preliminary outcome data indicate that approximately 75% of our clients are injury-free at the two-year post-discharge mark.

David: And what kinds of treatments are available to help someone recover from self-injury?

Dr. Lader: We believe in a combination of cognitive-behavioral and psychodynamic approaches. In other words, we attend to the symptom of self-injury as a clue that indicates underlying unresolved issues. But we also believe that as long as one is edging in the symptom and therefore self-medicating, that it is harder for them to deal with the underlying issue.

David: How do you make someone stop self-injuring?

Dr. Lader: One of the reasons we do this in an intensive care setting, is because we know that self-injury is a difficult symptom to give up without twenty-four-hour support. Once someone has recognized alternative choices, and has learned how to deal with the feelings, self-injury is no longer necessary.

David: Earlier, you mentioned the use of "impulse control logs". What are those and how do they work?

Dr. Lader: Impulse control logs are designed to give clients a "window of opportunity."This means putting a thought in-between an impulse to self injure and the actual action. We recognize self-injury as a clue that one is wanting to avoid a seemingly intolerable emotional state. The logs identify the precipitant of the impulse, the related feelings and what the individual is trying to communicate to others, and what the consequence for the action would be.

David: Our audience members have lots of questions Dr. Lader. Here are some:

Marci: What are the main things that one can do to manage self-injury, especially if a program like yours is unavailable to them?

Dr. Lader: We strongly advise being in individual psychotherapy. We also encourage within this therapy, the use of impulse control logs and our writing assignments (also included in our book) to help structure the therapy.

sadeyes: I haven't had any success with impulse control logs. Do they work for some, and not for others?

Dr. Lader: In general, the clients who come here find them extremely helpful. It may be that you need some guidance on how to use them, and for some, it takes some practice. They don't always help right away.

tiggergrrl555: Is it possible to recover from self-injurious behavior without going to a program like SAFE?

Dr. Lader: Yes, many people do.

David: And how do they do it?

Dr. Lader: Through supportive individual therapy, and the willingness to take the risk to face the uncomfortable feelings.

wendles: Many people I have met and asked about my scars have never heard of self-injury. What is the best way to explain it to them so I can get help?

Dr. Lader: Self-injury has been my way of coping with intense feelings. It has helped me survive but I would like to learn how to communicate feelings through words instead of action.

David: And that also brings up another point, Dr. Lader. Some people have great difficulty finding a therapist who will treat those with self-injury. How does one deal with that?

Dr. Lader: I think it's good that certain therapists admit that they don't know how to deal with this particular issue. It's fine to interview therapists to find one that has treated other self-injurers or is willing to get supervision.

David: For those in the audience who are self-injurers, I'd be interested in knowing what you did or said to let someone know about your self-injury behavior.

What about the use of medications to treat self-injury, Dr. Lader? Are there any that are used in the treatment of self-injury?

Dr. Lader: Our clients come in on many different medications and we do believe that medications can help clients deal with the acute and intense anxiety that many clients experience.It has been our experience that a low dose of neuroleptics helps with this acute anxiety, and the hope is that clients only need to be on them for limited amounts of time. Other medications that some people find helpful are anti-depressants and mood stabilizers.

David: Here are some of the audience responses to how do you let someone else know about your self-injury? Hopefully, by sharing these, we'll be able to help each other:

wonder: I only let people know about my self-harm if they ask. I am very scared that they will interpret it as attention seeking if I tell them without their asking.

Liz Nichols: The first person I told was my mom. I didn't know what to tell her, so instead, I just showed her the cuts/scars and started crying. She thought they were suicide attempts but later on, she started to understand what it was.

kayla_17: The first time that someone found out, he was shocked, and he didn't really know what to do. He asked me about it and wanted to know why I've done it. But I really was trying to let him see it because I needed someone to know

Lela: When someone asked me about my scars, I said that I deliberately cut myself. I added that it was the dumbest thing I'd ever done and that I don't recommend it for anyone.

Chickie96: One of my friends brought up her problem, and it turned out that another two people present (myself included) in this group of four were doing it too. We use each other for support, and we talk to each other about our problems too.

Trainer: How my husband found out? I had been very withdrawn. I couldn't bring it up verbally so I purposely left drops of blood on the floor by the toilet. He then confronted me on it.

BPDlady23: I tell people that ask about my scars that I self injure. I go on to explain that I cut myself, but am not a danger to others. This usually leads to more questions, which I am glad to answer.

David: What is it like to get treatment for self-injury, Dr. Lader? You mentioned the possibility of needing anti-anxiety medications. For instance, alcoholics need to "dry out" first and go through the "shakes". Do people who self-injure have similar withdrawal experiences?

Dr. Lader: People have all kinds of fears about what will happen if they don't self injure such as, "I'll go crazy, "I'll explode," "I'll start crying and never stop," or "I'll die."But in all of the fifteen years that we've been doing this, I've never seen any of these happen.

David: Some more audience responses to how you shared the news with others that you self-injure:

darknesschild: When people say "what happened?" I just say "razor blade." Then they don't ask anything else.

Cathryn: I've only told a few close friends. No one in my family knows, not my husband nor my daughters.

ang2 A: The first person that asked me, saw wrists bandaged and motioned a question so in private simply told him the whole story. The second one found me out one night and asked how I was. When I said "I've been better," he questioned me what's wrong. So told him what was bothering me and the whole thing.

wendles: I never tell anyone unless they ask. Sometimes I tell them my dog scratched me. I finally confessed to my mom and my best friend.

bluegirl: I told a friend that I had tried to hurt myself. I didn't really say self-injury or suicide attempt or anything. And I told her that I had been at the hospital getting stitches and they had tried to admit me involuntarily. She was the first non-therapist-type person I told.

Rabbit399: What is the draw that a person may have that moment right before they self injure for the first time? Have you any information on the reasons why a person may pick up that object and hurt himself or herself without ever doing so before? Also, is it more common for people to just be self-injurers, or is it something they become because they first saw it and wanted to try to see if it worked?

Dr. Lader: Most people don't know why they picked up the first object to hurt themselves. It's becoming more common, however, for people to have heard about it from other people and then try it.

David: For those of you who are wondering if it's possible to recover from self-injury, here's a comment from one of our audience members tonight:

mazey: I have been in treatment 2 times with Dr. Lader being my psychologist. I have been injury-free, I'm honestly not sure, maybe going on 2 years now. I didn't think that I would ever stop, but I did. Not easily, though. It's been a lot of hard work and tears.

I attended treatment. I have impulse logs in my car, by the computer, in my binder so when I'm in class, I surrender. I barrel right on through the emotions. I take it head on because I have the tools to not injure. I try to just say it, and I cry and cry and don't try to stop the feelings. The thoughts of injuring lessoned until I realized I was thinking about it all the time

Lela: I've been a self-injurer for 2 years and recently decided to quit. But I keep occasionally going back to it. How can I stop completely?

Dr. Lader: It's important to recognize that the self-injury itself is not the problem. Many people have been able to go for months and sometimes even years between episodes, but unless they deal in more direct ways with their feelings, the symptom is likely to persist.

David: For those who asked for it, here's the link to the HealthyPlace.com Self-Injury Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this.

Now, to follow-up on that comment, what you are saying is, even after attending a treatment program like yours, it's important to receive follow-up therapy on a regular basis?

Dr. Lader: Absolutely.

thycllmemllwyllw: I have not been self-harming as long as some people but I know a lot of people that have self-harmed for a while and they come to me to vent, and they are always threatening to die. I want to know what are some ways that I can calm them down without talking about myself or getting myself down about it?

Dr Lader:I would suggest helping them focus away from the "escape" (self-injury or suicide) and focus instead on identifying feelings and finding solutions for the problem. Also, to identify and challenge thoughts that fuel escalation rather than calming.

mammamia: It's important for me to cut veins, in order to see the blood run out. It feels almost like I'm ridding my body of all the bad stuff. I'm getting very weak because of this. It has become very serious; I'll cut 3 or 4 times a day. How do I get help when living so far away from Illinois? I'm scared.

Dr. Lader: It's important to be in therapy and to recognize that the object is not to rid oneself of anything but to accept uncomfortable feelings like anger and sadness. These feelings are not "bad" just uncomfortable.

Cathryn: OMGosh! mammamia, I do that for the same reasons too!! Actually, I cut different ways for different reasons. I am trying so hard to get the feelings out, rather than cut. But being threatened with abuse for crying as a child dries up the tears. I cry red tears now.

David: And mammamia, even if you can't get to the SAFE program, hopefully, you can find a therapist near where you live who can help. That's the most important thing. Finding a treatment specialist who can help you.

Sometimes I hear people say, "What you are saying is triggering to me. I have to cut myself." For some who are not self-injurers, it's difficult to understand how just saying something can induce someone to self-injure. Can you explain that phenomenon to us?

Dr. Lader: Some of these questions are very complicated and we recognize that some of our answers may seem and in fact are simplistic. However, in answer to this question, triggers are important clues. Don't lose that information. Analyze it and try to understand and face the fear directly.

We B 100: Is it normal to not know why I self-injure?

Dr. Lader: Yes. Most people don't know why they injure. The action itself is at first so automatic that the reason is often lost. In fact, the purpose of self-injury is to distract from the underlying problem.

David: Here are some audience comments about what is being said tonight:

insight: My experience has been that it was easier to self-injure to prevent memories of past abuse to surface. The emotional pain was what I was afraid of.

sweetpea1988: We all need to learn to let ourselves express our feelings

sweetpea1988: Plus it is what we were taught about anger

jenny3: I have been cutting since I was 17 and I am now 26. I find it is very hard to keep hiding from people. I am on medication to help me with this but they don't seem to be working yet

sweetpea1988: To not know why is because we have not learned to express ourselves in a safe way.

Lela: The reason I first cut was out of curiosity. A girl at school triggered me and I picked up a pair of scissors. I was amazed by the way the pain left me so quickly.

tree101: I find that when I am triggered, it's because what someone is saying is taking me back to uncomfortable feelings or situations. It increases my feeling of been bad and my need to be back in control

wonder: There has never been an instance where someone has said something that made me want to cut. But usually, I feel like I want to cut after reading a lot about it or very graphic descriptions on the net. It brings up old "junk" when I think about self-harming too long.

cherrylyn24: My parents are not very supportive of me and I have reached out for help in other ways. They have gotten angry at me for that, and whenever they yell at me, it seems like the answer is to cut. I know I need help, but have been in therapy before and hated it, plus my parents complained about taking me.

Chickie96: my father's alcoholism numbed me as a child, and now I can't really deal with admitting emotions easily.

jenny3: My parents don't know that I cut and I don't want them to know

TeddybearBob: We need to see that self-injury is a lie that it takes the pain away from us. It doesn't give us any real control..

Liz Nichols: The first time I ended up cutting myself was when my family was having a fight. When I was cutting myself I was more thinking about killing myself than anything. Then I started feeling better. I started when I was 16 and I'm now 18.

wendles: I took chunks of skin out of my arm with a fingernail clipper. I didn't even realize what I was doing was self-injury. I still don't understand why I did it.

David: I'm getting some comments about Dr. Lader's book "Bodily Harm" not being available in stores. If you click on this link you can get it now: "Bodily Harm: The Breakthrough Healing Program for Self-Injurers".

ang2 A: The book is wonderful, finally people that understand!

Dr. Lader: Thanks! That's what we hope for.

David: Here are a few more questions:

imahoot: Is severe headbanging to the point of fracturing skull common in Self-injury as is cutting?

Dr. Lader: Yes. Many of our clients hit various parts of their body severely.

ktkat_2000: I was told by my psychiatrist that the self-injury behavior would be in my life until I am in my 50's when I will "grow out of it". Is there any truth to this?

Dr. Lader: No. We have many teenage clients as well as young adults who have stopped this behavior. It's not a matter of growing out of it. There are things you can do to take true control. We know that people don't just grow out of this, as we have many clients calling us and coming to our program of all ages, including those over 50.

Maddmom: Is it uncommon to not plan, not have a favorite tool, and to hurt in other ways rather than cutting?

Dr. Lader: No. Some clients have rituals and plan their self-injury, but an equal number or maybe more, act impulsively.

David: Maddmom breaks her fingers. Does that fall under self-injury?

Dr. Lader: Yes, it does.

biker_uk: Do you think that message boards are a good or bad thing for self-injury?

Dr. Lader: I think there are many people, including therapists who try to be helpful, but may not be accurately informed.

David: Thank you, Dr. Lader, for being our guest tonight. We're grateful that you came and shared your knowledge and insights with us. The SAFE Alternatives phone number is 1-800-DONTCUT. Their website address is www.safe-alternatives.com.

Dr. Lader: Thanks so much for having us. The audience and moderator questions were excellent.

David: I also want to thank everyone in the audience for coming tonight and participating. I hope you found tonight's conference helpful.

Thank you again, Dr. Lader. I hope you'll agree to come back and be our guest again.

Dr. Lader: We'd love to. Good night.

David: Good night everyone.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Emily is our guest speaker. Is self-harm recovery REALLY a possibility or are self-injurers doomed to a life of misery and self-mutilation? Emily is an 8th-grade teacher who started self-injuring when she was 12. By the time she was a college senior, she was battling anorexia and severely injuring. The only thing that could help her was a treatment program. And it worked. Emily shares her story of pain and recovery from self-injury.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

Self-Injury Conference Transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Recovering From Self-Injury" and our guest is Emily J.

We've had several conferences where doctors come on and talk about recovery from self-injury. Then I get e-mails from HealthyPlace.com visitors saying that recovery is really impossible. It doesn't really happen.

Our guest, Emily, has recovered from Self-Injury. Emily started self-injuring when she was twelve. By the time she was a college senior, she was battling self-injury and anorexia. She says that while she was able to recover from anorexia, recovering from self-injury proved far more difficult.

Good evening Emily. Welcome to HealthyPlace.com. Thank you for being our guest tonight. So we can find out a little bit more about you, how did your self-injury behaviors begin?

Emily J: Good Evening. I really can't remember why I started, except that I was under a lot of stress at school.

David: And how did it progress?

Emily J: Well, my injuring was not severe until my senior year in college when my fiance broke up with me. I was in a lot of pain and I was looking for anything to lessen the pain.

David: When you use the word "severe", can you quantify that for me. How often were you self-injuring?

Emily J: It started out as very, very mild injury; for example, scratching my skin. Then it got to the point where I had to go to the emergency room almost every other day.

David: At the time, did you realize that something was wrong?

Emily J: I think I knew something was wrong when I was a very little girl.

David: What did you do to try and quit?

Emily J: I did not try to quit. It was my coping mechanism. I had endured sexual abuse as a small child and never learned healthy coping strategies. I didn't decide to get help, until my therapist threatened to quit seeing me.

David: Did you find that therapy helped?

Emily J: Somewhat. I think it prepared me for when I went to the S.A.F.E. Alternatives program (Self Abuse Finally Ends) in Chicago last year. It was only after attending and completing the program that I was able to quit.

David: You mentioned entering the self-injury treatment program, and I want to get to that in a few minutes. What about self-injuring made it so difficult to quit on your own?

Emily J: Like I said, it was my main coping mechanism. I wasn't able to handle my overwhelming feelings and emotions. I wasn't able to confront people or set personal boundaries. I became severely attached to authority figures, like my therapist. I liked self-injuring because it provided me with a sense of relief. Of course, that relief did not last very long at all and then I had large medical bills to deal with.

David: Here are a few audience questions, Emily:

lpickles4mee: How were you self-injuring?

Emily J: A boundary I would like to set is not to mention how I was injuring because it was graphic and I don't think that will serve any purpose for this chat on self-injury recovery. I will say that most people injure by cutting themselves.

Robin8: How did you get the courage to enter into recovery?

Emily J: My life was totally falling apart. I had lost so many relationships due to my self-injury behaviors and I almost lost my job over it. I knew I needed help because my life was one big mess. I hated myself and everything in my life and I knew the only way I could go, was up.

meagain: What was your family's reaction to your self-mutilation?

Emily J: I was terrified to get help, but now I'm so glad I did. My family didn't know quite how to react. My mother got mad at me and my dad was sympathetic but didn't understand. I couldn't talk to my sister about it. I think my sister basically thought I was crazy and my parents didn't know what to do or how to help me. As they learned more about self-injury, self-mutilation, I was very fortunate to have a very supportive family.

David: Did you just come out and tell them, or did they discover what was going on, on their own?

Emily J: I didn't tell them until after I graduated from college, and I only told them because I needed medical attention and I needed a ride. Before that, I tried to hide it.

Keatherwood: Did you find that you were treated badly at the hospitals when you had injured yourself?

Emily J: No, I was fortunate to have doctors that, at least, used numbing medication! Other self-injurers have not had such good experience with doctors. I'm ashamed of this, but most of the time I lied to the doctors so they wouldn't suspect that I was self-injuring. Of course, a couple of times it was obvious I was lying, but I was never questioned about it.

meagain: What would you say to someone who doesn't have any family for support? How would you convince them to get help?

Emily J: Well, people have to want recovery for themselves, not for their families, friends, etc. It's important to know that even without family help, and support, you are worth recovery. Sometimes friends can be your best support system.

David: Emily has been "fully recovered" for about a year. She entered into the S.A.F.E. Alternatives treatment program (Self-Abuse Finally Ends). Click the link to read the transcript from our conference with Dr. Wendy Lader, from the S.A.F.E. Alternatives program so you can find out more details about that.

Emily, can you tell us about your experience with the program. What it was like for you?

Emily J: The experience was absolutely wonderful. They helped me when years of therapy, hospitalization, and medications could not. They gave me the formula for a successful recovery, but I did the work. No one did it for me. The program was extremely intense: they taught me how to feel, how to challenge myself, set boundaries and they taught me that self-injury was just a symptom of a larger problem.

David: And that larger problem was?

Emily J: Many years of pain that I did not deal with. At S.A.F.E., I dealt with my childhood abuse, my negative self-image (non-existent) and years of letting people walk all over me.

David: How long were you in the self-injury recovery program?

Emily J: It is a thirty-day program, but I petitioned to stay an extra week, so I was there for a total of thirty-seven days.

David: Can you give us a brief summary of your typical day?

Emily J: There were at least five support groups a day. Each support group covered a variety of issues such as trauma group, art, and music therapy, role-playing, etc. There were a total of fifteen assignments that we had to complete. Each patient had their own psychologist, psychiatrist, social worker, a medical doctor, and a primary, who was a staff member who reviewed the writing assignments with us. When we weren't in group, we bonded with each other. We had our own "smoke room" therapy sessions.

David: Since entering the inpatient self-injury treatment program a year ago, Emily has not self-injured and says she's never been happier.

Emily, what was the toughest part about the recovery, stopping self-injuring?

Emily J: Learning to deal with my emotions instead of running and injuring. I had to feel the pain, anger, sadness, etc. that I had denied myself from feeling for so long. There were these things called impulse control logs - whenever I felt like injuring I had to fill out one. The logs didn't necessarily stop the urge but it helped me to identify my feelings so I could understand why I was feeling the way I was feeling.

David: We have a lot of audience questions, Emily. Let's get to them:

Montana: Could you please give us some examples of tools that can be used to keep from self-injury?

Emily J: Building a healthy support network of friends and family; finding a healthy hobby and pursuing that. When I got to S.A.F.E., they asked that I make a list of five alternatives to self-mutilation. Talking to peers, talking to staff, and listening to music were some of my alternatives.

To be honest, I still had urges for quite a while after coming home. I did not give into them because I didn't want to go back down that road. S.A.F.E. taught me to deal with my feelings and how to handle them. I still fill out a log every once in a while.

ZBATX: Can you talk a little about separating thoughts from feelings?

Emily J: I used to say things like I feel like crap. Well, crap isn't a feeling. Anger, sadness, joy, frustration, anxiety...those are all feelings. Saying you feel like dying or feel like injuring aren't feelings - those are thoughts.

heartshapedbox33: Did you ever feel like you were addicted to cutting?

Emily J: Oh yes, definitely. I knew self-injuring was ruining my life but I was powerless to stop it. Or I thought I was powerless.

rig: Can you give us a rough estimate of the cost of these self-injury recovery programs?

Emily J: Well, the program is very expensive and it's the only inpatient program in the country specifically for self-injury. Without insurance, I would say roughly $20,000 but my insurance and many others have paid for all of it. First, I went to my therapist, and one of the program directors called my insurance company and said they could either pay for this one-time program or continue to pay for every visit indefinitely. So they paid for it. I live outside of Illinois and they still paid. For those that simply cannot attend the program, I recommend the book "Bodily Harm" by Karen Conterio and Wendy Lader. They are the founders of S.A.F.E.

tootired: Do you think that the self-injury was ever for attention?

Emily J: No, because I usually hid it when I injured.

precious_poppy: The more I self-injure, the more I want to do it. What do you do then when you have no one to turn to?

Emily J: I think you have to be honest with yourself. Is injuring really working for you? Have you lost anyone or anything because of it? Do you want to spend the rest of your life mutilating yourself? I agree it's harder when you have no one to turn to, but that's why it's important to build a support system. Some examples would be attending a church with a large population of people your age, or something like that.

David: Here are a couple of audience comments regarding "paying for treatment":

Montana: From my experiences, the insurance would not pay the emergency room visits because it was obvious that it was involved with self-harm. I have to pay out of pocket.

rig: OH MY GOD! I can't even get anyone to insure me right now!!!!! If anyone knows of any insurance company that will insure posttraumatic stress disorder (PTSD), let me know!

Nanook34: What about aftercare?

Emily J: They have an aftercare group for people who live in the Chicago area, but I live nowhere close to Chicago so I had to build my own support here, after I got back.

David: Are you still in therapy?

Emily J: No. That was a big step for me, because I was very attached to my therapist in a very unhealthy way. She set boundaries with me but I was almost obsessed with her. Saying goodbye was so freeing. The S.A.F.E. Alternatives program recommends that you do continue therapy after the program, but I thought I was at a place where I did not need it, and I have not been in therapy for a year now.

David: Just to clarify, you went into the S.A.F.E. Alternatives program last summer and spent five weeks there as an inpatient, correct?

Emily J: Actually, I spent two weeks inpatient and the last three outpatient. S.A.F.E. owns some apartments right next to the hospital and we stayed there at night when we reached outpatient status.

David: Do you still have urges or feelings of wanting to self-injure?

Emily J: I have not had an urge in quite some time now, but when I first came home, I had them quite often. When I have an urge to self-injure, I fill out an impulse control log, so I can identify what I'm feeling and why I want to injure. After I fill out a log, the urge has usually diminished.

David: The SAFE program is in Chicago, right Emily?

Emily J: Berwyn, Illinois, a suburb of Chicago.

David: Can you describe the impulse control log for us. Can you give us an idea of what it contains?

Emily J: There are several boxes to fill out.

1. time and location
2. what I'm feeling
3. what the situation is
4. what would be the results if I did injure
5. what would I be trying to communicate through my self-injury
6. the action I took
7. the outcome.

David: Here are some more questions, Emily:

twinkletoes: Have you found that other friends from the program you went with, are still injury-free as you are? Or have they relapsed?

Emily J: I met two people in the city I live in, that attended S.A.F.E. Of course, I have many friends nationwide that I still keep in touch with. Most are doing very well and are still injury-free.

jonzbonz: I was wondering how one goes about starting a program of recovery from self-injury without a therapist. I cannot afford one.

Emily J: Most communities have mental health resources where counseling is offered for free or at a reduced rate. Look in your yellow pages under mental health resources. Also, I mentioned the book "Bodily Harm." The book outlines everything the program does and it offers advice and help for people who cannot attend the program.

David: I'll add here, you might try your county mental health agency, a local university medical school psychiatric residency program, even the local women's shelter. You do not have to be battered to take advantage of their low-cost counseling services.

lisa fuller: Is there any medication that is helpful?

Emily J: I didn't find any that helped for my self-injury behaviors.

David: Why did it take an inpatient/ intensive outpatient program like S.A.F.E. to help you stop self-injuring? What did the program offer that your therapist couldn't or didn't?

Emily J: Mainly, time and an intensity that cannot be offered in a fifty-minute therapy session. Also, I was surrounded by a group of peers who were struggling with the same thing I was. Unlike most psychiatric hospitals who lump all psychiatric patients together, S.A.F.E. was just for self-injury.

meagain: I have found that many professionals don't really care--with that I get real belligerent. How, if at all, does this program deal with someone like this?

Emily J: I was probably the most belligerent I had ever been in my whole life! I was very scared, and masking it as anger, and taking it out on the staff. They are very used to this type of reaction.

twinkletoes: If you injured at S.A.F.E., did you automatically have to leave? Were there consequences?

Emily J: We had to sign a no-harm contract. If we broke it once, we were put on probation. If we injured after being put on probation, we would probably be asked to leave. I did break my contract but I learned a lot by being put on probation and answering the probation questions. I might add that I was absolutely terrified. How was I going to cope without my "best friend"? I learned how to cope and how to feel. Also, I had the mentality that I was too bad to be helped; that I was too severe and no one could help me. I held onto that belief even three weeks into the program. Well, a year later I'm injury-free and my life has never been better. I still have the normal stresses of everyday living, but as I've said, I know how to cope in a healthy manner now.

David: That's wonderful, Emily. Are you concerned about future relapse? Do you worry about that?

Emily J: NO! I have made it a personal goal of mine that I will NEVER self injure again. I've gained so much in this year, and I've worked too hard to throw it all away. That was a promise I made to myself, the minute I was on the plane back home.

David: Would you say that you are "in" recovery, meaning it's an ongoing process... or that you are "recovered", meaning you are completely healed?

Emily J: That is a hard question. Well, I would say I'm in recovery and I do believe it's an ongoing process because I always have to challenge myself to feel.

David: Here's an audience comment on another form of treatment:

crazygirl: I'm in DBT (dialectical behavior therapy) and I find that it is helping me a lot. It really changed my life and I would recommend it to those who have Borderline Personality Disorder.

Emily J: Ninty-nine percent of people I met, who also injure, have Borderline Personality Disorder. I do want to say that I don't believe S.A.F.E. is the only answer; but it was for me.

David: At the beginning of the conference, I mentioned that you also suffered from anorexia. Do you feel that the eating disorder and self-injury were linked in some way? (Read more on the types of eating disorders.)

Emily J: Yes, at S.A.F.E. I'd say 85% of the patients there have or have had an eating disorder. Mainly, all of us were diagnosed with Borderline Personality Disorder, an eating disorder, and self-injury.

David: Do you still struggle with the eating disorder?

Emily J: No. I was able to overcome that two years prior to going to S.A.F.E. Fortunately, I was able to overcome that but I had a harder time overcoming the self-injury.

David: I know it's getting late. Thank you Emily for coming tonight and sharing your experiences with us. Congratulations to you. I'm sure it wasn't easy, but I'm glad to hear that you are doing well. Also, thank you to everyone in the audience for coming tonight and participating. I hope you found it helpful.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Janay is 18 years old and has been engaging in self-injurious behaviors since she was 13. Here, she talks about why she first started self-injuring, how she became suicidally depressed and later developed an eating disorder.

17 is the number of hospitalizations for cutting and suicidal ideation that Janay has been through. She has since stopped self-injuring but continues to struggle with an eating disorder.

Janay also related her version of what it's like to tell your parents about the self-injury, her experiences with treatment for self-injury, and her battle to not SI. We also talked a bit about being a black woman who self-injures.

Audience members also shared their experiences with cutting, ranging from how to handle it to what made them realize they needed to stop harming themselves.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Self Injury Experience." Our guest is Janay, one of the journalers in the HealthyPlace.com Self-Injury Community.

Our plan for tonight was to have 2 guests, but one of the guests had an emergency and had to cancel at the last minute. So, I'm going to interview Janay for about 20 minutes, then open the floor to audience questions. Also, tonight, I would be interested in hearing from audience members who have received any type of treatment for self-injury. I'd like to know what kind of treatment it was (weekly therapy, out or inpatient hospitalization) and if you thought it was effective or not and why. I'm hoping that sharing this information will be helpful to everyone here.

Now onto our guest. Janay is 18 years old. She had been engaging in self-injurious behaviors for about 5 years. She says "my most recent therapist terminated treatment because I am 'cured,' meaning I am no longer an active self-injurer and I'm not suicidally depressed." Janay also has an eating disorder which she finds is growing worse because, as she says, "I no longer have razor relief." (Read here:  types of eating disorders)

Good evening, Janay, and welcome to HealthyPlace.com. You started self-injuring when you were 13 years old. Do you remember why and what that was like for you at that young age?

Janay: Hi. I don't really know why I started. It was just a test of endurance at first.

David: Can you explain that further, please?

Janay: I think I read a book about a cutter and wanted to see how strong I was.

David: And why did you continue after that?

Janay: I cut with a piece of a broken lightbulb, so light it barely broke the skin. I did that when I was 12 and didn't do it again for another year. I remember being late to school one day and, as I was crossing the grass, just for no reason turned around and went to a corner of the school campus and cut myself with an Exacto knife.

David: What is it that you got out of doing that?

Janay: I was really kind of upset from the night before and that morning over a fight with my mom. I was angry and upset and felt like I'd freak out at school if I went. I had the Exacto knife on me because I used to help my mom with various crafts. I also kept it with me as a "just in case" type thing; security for cutting, though I'd never used it for that before that day.

David: From previous guests, we have learned that many people start self-injuring possibly as a way to handle certain feelings stemming from sexual abuse. Is that the case with you?

Janay: Ummm... Yeah, I guess you could say that, but I'm reluctant to blame my self-injury on that.

David: In the letter you sent me, you said: "I (used to) self injure because it was the only way I knew to relieve extreme stress or emotion, i.e pain. The more extreme the pain or confusion, the less I felt, so the deeper I cut." Since this was going on for 5 years, I'm wondering if your parents knew about it and if so, how they reacted to it?

Janay: Actually, my mom didn't find out about it until I was about 15, and that happened during my sophomore year of high school. A few of my friends knew I cut. They told the teacher and the teacher called my mom. Everything went crazy after that. She called me names, yelled, hit me, and threatened repeatedly to send me to the hospital (though she'd been threatening that for about a year because she said my behavior was out of control).

David: So, to put it mildly, she didn't take it too well. I'm wondering if that was because she heard it through a third party, your teacher, rather than through you. It must have been a shock for her.

Janay: I think it was more that she was ashamed of me - having a crazy daughter. When I was younger I was "so smart, so pretty, I could be whatever I wanted," and then they found out about my cousin (child sexual abuse) from someone else. She was mad that I didn't tell her, and since that happened I sorta stopped talking to her; like being rude, withdrawn, disrespectful, to say the least. She was just disappointed in me, that I turned out the way I am.

David: We have a lot of audience questions for you, Janay. I want to get to a few, then we'll talk about what kind of treatment for self-injury you received and whether it helped or not. I'm also going to post the audience responses to that later.

David: Here's the first question:

shylacious: Did you feel betrayed by your friends?

Janay: Oh, very much so! I was furious, but at the same time, it made me feel good that they even cared enough to tell. I didn't talk to them for a long time though.

David: Here are a couple of audience comments on what's been said so far:

BelleAngel: I don't understand why I do this!

loonee: I started self-injuring when I was 15. Now I am 22 and stopped doing it at the end of last year. I wanted to stop because I knew it was getting out of hand - cuts were reaching muscle. I was getting nerve damage. I saw a therapist, told my mum, and stopped lying to myself. Every day is a battle to not SI but, so far, I am getting there.

jess_d: The best thing to do is to be honest with your friends and don't take what they say too seriously because they probably don't fully understand the problem.

space715: I just wanted to say that my therapist is insisting that if I cut again, she will have to tell my parents about my SI. I am very concerned that my parents will have a reaction similar to your mom's. Any suggestion on how to handle that?

Janay: I don't think anything I'd suggest would be helpful, space. If it were me, I wouldn't tell my therapist if I cut. I hate being threatened with anything. It wouldn't serve an actual purpose for the therapist to tell your parents. It would only cause more problems. Try to explain that to her.

To loonee: I know it's hard not to cut; I'm there myself. Congratulations on not cutting for so long :-)

David: space715, I also want to mention that we've had several experts on to talk about how to address your parents on this issue. You can read the transcripts here.

I want to add, too, that hopefully not all parents will react the same way as Janay's mom did in this instance. From everything I've read and heard, it's difficult to recover from any psychological disorder without support.

Janay, I want to get into the treatment issues now. Can you tell us about that? When was the first time you received professional treatment and what were the circumstances?

Janay: The first time I was hospitalized, I was 14, but it wasn't for anything real. My mom said I was a smart ass, so she put me in the hospital to scare me.

Hospitalizations for cutting and suicide attempts: I've been in about 17 times since I was 14, not counting a 6-month stay in a (crappy) residential treatment center. Most of my stays were only 3-5 days because of insurance. A lot were just for "suicidal ideation," 2 for overdoses. And the cops put me in a few times because my mom told them I was suicidal. I've been through so many therapists, I've lost count. There were only two that I ever "cooperated" with. I don't like therapists.

David: So, in combination with the self-injury, you were suffering from depression. That's not unusual. Did you get anything positive out of treatment/therapy?

Janay: Yeah, I am diagnosed with depression, and anorexia, bulimia, and OCD, and a billion other things. Out of hospitalizations? Not particularly, no. I learned to hide what I was doing, better. I got sicker in the hospital. Whenever I was in, I wouldn't eat anything. It caused a lot of problems, mainly pissing off the staff, and when I got out, I'd continue that. And I'd always take razors into the unit. They never checked me good enough. I think they were incompetent, and I was sneaky and didn't want help. I hated them. I see no point in hospitalization because if I want to hurt myself, I can do it in the hospital or at home. They can't stop me.

David: You still sound very angry and like you are still dealing with a lot of issues, including depression and the eating disorder. How did you manage to stop self-injuring? How long ago was that? And how did that come about?

Janay: No, I'm not quite so depressed anymore. As for stopping - it caused a lot of problems with my "sorta girlfriend" Sarah. On new year's day, I cut myself at her house and she cried for a long time. I felt awful because I realized that it was my fault. I was screwing things up. I was hurting her. She made me promise not to do it again two weeks prior to that night. I broke that promise once. I won't ever again. I love(d) her so much, and I lost her. The cutting was only one of many things, but I'll never lose another person I love over something that I can control, over something so completely stupid and useless. So I haven't cut since that night, though I've had urges to cut and I've come really close.

David: We have a lot of questions and a lot of comments. I'm going to post the audience comments first, then we will get right to the questions. Here are the comments about things we've talked about so far:

jjjamms: My current therapist allows me to talk about all the aspects of self-injuring, unlike other therapists I have seen. It has helped me to realize just what I am doing to myself and why. Journaling is a great way to head off self-injury. I make myself journal a whole page about how I am feeling before I self injure. That either lessens the severity of the SI or stops it most times now. At first, it was hard to "make" myself journal about feelings at all.

shylacious: I think you look beautiful now (from your picture in your diary), and thanks for talking to us!!

jess_d: I had the same problem. When I was in the hospital, I'd be put in isolation for messing up and when I'd get out, I'd be so pissed I'd slam my head against walls and want to hurt myself even more.

loonee: I think that most mothers are very concerned to learn that their daughter/son is doing this. My mother overreacted (my opinion at the time at least), but I understand how it must feel to be presented with the news that the daughter you thought you knew thinks that she must physically injure herself to handle the pain going on inside her. I actually found that my mum was very relieved to find out why I was depressed.

jess_d: Sometimes, it does help to tell your parents about self-injury.

space715: I have thought about stopping seeing my therapist because of her threats to tell.

Myst15ical: Don't be afraid of what others have to say. This is something that I have dealt with a long time and people don't understand, so they say dumb things. Get help!! Don't be afraid to get help because we all need help. You can't do this on your own.

lonelyhearted: I haven't cut in almost a year and I know how hard it is. I pray that you can continue on the same path.

KarinAnne: Is anyone a parent that SI's? I have two children and sometimes they are the only thing (next to my therapist) that keeps me from hurting myself.

David: Janay, here is the next question:

MansonNails: I'd like to know what it was about the therapists Janay didn't like and how could they have acted differently that perhaps may have gotten Janay to be helped more by them?

Janay: Well, basically they would tell my mom the majority of the things I said and they would tell me how I felt when no one but me knows how I feel. I resented that. I had (still have?) a bad ass attitude and if I decided I didn't like someone initially, that was just it. They were too condescending towards me. I didn't want to be treated like a two-year-old.

Marquea: What things are you doing now to keep you from Self-Injury?

Janay: I work and I go to ROP. It's like job training. It's in a daycare. I can't be around the kids with fresh wounds. As it is, they see my scars. They finger them. They say "Miss Janay, what happened?" They say "Miss Janay has a lot of owies." It makes me want to cry. If only for them, I can't do it. They don't need to be exposed to that.

I'm determined to be functional - work. I have scars, deep ones, all over my left arm that will never go away. Employers don't want to hire someone with tons of scars. I have enough; I don't need to make new ones. People talk, anyway. People ask, they're nosy.

cassiana1975: Have you taken meds in order to stop SI-ing?

Janay: I used to. Not for the SI though, for depression and stuff. I stopped because they made me either incredibly nervous to where I was shaking constantly or they made me gain weight and worsened my eating habits. I don't take meds anymore, and I'm fine.

David: Here are some more audience comments, then we'll get to the next question:

jjjamms: I kept my SI a secret for over 35 years. My earliest memory of SI was at 5 years old. I think it must be really hard on children or teenagers. I didn't even know other people did what I was doing until about 5 years ago!

loonee: I thought therapists weren't allowed to tell anything you said to them. Mine never did. I decided for myself to tell my mum. My shrink had nothing to do with that.

jess_d: Being in the hospital was the worst thing in the world for me. It did absolutely nothing. I also want to say that not all parents have the same reaction as Janay's mom. My parents got me help and supported me completely in my struggle to stop and still support me even when I have relapses.

hurtin: I changed to a therapist that I can talk to about any aspect of my self injuring without them trying to save me. That helps immeasurably. I am currently dealing with sporadic bouts, rather than it being a daily ritual.

David: Here's the next question:

loonee: Janay, did you find that hearing of the experiences and methods of others triggered you to injure more?

Janay: Not really. It makes me sad, and I want to help them. It doesn't trigger me unless I am unstable at the time and wanting to cut already.

rekowall: How do you keep from cutting when the need becomes unbearable?

Janay: I think of the kids. I'm going to be a preschool teacher. It isn't something a teacher does. Or I cry and hyperventilate ( a lot), but afterwards, I'm exhausted and I fall asleep.

space715: Hospitalization has been suggested to me if I can't keep from SI-ing. What do you do in the hospital?

Janay: For me, the hospital is a bunch of BS. I've heard people say it was positive for them though. Basically, you wake up at 6 a.m., have morning group, breakfast, shower and have about a million more groups all day; like anger management, drug and alcohol group, affirmation, occupational therapy, etc. Things that cover the "issues" of the majority of patients along with a 5-minute daily meeting with a psychiatrist who puts you on meds. You'll see this person maybe a total of 20-30 minutes your whole stay.

David: Here's an audience suggestion on how to keep from cutting when you feel the need to:

KarinAnne: I've used rubber bands (to snap on my wrist) at times, but it's been 2 weeks and tension mounts when I don't take things out on myself.

David: Janay, I have a question, and I want to add here that I am not putting you down, but I'm wondering if you felt if you just weren't ready for treatment. We had a guest recently who said, if you are not ready for treatment, there's nothing in the world anyone can do to help.

Janay: I wasn't ready for treatment. I had nothing else to hold onto. They were trying to take away my coping methods without replacing them with ones I found were adequate replacements.

MellyNCo: It sounds like past therapists were violating Janay's confidentiality, and the resentment is understandable. However, I'd like to ask Janay, if you stop injuring for other people, instead of yourself, does that also stir up resentment?

Janay: It depends on the person. To be honest, I wouldn't do it for myself. I hate myself, which is something I'm still trying to get over. If I love a person, I'd do anything for them. It doesn't make me resent them because I love them. I don't know - it's different. I need that motivation from another person.

David: How has the self-injurious behavior affected your other relationships, in terms of having friends, etc.?

Janay: I've lost a lot of them. I push people away... I hide things... I'm tired of losing people over it.

David: What do you tell people (adults) about your scars, if they ask?

Janay: lol, at school the counselor told me to tell people I got bit by a dog, but the scars are obviously intentional. If a person is nosy enough to ask, I tell the truth. "I got upset, I took a razor, pressed it down and pulled it across my arm." Good for shock value anyway; they leave me alone. If they don't go away and they ask more, I walk away. It annoys me.

David: Here are some more audience comments on what we're talking about tonight:

loonee: I told my mum I was attacked by a dog before I told her the truth. I still say that to anyone who asks. I wasn't ready for treatment for about 5 years. I didn't want to stop. It was all I knew would stop the pain, even if only temporarily. I have tried to stop for other people; it worked for a while but eventually, I got sick of it. I just hid it better. I wore long sleeves and withdrew from them. I had to want it for myself before I could stop.

rotten_insides: One night, while I was having a cigarette outside at a concert, I overheard these 12-15-year-olds talking FREELY about how they CUT themselves and how DEPRESSED they are. I was standing behind them, watching them and feeling ill while listening to them speak of slicing open their arms and how it's "cool" watching the blood run down your arm. One says, "if you use a razor blade, you can actually cut REALLY deep and watch your wound split wide open." The other says, "Yeah, but I'm too scared to hurt myself."

Janay: rotten, I see that too. I think those kids do it because, for some reason, it's become the "cool" reject thing to do. At school, kids would draw wounds on their arms or write things like "insert razor here" on their wrists.

rotten_insides: I just don't understand people that would go around showing off their scars.

shylacious: Here's what helped me. EMDR (Eye Movement Desensitization and Reprocessing), for dealing with sexual abuse memories, led to a decrease in panic. Celexa dealt with depression. It's easier to not cut. It's been one month.

tinirini2000: Do you feel better now that things seem to be coming together?

Janay: Yea, I do. I am proud of myself for coming this far.

tinirini2000: That's really good, Janay. I'm really proud of you! You have come a long way! :-)

jess_d: I think it's really great that you're talking to people about this. I know for me it makes me feel like I'm not alone in my struggle.

David: One other thing I wanted to touch on tonight, Janay. You are a black woman. I have been with HealthyPlace.com for 14 months, since we opened, and have not heard of another black woman who self-injures. Do you know of other black women who are involved in self-injury?

Janay: I met two black girls in the hospital who self injure, but I don't talk to them anymore. My dad is white, and I've grown up in a white community. My mom and the rest of my family say I'm like this because I hang around white people and I think I'm white. ::shrug:: go figure. I know a couple of black guys that cut, though.

David: Here are a few more audience comments:

anaj2281: lol. We have a lot in common, Janay. I cut, my father is white, my mother is black, and my name is Jana.

jess_d: My dad is white too and my mom is Hispanic. The rest of my family say I think I'm white, too, because I grew up with mostly white kids.

loonee: rotten, I think that showing off scars is, for some people, a way of dealing with what they do. Making a joke of the fact that they do it may help them mask the reasons why they do it.

anaj2281: I self injure, and although I am multiracial, I mainly consider myself black.

David: I know it's getting very late. Thank you, Janay, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others.
http://www.healthyplace.com

Thank you, again, Janay, for sharing your life with us.

Janay: You're welcome. Thank you for inviting me.

David: Have a good night, everyone.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Dr. Sarah Reynolds, our guest speaker, is an expert on Dialectical Behavior Therapy (DBT), a type of psychotherapy used for reducing self-injury and suicidal behaviors.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our topic tonight is "Self-Injury: What it takes for you to stop self-injuring and DBT for treating self-injury." Our guest is Sarah Reynolds, Ph.D., who is a research coordinator at the Behavioral Research and Therapy Clinic (BRTC). The BRTC, directed by Dr. Marsha Linehan, is devoted to the study and treatment of self-injury and suicide. Dr. Reynolds has extensive training and experience with Dialectical Behavior Therapy (DBT), a well-known and scientifically based outpatient psychotherapy for reducing suicidal behaviors.

Good evening, Dr. Reynolds and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Many people talk about wanting to quit self-injuring, yet they find it extremely difficult to accomplish that. Why is that?

Dr. Reynolds: People self-injure, usually to regulate extreme negative emotions. It is often their only way to cope. It is the only way that they have learned, and so they keep coming back to it. It is obviously ineffective for having a reasonable quality of life, but it can work in the short-term for reducing the emotional pain.

David: What skills, exactly, do they lack?

Dr. Reynolds: Well, first of all, they usually are quite emotionally vulnerable, that is, they have a lot of ups and downs in their moods. Thus, they have a lot of emotionalities to try to deal with, just because of their biology. Further, people who self injure, typically have a lot of difficulties tolerating their negative emotions without doing something impulsive to try to stop them, and they may have difficulty forming good relationships with others.

David: Is it possible for someone to learn to stop self-injuring on their own, without professional treatment?

Dr. Reynolds: It may be possible, depending on the severity of their self-harm, but it might be quite difficult.

David: And I want to get into the treatment aspect in a moment, but you mentioned that some people use self-injury to regulate their emotions. How does that work?

Dr. Reynolds: A lot of emotional regulation skill involves refocusing attention away from emotional pain, a skill that self-injurers often lack. So, self-injury can focus attention away from the original problem and onto the physical injury. It can also validate for the person their own sense (although it is false) that they are a bad person and deserve to be punished. So, in this way, it can be calming because it validates their sense of the world.

Finally, people sometimes self injure because it can take them out of a difficult situation that causes stress. This indirectly reduces negative emotions.

David: What is the most effective method of treatment for self-injury?

Dr. Reynolds: The only treatment that has been shown to be effective in a scientific study is Dialectical Behavior Therapy (DBT). Several studies have shown that DBT reduces self-injury (both self-mutilation and suicide attempts) for women diagnosed with borderline personality disorder (BPD). There may be other treatments out there that people consider "effective" but none have been researched. Unfortunately, not much research is done on this problem.

David: Can you please explain what Dialectic Behavior Therapy is and how it works?

Dr. Reynolds: DBT is an outpatient (out of hospital) psychotherapy that views self-injury as an ineffective attempt to solve problems. Therefore, the goal of DBT is to stop self-injury and figure out better solutions. It is a structured treatment that is cognitive-behavioral. It has a number of different parts, including individual therapy, and a skills group that teaches skills for tolerating distress, increasing awareness of surroundings (mindfulness), regulating emotions, and interacting effectively with others.

David: We have a lot of audience questions, Dr. Reynolds. Let's get to some of those and then we'll continue on with our discussion about the treatment of self-injury.

Fragil Heart: My neighbor Michele, a single mom of three, is a self-injurious person who cuts herself repeatedly. I know that she refused treatment for her drug addiction and the Department of Human Services is going to remove her children. She has no knowledge of this. My question is, after the kids are gone, her chances of cutting are great and she has begun to hide her cuts. How can I help her, if I can? I do support and listen to her.

Dr. Reynolds: Well, the best thing is to encourage her to get into treatment. I would also consider telling her that you think her kids will be removed from the home. Often times, it can take major consequences as a result of our behavior before we can change. I am sure that even your emotional support is a great comfort to her, as many people who cut are very socially isolated.

2nice: How common is self-injury in people with a depressive illness?

Dr. Reynolds: Self-injury is very often associated with a diagnosis of BPD (Borderline Personality Disorder), and very often with a mood disorder, such as depression. People who self-injure are often chronically miserable.

Keatherwood: I haven't done any self-injury for over five years. Because of some things that happened this past weekend, it is all I can think of. I'm taking extra medications, doing all the alternatives I know, talking with my therapist, etc., but I can't get the idea out of my mind. I feel like I'm going to explode if I don't do something. I thought I was past this. Any suggestions? The hospital has been suggested, but I'd like to avoid that.

Dr. Reynolds: Wow! It is fabulous that you have not self-harmed in so long. You clearly have a lot of good skills, if you have been able to resist previous urges to self-injure, which I bet you have done. How did you get through those rough patches before? Think about that.

Also, I would think about the pros and cons of doing it at this point. What are the bad things about doing it, and is it really likely to make you feel better? Think carefully about it, and my guess is that in your heart of hearts, you know it will ultimately make you feel worse. You've done wonderfully for this long. Stay committed to no more self-injury.

David: Is it unusual, or not unusual, for someone to suffer a relapse once they have "recovered"?

Dr. Reynolds: It is not at all unusual. Self-harm has an addiction-like quality. But the longer someone avoids it, the longer they will likely keep from doing so again. The trouble is that each time one self-injures, it teaches your brain that self-injury is the way to solve problems, and thus, blocks you from finding more effective solutions to what is really happening in your life.

secret*shame: I am sixteen, and I have been cutting for five years. Why can't I stop? I don't want to tell my mom because I don't want to hurt her. What can I do?

Dr. Reynolds: I am so sad to hear that you have been cutting since age eleven. From your name, it sounds like you have a lot of shame about who you are and your self-injury? The thing is, you probably should tell your mother or someone you can trust if not her. The point is, you have been doing this for a long time, and it is too big of a problem for you to get over it by yourself! I desperately hope that you talk to an adult who can help you out with this. That is the only way you can stop it right now. I want to emphasize, secret*shame, that your mother will be far more hurt if you do not tell her about this so that she can help you.

David: I want to add, secret*shame's situation is not unusual. Many teens are afraid to tell their parents about things like self-injury. How would you suggest they handle that, Dr. Reynolds? Because without their parent's help (insurance and support), they can't get the therapy they need. How, specifically, can they broach the subject with their parents?

Dr. Reynolds: Yes, that is true. If they don't want to acknowledge the self-injury itself, they could consider getting help simply due to depression and misery. Once in therapy, their responses will likely be confidential, or at least they can ask the therapist if it can be kept confidential. Certainly, for someone who is sixteen, the therapist is unlikely to talk to their parents without consent unless the adolescent is at risk of suicide. If not their parent, I would strongly urge them to try to find another adult that they can trust such as a teacher, an older sibling, etc.

David: That's a good suggestion.

here2help: I am a seventeen-year-old male student in England, UK and I have a seventeen-year-old female friend who does self-injury. She has been doing this for about two years, I think, but it has only recently become known to anyone but herself. I was the first person she told out of choice, but others found out either after she fainted or by finding blood on her. I want to know what I can do to help her. She is on anti-depressants, although she's not very good at taking them. She does have therapy and she also drinks.

Dr. Reynolds: She is in a relatively good situation given that she has treatment and friends. If you think that her self-injury is a bad thing, it might help to be honest with her about that. Communicate to her that you think it is a big problem. I think that would be helpful.

teatranna: Are the use of "ice cube" therapy (holding ice cubes in the hands to feel pain) or "line" therapy (the drawing of lines on one's body with a red marker) effective alternatives to self-injury, or are they dangerous substitutions that only perpetuate the urges?

Dr. Reynolds: I think this is a much better alternative than actual tissue damage (breaking the skin). It is qualitatively different from inflicting tissue damage and is a great way to work on stopping self-injury.

David: Here are some more questions:

scarlet47: My therapist is sending me for four DBT sessions. Can that amount help with success. I refuse to attend more. It was unnatural and brainwashing to me, and I don't have patience and won't attend any group sessions. I committed to him to attend, but I am not open to it. He wants to see the impact. I believe you can take the horse to the well, but you can't make him drink.

Dr. Reynolds: Four sessions of Dialectical Behavior Therapy will not help. However, a year of DBT can help you to bring about incredible changes in your life. You must have some reasons for going to even four sessions? Think about the advantages and disadvantages of going. But you are right, you must be absolutely committed to ending self-injury. Otherwise, the treatment won't work. I hope you change your mind. Good luck.

ill_fated: What is the difference between DBT and CBT (Cognitive-Behavioral Therapy)?

Dr. Reynolds: DBT is specifically designed to treat people who have problems with self-injury, and who have severe personality disorders, like Borderline Personality Disorder. It is actually a form of cognitive-behavioral therapy, but the other types of CBT that are currently available are only for anxiety, depression, and eating disorders. Also, one piece of DBT that is relatively unique, is that it emphasizes validating the patient. This is important because self-injurers often do not trust themselves, their emotional reactions, or their experiences as valid and meaningful. DBT helps the client to learn to trust and validate themselves.

Crazy02: Dr. Reynolds, I am in the Philadelphia area and the mother of a nineteen-year-old self-injurer. I hear what you are saying, but what can I do to help my daughter?

Dr. Reynolds: Have you tried to get her into therapy?

David: That would be the first thing. What else can a parent do to help? And also, a lot of parents feel guilty, thinking they are the cause of their child's self-injury behavior.

Dr. Reynolds: Well, I realize that you may not be able to interact with me and answer my question. Basically, I think that is the central piece. If she refuses to go, then, providing the emotional support that you do is no doubt helpful. Beyond that, it is essentially impossible to control a nineteen-year-old's behavior. I know this must be very frustrating, but your hands are somewhat tied.

For parents in general, there are some good self-help books that they might consider reading, such as "Eclipses" by Melissa Ford Thornton. Another book I want to mention that can be helpful for friends and family of self-injurers is "Stop Walking On Eggshells."

I also emphasize that it is not reasonable for any parent to think that it is their "fault" that their children are engaging in self-injury. Things are not that simple.

hippiemommy3: Other than cutting and forms of self-mutilation, is taking overdoses a form of self-injury? At least once a week I seem to take 20 Darvocet and I want to stop. I am in a day treatment program and have a good therapist. I have medication management, but whenever I get my hands on my pills, I just take too many. Is this self-injury, or something else?

Dr. Reynolds: Taking overdoses can be a form of self-injury. In your case, I would want to know your intent. It sounds like your problem is more likely drug addiction.

David: Someone asked a question about the books Dr. Reynolds mentioned. You can find some in our online bookstore.

xXpapercut_pixieXx: Can DBT also be used to bring a person back from a sense of numbness or blankness?

Dr. Reynolds: This sense of numbness is not uncommon in people who have BPD and who self-injure. The answer is yes, DBT can be very helpful for addressing this problem as it so often coexists with BPD and self-injury.

arryanna: Is there any specific medication you have found to help reduce the amount of self-injury?

Dr. Reynolds: No, the few studies that have been done, indicate that no medications are effective in the long-term.

Filly: What if part of the problem is not learning the proper skills. I made it fine through the teens, twenties and most of the thirties with only a few thoughts of self-injury and now, suddenly, after the break up of a long relationship, added with high stress from work, I started to self-injure? By the way, I am in the DBT of Portland, and I do believe it will work.

Dr. Reynolds: It is not uncommon that people may "fall apart" and self-injure in instances of extreme stress. It sounds like that's what happened to you. But, you have an excellent prognosis for getting past this, since it started late and you are already in a good treatment program. Good luck.

megs5: I have heard that self-injury is most common among people who have been abused or raped. Why would someone like me cut? I have not been through anything?

Dr. Reynolds: Many people who self-injure or attempt suicide have a history of abuse. However, many do not. The etiology of this behavior is not exactly known. What I believe, is that a person is born biologically with a predisposition to be very emotional. Then, they have an environment that does not meet their needs.

angelight789: Is self-injury related to one's menstrual cycle or hormone level? I am taking a drug called Lupron that induces menopause and I have been cutting more. I have severe endometriosis and a lot of female-related problems. Could this impact my self-injury problem?

Dr. Reynolds: I am not sure whether it could directly affect your cutting. A medical doctor would be better able to answer that. What I can say, is that having health problems increases stress, which certainly increases the likelihood of self-injury.

dazd_and_confusd: I was hospitalized for an attempted suicide last year for 8 and 1/2 months. I'm still suicidal and I self-injure. I'm in therapy, but nothing helps. I'm afraid of going back to the hospital because I don't think it will help, but that seems like the only option. I'm afraid. I hate the way I am and how my life is, and I don't know what else to do.

Dr. Reynolds: You sound really desperate. The thing to do at a time like this is to try to generate some hope that things will get better and that this will pass.

As for the hospital, I am not an advocate of hospitalization for suicide attempts, because there is absolutely no evidence that it helps. In fact, I think in some cases it can harm because it does not teach you to cope in your everyday environment. So, I agree that the hospital is probably not the answer. Please remember when you are acutely miserable, things will get better. No emotion lasts for a long time. It always peaks and then dissipates like a wave. Hang in there.

bleedingpink: I started cutting last year. It got really bad to the point where I was cutting thirty times a night. I was able to stop for seven months. Then, one day I found out my best friend was cutting again, and it made me start cutting again. Why is that?

Dr. Reynolds: It is very common that talking to another who cuts, or talking about cutting, is a trigger for people to cut. I would urge you to not talk to her about this, and be sure that you have friends who cope in more adaptive ways.

betty654: I have been in DBT for almost a year now and have not cut. The thoughts are worse than ever and I feel worse than before. Will the thoughts ever go away and for how long?

Dr. Reynolds: It is wonderful that you have not cut! You're obviously working hard toward building a life worth living. It is no surprise that the thoughts are still there. I assume that you mean thoughts or urges to cut and misery? The bad news is, that the misery and urges take longer to go away than just the cutting itself. The good news is that you will get there, it just takes a lot of work and some radical acceptance that you may not be the kind of person that will ever be light-hearted and happy-go-lucky. Good luck betty654.

David: Dr. Reynolds, referring back to your earlier comment regarding hospitalization, you mentioned that you didn't think it was particularly helpful for those who are suicidal. One of our audience members thought that hospitalization would stop the person from following through, at least for a while. Can you respond to that?

Dr. Reynolds: Yes, people assume that the best treatment is to be very restrictive to those who are suicidal, but no one has ever done a study on that. This is a good point, because it may stop them for twenty-four hours, and I would never say that hospitalization is always bad, but what is to be done after that short period of time is up? Also, any short-term gain is offset by the long-term disadvantage of what they have learned: that when they fall apart and can't cope on their own, they are taken to the hospital and taught that they cannot care for themselves.

Also, they cannot live in the hospital forever, and they need to learn how to control their emotions in everyday life. Studies have shown that learning needs to take place in the environment in which it will be used, which means a person's daily life.

dianna_mcheck: Can practicing sado-masochism relate to self-injury? When I am in a sexual relationship where S&M is present, I don't self-injure, but when it is not, I do. Is it just a fluke, or is it connected?

Dr. Reynolds: It could be connected, particularly if you are masochistic. But self-injury is typically not done to cause sexual arousal.

Jayfer: At the moment, I am trying really hard. I am seeing a therapist but finding it really hard to stop at the moment. I quite often rely on the thought of, "Well if I can't cope, I can always self-injure." Would you say that this thought is natural and healthy? If not what can I do to change this thought?

Dr. Reynolds: That thought is understandable given that you have been doing this for a long time, but it is definitely not healthy or natural. That thought is really your mortal enemy because it is "keeping the door open" to self-harm, and therefore, not really teaching you new ways to cope. What you should do is commit that there will absolutely be no more self-harm. SLAM the door, as if you were a drug addict.

tracyancrew: Do you think a day treatment program like partial hospitalization helps someone who self injures?

Dr. Reynolds: An intensive treatment like partial hospitalization can be great. It is not the same as an inpatient hospitalization because you do go home at night, and also typically have assignments at home, etc. So, beyond that, I would have to know what type of treatment it is.

There are a number of DBT partial hospitalization programs, for example, the one I know of for certain is Cornell Medical Center in New York. For those interested in finding DBT providers in their area, you can check at this website: www.behavioraltech.com. This is the website of the Behavioral Technology Transfer Group. It is a company that specializes in empirically supported treatments such as DBT. So, they have a resource list on their website.

earthangelgrl: OK, when does self-injury come to the point where it is dangerous and you should seek help for cutting? I have had days where I have done nearly 500 cuts.

Dr. Reynolds: Clearly, you have reached the point of "dangerous" in the sense that the quality of your life is probably nil. It does not matter that your cutting is not medically serious, I strongly advise you to get professional treatment as soon as possible! I wish you well.

smilewmn: I see a therapist for abuse related issues. She knows I cut, but doesn't tell me it's wrong., so I feel like it's okay to do. Why wouldn't she tell me it's wrong?

Dr. Reynolds: There are a number of treatment providers who may say that it is "okay" to cut while you work on the underlying problems related to the cutting. My treatment approach, DBT, takes a very different approach that you cannot have a good life when you are intentionally harming yourself. Each time that happens you teach yourself that it is the only solution, and perhaps also that you are a bad person deserving of pain. It just depends on your treatment goals: if you want a better life, you have to commit to stopping any cutting or suicide attempts.

Tigirl: I have been cutting, burning, and breaking bones for about two years and I have been anorexic for fourteen years. What are my chances of getting better? (Find information about anorexia)

Dr. Reynolds: You have good chances of leading a good life, if you get help. You seem to be looking for help, and if so, that is definitely on your side because people who don't ask for help have a lot less chance of getting better. Good luck, Tigirl.

Nerak: I have not self-injured in thirty-two days, but I feel the urges coming back, and am so afraid that one day I will not be able to stop. Any suggestions on what to do to not get to that point?

Dr. Reynolds: Try to identify things that you have done before that help. For example, some people know they will not cut when around others. Also, consider the ideas earlier such as holding an ice cube. I would also make out a list of pros and cons for self-harming so that you can look at it when you begin to get dysregulated. Finally, you have to remember that even when you have an urge, it will peak and then go down. So, you just have to get through it.

David: Thank you, Dr. Reynolds, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. Also, if you found our site beneficial, I hope you'll pass our URL http://www.healthyplace.com around to your friends, mail list buddies, and others.

Dr. Reynolds: Thank you very much for having me. I have enjoyed it.

David: And again, Dr. Reynolds, thank you for staying so late and answering questions. We appreciate it.

Dr. Reynolds: Good luck to everyone, and take care.

David: Good night, everyone.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.