THE CUTTING EDGE

In the Oscar nominated movie “The Banshees of Inisherin” a character named ColmSonny Larry is seen to be living in despair and evident emotional pain. He breaks off his long-standing friendship with Padraic and threatens to cut off his own fingers if he spoke to Colm again. Colm does cut off all the fingers of his hand one by one whenever Padraic attempted to engage in conversation with him. When the priest at confessional asks him how is his despair, he says he feels better and freer since he chopped off his fingers. This is a prime example of Non suicidal Self Injury. The need to avoid pain is a natural human phenomenon. Yet there are many people, about 18% of the population worldwide (2019) who, in their adolescence and well into their adulthood if not taught or learn to deal with or regulate their emotions, tend to cut themselves, self-mutilate, burn themselves with cigarette butts, hit their heads etc. They say that they do so to escape pain, albeit emotional pain

Definition

By 2006, a small cadre of scientists at the first meeting of the International Society for the Study of Self-Injury (ISSS) defined this phenomenon called as Non-Suicidal Self-Injury (NSSI) as follows
“non-suicidal self-injury is the deliberate, self-inflicted destruction of body tissue without suicidal intent nor for socially sanctioned purposes such as piercings or tattoos.”
Males and females are roughly equal in proportion for the same.
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (2013), the condition is classified as a “new disorder in need of further study,” and a symptom of borderline personality disorder, which manifests as low self-esteem, negative self-image, turbulent relationships, and feelings of emptiness.

The most common Methods of self-harm are

• Cutting oneself with blades, knives, pencil sharpener blades, nails and other sharp objects
• Burning oneself with lighters, cigarette butts, hot ladles, irons etc
• Banging one’s head against a surface or hitting one’s head with an object
• Biting oneself to a point of bleeding
• Picking at wounds and not allowing them to heal
• Scalding hot water/ showers
• Scratching the skin with nails, digging in with nails till blood is extracted.

The Neuroscience of Self harm

Cornell research program on Self Injury and Recovery revealed that

• People who are prone to self-injury feel better emotionally with pain
• It relieves unwanted emotions and generates good emotions.
• Neurobiological research backed this by the findings that physiological indicators of emotional pain reduced and physiological indicators of feeling good increased – these are endogenous opioids that release and give a sudden short feeling of intense euphoria
• The Limbic system comprising of the amygdala, hippocampus and para-hippocampus play a major role in memory storage and generation of emotions.
• In people prone to self-injuring there is an atypical processing of information regarding one’s sense of self. There is seen to be hyperactivity in the cortical midline structures like the anterior cingulate cortex (ACC) and the orbital frontal cortex (OFC) resulting in emotional dysregulation in individuals with tendency to self-injure- thereby they have negative beliefs regarding their self, a negative pattern of processing emotions regarding themselves and an unresolved sense of formation of one’s identity.
• They have a heightened neural reactivity to social exclusion and rejection.
• Also found was that emotional pain and physical pain areas overlap in the brain.
• Findings show that people prone to self-injury have a higher tolerance to pain than most people.

The Benefit felt by the person doing the NSSI -Pain Offset Phenomena

Literature from more than 70 years ago written by psychologists revealed a phenomenon called ‘pain offset relief ‘. The explanation is – everybody experiences pain as an unpleasant physical reaction. Relief from that pain does not take the person to a pre stimulus state but leads to a sudden short rush of intense euphoria. The first recorded case being from 1848 of a woman who would mutilate her eyes.
In the case of people who self-injure, the first experience of pain must have been unpleasant but relief was experienced in the pain offset phenomena. The repeated action of self-injury probably helped them access this intense temporary euphoric state, seeking which, the behaviour of self-harm repeated itself.

Probable Causes of NSSI

Probable Causes of NSSI

Social pain- rejection, friends being non inclusive, abandonment – real or imagined

The level of endogenous opioids or endorphins drop.

Pain of childhood neglect ( real or perceived) – where the parents were absent or not participative in the child’s emotional growth by which the child when needing to share or express one’s emotions was not heard or understood the way it needed to be . This leads to the child feeling a deep sense of neglect, feeling lost and confused thereby resorting to unhealthy coping mechanisms like self-injury and self-harm including substance use.

Traits seen in People who self-harm

• They believe they are “bad”
• They believe they are “not worthy of” love and friendship
• They believe they “are not good enough”
• They believe they “deserve” the pain inflicted, they deserve the abusive relationships they would unconsciously get involved in, into the unpleasant life experiences they put themselves through due to these self-limiting beliefs.
• They feel tremendous “insecurity” within themselves. This results in an out of sync between the heart and breath resulting in activation of the sympathetic nervous system resulting in living in a constant state of threat and stress. This leads to a constant anxiety resulting in shallow chest breathing.
• The “postures” tend to change – they tend to slouch which are retracted chests and downcast postures. These are muscular ways of protecting the heart from further hurt and preventing wholesome engagement with others out of fear of being hurt again.
• People who self-harm are prone to addictions to alcohol and drugs and vice versa. Using substances addictively is also a big way to self-harm. The vortex of physical self-mutilation gets compounded when substance use is added to it.
• They feel abandoned by those who are supposed to protect them, parents, friends
• There is guilt and shame following the cutting. So, many will hide their cuts and burns. There is more shame.
• The mind is ridden by a self-talk of repetitive negative thoughts and judgements about self. There is frequent labelling of oneself. For e.g..- calling oneself fat, stupid, moron, slut, boring, un intelligent, no one wants to be with me, I am no good to be friends with, I can’t do anything right, etc etc.
• The reason for cutting is to prevent themselves from doing anything worse, a slow release of emotional pain – so it becomes a negative coping mechanism.
• They feel tremendous anxiety and feel out of place in social situations. They usually also are seen to have negative body image issues and/with probable co-occurrence of bulimia or anorexia.
• They do not want to live the way they live in such emotional states and hence may be mistaken to have suicidal ideations as they may use terms like “I do not want to live anymore” “I do not want to live like this anymore”
• They are unable to express themselves emotionally in a healthy manner. They tend to isolate themselves, though they do not wish to, but their limiting beliefs regarding themselves of “not being good enough”, low self-confidence do not allow them to.
• What this presents in the family is that the child would be locked in its room constantly, more withdrawn from family, more reactive, weeping alone.
• They cover themselves with long-sleeved jackets and long pants to hide the marks of self-harm.
• The academic performance gets affected
• They can cut on hands, forearms, on the inner thighs, at times on the vulva in females indicative of feeling unattractive sexually – they can also indulge in sexual activities against their will in order to feel accepted. “If somebody else says I am beautiful and sexy then I must be those things, as I, on my own believe I am ugly.”
• There is a constant feeling of being judged, as they judge themselves always negatively.
• They might feel numb eventually due to the immense emotional suppression, repression and self- inflicted shame. When we numb feelings that are unpleasant, we also numb joy, happiness, gratitude as we cannot compartmentalise emotions.

It is very essential to understand the difference between Shame and Guilt.

Guilt says “I have done something bad” Shame says “I am bad” This is most commonly seen in individuals with the trait of NSSI

• They are mistakenly believed to indulge in such behaviours to seek attention, they might be, but this is done to seek attention to their need for help.
• Many times when asked: “Why do you cut yourself” the common answer can be “I don’t know” This is because, there is so much accumulation of unresolved emotions, there is a sudden tipping point and an intolerable feeling of being overwhelmed by one’s mental record of detrimental thoughts and emotions that one cuts and then feels better by the pain offset phenomenon.
• It is not easy to not self-harm as that has been the first coping mechanism for a long time and the brain gets wired by that. Re- wiring the brain or enabling the brains neuroplasticity to take over healthily is the process of treatment.

Progression

What begins as an occasional event, becomes a habit and can get worse with the frequency and intensity of the same, requiring frequent medical attention. Ultimately can prove to be fatal if left un treated. The reason they do not seek help or quit is that they are not yet prepared to do so.

Influence of social media

Seeing other people who self-harm can influence others who do so to indulge the behaviour more. If people are friends with you just because they also self-harm, then there is a tendency to glorify it, thereby, re-enforcing the habit. Social media could glamorise it and make it into a fad.

Solutions

Existing Therapeutic Interventions for NSSI

Dialectical Behavioural Therapy (DBT), Mentalization based treatment (MBT) and Cognitive Behavioural Therapy (CBT) have all seen to be effective in NSSI.

DBT is a modified CBT- it aims at teaching individuals to live in the moment and develop healthy ways of dealing with stress, emotions and relationships

MBT is a form of long term psychotherapy with weekly individual and group sessions extending to 12-14 months. It helps to understand one’s thoughts and emotions and their link to our behaviours and actions. Suits children, young people and adults. Hence it is a way to develop one’s ability to think about thinking.

CBT CBT therapists focus on the current circumstances of the individual rather than the factors that have contributed to their challenges. It focuses on facing reality, identifying one’s limiting beliefs about self and changing the patterns of thinking and consequent behaviours. Learning to relax and be calm. The goal is help the individual cope with life’s current situations in a healthy manner.

These have been more recommended to be done in a clinical OPD environment and or through a telephonic conversation.

These therapies that happen say once or twice a week, with the individual left to his/her own measures the rest of the days, do not bring about the desired lasting results as the person is in the environment that triggers these emotional states and behaviours. There requires to be consistent dedicated persistent work to be done by the individual indulging in NSSI to get beyond these states. This, in a clinical environment can be very tedious, long drawn and not with great results. The individuals are referred to a psychiatrist who in turn will prescribe an SSRI or other similar anti-depressants or major tranquilisers which do nothing to alter the belief systems about oneself that have been self- created resulting in the self-destructive behaviours.

Aetiology and Development of NSSI behaviours

Trauma is not what happens to us but the way we perceive what happens to us and what learnings or beliefs regarding ourselves do we develop from them. These beliefs are false and have nothing to do with reality. These beliefs about who we are then govern our lives and dictate, who or if we express or not express what we feel. who we make friends with, what careers we choose, what relationships we get into, what kind of partners we choose, what apparent solutions or coping mechanisms we adopt and adapt- whether self-harm, NSSI or substance use .

E.g. when a child runs to her parents to share about being bullied and they do not listen to her but send her back to face her bullies- she learns that she deserves to be bullied, she believes that her parents cannot protect her and do not love her. Next time, she gets aggressive or suppresses her emotions and submits to the abuse and believes whatever the abuser tells her about herself because it was not refuted by her parents whom she sought refuge with. This child grows to be timid, anxious, withdrawn. She can get confused and fearful and not know how to deal with the emotional pain and start cutting herself and learn that that gives some relief and she can depend on that as nothing else and no one else is dependable. She loses trust in people and finds it difficult to make friends. She develops a belief that she is uninteresting and no one will listen to her. In romantic relationships she can be submissive and non-assertive and non-expressive, resulting in abuse , confusion and if it ends then another belief sets in that she is to blame for it and she deserves it.

In the Anatta Experience

The Residential program at Anatta’s facilities is an ideal, holistic, voluntary, conducive, compassionate, non-judgemental environment that fosters trust enough for the client to be able to be oneself and share freely despite the shame, self-recrimination, low self-esteem and low self-confidence. The duration of the program can be anywhere between 3 to 6 months.

a). Psychiatric evaluation prior to the process, to assess the individual and rule out other pathological underlying mental health issues. b). Counsellors in residence- experiential and professional counsellors living with the client, being available in residence to them any time of the day or night. Sharing, self-disclosure and eclectic modes of counselling that evolve with client interaction and eventually gets tailor-made to the client is the thread that weaves through every activity. c). Introspective Writing – NSSI is only a symptom of far more deep-rooted accumulated emotions and false beliefs regarding oneself that have been embedded in the client’s psyche due to the way one looked at one’s experiences from childhood through life. Writing in the technique guided into –

• Makes one aware of the actual detail of the incidents
• Allows one to separate the thoughts and analyses regarding them with the understanding that they are the mere construct of the mind- becoming aware of the constant self-talk
• Which in turn lead to identifying the consequent self-demeaning and hurtful emotional states labelling oneself -developing thereby false beliefs about who one is-
• Which in turn lead one to understand how and when one began indulging in particular patterns of behaviour and self-destructive coping mechanisms like self-harm substance use etc
• This reduces and does away with the emotional impact of the incidents
• One is able to view these incidents for what they are, devoid of the self talk and emotions
• Looking at this mirror of their writing then through compassionate enquiry and counselling, the client realises what has been one’s role and responsibility in all these experiences of their life. They then come up with new solutions of dealing with life’s situations that don’t involve self-harm in any way.

d). In NSSI, it is observed that due to overwhelming states of anxiety and fear, the breathing becomes shallow and is considered to be normal. This leads to increased intake of carbon dioxide and less of oxygen thereby leading to confused and hyper emotional states. The posture as a consequence can be a slouched which is an inward bent of the sternal or heart region un consciously assumed to protect oneself from further hurt. At Anatta, various breath awareness techniques are practised to correct the breathing pattern. This, in turn leads to happier mental states through consistent practice. The regular practice of Yoga asanas brings more grounding and awareness of ones postures and leads to correction of incorrect ones. Yoga asanas also tone the muscles and bring about a correction in the irregular hormonal levels that are resultant to incorrect breathing and eating that accompanies NSSI

e). Regular meditative practices enable the release and resolution of suppressed and repressed emotions and aid in activating the autonomous nervous system thereby generating higher states of awareness, self-love and self-compassion. This happens through increased serotonin levels, melatonin levels, calms down the sympathetic nervous system that creates stress, strengthens the brain areas that deal with memory, self-awareness , learning , attention, self-compassion etc.

f). Art plays a significant role in therapy of NSSI as it becomes an outlet for the release of subconscious and unconscious emotions through colours, spontaneous patterns, zen tangles, perspective drawings etc. g). Physical activities like walking, running, working out, playing sports, engaging in watching movies, group and team activities generate natural endorphins.
h). Adequate, balanced diet also enhances one’s energy and health.

All of the above entail in re wiring the brain. Utilising the brains amazing capacity of neuroplasticity in scientifically creating new neuronal pathways through new understanding of self and engaging in activities that are towards self-growth.

This requires the therapeutic team to be present with immense patience, love and compassion giving the time required to enable true transformation and healing in the suffering client. Team Anatta provides all of the above.

Equally important in NSSI is the family therapy. Through their experience with their loved ones Parents are left at a loss and confused as to how they can help themselves become more matured individuals and conscious parents. So also, other family members of the client. The frayed relationships with the family are repaired through consistent family therapy and regular interventions with the client at our facility in the presence of the counsellors.

Thus individuals inflicting NSSI, at certain stages, after adequate assessment by the team psychiatrist and physician can greatly benefit and transform through this program.