Friday, July 11, 2008 the heart of the matter

Of late there's been a lot of chatter--on various blogs but also in the media in general--about cutting. Self-injury. So I thought, in a psychiatric version of our regular 'welcome to your body' feature, we'd have a little chat about it. Most people, upon hearing of self-injury for the first time (or having it hit a little closer to home, through a friend's 'coming out' as a self-injurer) have a lot of questions, make a lot of assumptions, and generally get ten different kinds of mind-f*cked about it. There are a lot of myths about self-injury floating around, too, and little things that are helpful to know. Unfortunately, health-care providers (even therapists and psychiatrists) get hold of the wrong end of the stethoscope a lot of times when it comes to are some of the myths that are especially prevalent.

1. Self-injurers do it for attention. Bzzz, try again, no cigar for you. Actually, most SI'ers are very secretive about it, ashamed of their behavior, and hide it as best they can (with long sleeves, by cutting parts of the body where it won't show, and--obviously--not discussing it with anyone). There are a few people who are very in-your-face about it, but usually if someone turns up at an ER or goes to a friend for help, it's because they're frightened and don't know what else to do (or they legitimately need medical attention for uncontrolled bleeding or suturing). They want help. Even if someone is "doing it for attention," what has gone so wrong in that person's life that they feel injuring themselves is the only way they can get what they need? Do they feel like they have to be in crisis to get someone's attention because otherwise they feel unworthy? Do they not want to be a burden, and so avoid asking for help until they're in fever-pitch crisis mode? Let's all show a bit more sensitivity and compassion.

2. A person who hurts themselves must be suicidal. Wrong again. While people who SI are at higher risk for suicide than the general population (largely because SI and mood disorders go hand in hand, and mood disordered folk are at higher risk for suicide), that doesn't mean that someone who cuts is ipso facto suicidal. In fact, many self-injurers report that cutting or burning helps them feel better, keeps negative emotions in check, and keeps them from going on to do something more drastic--like attempt suicide. A self-injury episode should not be automatically assumed to be a suicide attempt; if there's a question of suicidality (a very deep cut on the wrist, cuts in locations with the potential to sever arteries, etc.) then for Buddha's sake ASK. A person who has self-injured should be treated like any other person in acute psychological distress--with care and concern, and as potentially but not presumptively suicidal.

3. Self injury automatically = borderline personality disorder. No, no, no! Of all the myths this is probably the one that pisses me off the most. First, I feel like BPD has largely become a pejorative label for "a patient we don't want to deal with"--someone whose behavior is distressing, who's difficult to get along with, etc. etc. Because a lot of people with BPD diagnoses cut, assuming that a self-injurer has BPD is common...but an ethical and diagnostic no-no that even a psych 101 student could spot. After that assumption is made, there's a tendency for "confirmation bias" to take over--the patient's actions are then all interpreted through the lens of a BPD diagnosis, and what could be normal (or abnormal, but still not personality-disordered) behavior becomes further evidence of the diagnosis. Second, BPD has such a bad rap, assigning it to anyone without solid, ongoing, exhaustive evidence is (in my opinion) ethically irresponsible. There have been numerous studies showing that even mental health providers--who should know better--are less likely to be empathetic, to provide adequate care, and to finish therapy with people labeled "BPD" (regardless-and this is important--of whether the label was accurate according to the DSM-IV or not). In fact, according to one study (by J. Horsfall, I believe) many therapists and psychiatrists even made disparaging comments about presumptively BPD patients, both to other health professionals and to the patients themselves. And I'm not talking about statements like, "Oh, they're a pain sometimes." These people used terms like "psychological cancer," "contamination," "manipulative," "hopeless," "beyond help." I don't see how giving anyone a label that comes with that kind of semantic baggage is in any way helpful. In fact, I think the BPD diagnosis should be stricken from the DSM and subsumed under other more appropriate and less-blaming labels...but that's another story altogether.

I've been lucky enough these past few years to have a doctor (and psychiatrist, and therapist) who understands SI and is supportive of change but empathetic when there are failures. I wish I could say the same of all the professionals I've ever dealt with, and for that matter of all health-care workers. We need to get more extensive eating-disorders training incorporated into the medical and nursing school curriculum...maybe some information on SI would be a good addition, too. Because when someone finally has the courage to seek help, the last thing they need is misunderstanding or bias making things more difficult.

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