I am a therapist working with clients who are self harming. Then I started cutting myself.

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 I am a therapist working with clients who are self harming.  Then I started cutting myself.

Just before the session was due to begin, I rummaged through a random stack of pens, rubber bands, and sticky notes in an unfamiliar desk drawer, looking for something sharp.

It’s OK, I’ll fix it I calmed down. “It” was an overwhelming sense of frustration after a difficult interaction with a colleague.

I longed for something I knew would lessen the intensity of the frustration—the feeling of a slight ache against the skin of my forearm. When I couldn’t find anything in the drawer and was forced to open Zoom and start the session, I chewed a boil on the side of my cheek instead.

I wasn’t a teenager. I was in my mid-30s and working as a doctor in an outpatient mental health center.

About six months earlier, I first experienced the power to pierce one’s skin to relieve overwhelming negative emotions. Under the stress of a project deadline and after a meeting where everyone seemed burned out and irritated, I instinctively grasped my left forearm, wrist and hand with my right hand. Difficult. Within seconds, all of my anger, pain, and indignation was gone, and I acknowledged it.

My self-harm escalated over the course of a few months. With each incident, I became less shocked by what I had done to myself and therefore willing to use tools that are increasingly likely to cause injuries and scars.

Cutting is perhaps the best-known form of nonsuicidal self-harm (NSSI), a term used to describe any intentional non-suicidal self-harm. Other forms of NSSI include burning, pounding, or picking at existing sores.

Most people who deal with NSSI self-injure to relieve uncomfortably strong emotions, like I did. Others may feel numb and want to feel, including trying to gain a sense of control or release past trauma or self-injury to prevent different and possibly more destructive behavior.

In that moment, I was so overwhelmed that if I didn’t, the emotion—usually a combination of anger, sadness, fear, guilt, and vengeance—would consume me and impair my ability to function.

For real? I berated myself. Are you starting now? You have been in the workforce for over a decade. They have two masters degrees, in public health and in clinical social work! If anyone should know better, it’s you.

Guess what the result of self-shaming is? Intense emotion. And intense emotions, in the absence of other coping methods, lead to more cuts. I have confessed my feelings and actions to both my own therapist and my clinical supervisor, who have responded perfectly – without shock or judgment.

“They were trying to deal with it,” my therapist stated simply after I described being—once again—overwhelmed with regret that my 15-year plans for an academic medical career didn’t materialize.

Eyes downcast in embarrassment, I confessed that I had eased that grief by cutting myself. She directed me to identify other coping strategies that I could use instead, but only after acknowledging that the feelings leading up to the behavior were understandable.

We need to give the same affirmation to everyone who self-harms. Of course Cutting is useful as a coping technique because it immediately lowers emotional intensity. and There are other strategies that carry less risk. First we validate, then we work on behavior change. This balance of acceptance and change is the guiding principle of Dialectical Behavioral Therapy (DBT), the gold standard treatment for NSSI. In DBT skill training groups, clients learn to be fully present in the moment, to tolerate stressful situations, to communicate more effectively, and to regulate their emotions.

I was familiar with DBT and would occasionally suggest a DBT skills worksheet to a client, but I had not yet internalized his skills enough to apply them in my own life. Knowledge and competence development are separate from each other. The skills take practice, and the person practicing will make a mistake. We are not born knowing how to regulate our emotions and unfortunately many of us are not taught as children or teenagers.

Why did I start in my 30s? I had battled anxiety since childhood and battled depression for most of my adult life, yet I had never intentionally pierced my skin before. This wasn’t the first time I’ve faced work-related stress and I hadn’t had any major life changes recently such as marriage, divorce, relocation, or serious diagnoses.

But I wasn’t alone. Studies show that between 4% and 23% of adults engage in NSSI, and those who begin the behavior as adolescents but do not successfully acquire alternative skills often self-injure into adulthood.

There is evidence that people who self-harm, particularly those with certain psychological traits, can learn their self-harm behavior from seeing another person’s behavior. In other words, NSSI can be contagious, and I may have “caught” it from exposure to other people who used it to cope with strong emotions. When I was a teenager and young adult, I did not know anyone in my social circle who would cut their skin to deal with it, although I had seen the behavior described in the media. That changed when I became a therapist. My clients cut themselves, and this time it was my job to know all about it.

Why did I “caught” cutting when other therapists who work with people who self-injure don’t start cutting themselves? I’ve always had problems with emotion regulation, I realized, and I never realized it. In the past, I’ve managed to smash steering wheels, desks and chairs, and slam doors. I was already primed to turn to cutting when my emotions became overwhelming.

“Why did I ‘caught’ cutting when other therapists who work with people who self-injure don’t start cutting themselves? I’ve always had issues with emotion regulation, I realized, and I never realized it.”

A few days after searching through that desk drawer at the office, I decided that I would no longer harm myself in any way, including chewing on my cheek and picking at my skin when I’m anxious. I had learned the alternative coping skills. The only thing missing was my commitment to practice it. I grabbed a piece of paper and wrote down a list of strategies, promising myself I’d go through the entire list before cutting myself or hitting myself or any hard object in anger, or chewing my cheeks to shreds. I wrote at the bottom of the page that any form of self harm is unacceptable. I then took a picture and saved it in the Favorites photo album on my phone for easy access.

The word “unacceptable” came to mind from a DBT-based book I read while trying to help a client who had been circumcised. The book acknowledged the desire to self-harm to cope with strong emotions, but also called the behavior “unacceptable.” Another reader may have felt embarrassed, but I felt motivated to commit to changing the way I respond to strong emotions. When we label the behavior unacceptable, we still acknowledge that it is our current reality.

In order to convince myself that self-harm was unacceptable, I had to make other actions acceptable. I had to give myself permission to cancel my clients’ sessions at the last minute when I wasn’t mentally able to do my best. I needed to remind myself that my therapist and supervisor are not uncomfortable or angry with me if I need to reach them between scheduled meetings. I had to weigh the real — and debatable — risks and benefits of using a fast-acting anti-anxiety medication rather than cutting myself.

Next, I had to train myself to identify my emotions and label them myself. Often the simple act of saying a word about my inner experience lessened the emotion without further intervention. But this step turned out to be surprisingly difficult. The feeling of overwhelming emotion was very familiar to me, but it didn’t always have a name. In the time it took me to consider whether I was feeling outrage, sadness, worry, anger, or all four, the emotional intensity often subsided.

That Name emotion strategy is supported by neuroscience. When we ask ourselves how to label our emotion, we turn on the prefrontal cortex, the region in the brain where high-level thinking and reasoning takes place. When the thinking brain is online, the amygdala—the part of the brain that processes strong emotions—retires.

The first few times I encountered overwhelming stress after I made my commitment, I struggled to convince myself that knowing cutting would reliably and quickly calm me down was worth trying my list of skills.

One day, a breakdown in communication with the veterinary office meant I couldn’t get the prescription medication for my sick cat before it closed for the weekend. After hanging up with the vet’s administrative assistant, my whole body was shaking and I had the urge to cut.

“Stop it,” I said to myself. “You promised you wouldn’t do that anymore.”

Name the feeling: Anger – both at the vet’s office and at me. worry about my cat

Count the seconds of each breath: One, two, three, four… in. One, two, three, four… out.

Mark the wrist with a pen where I want to cut.

Text a friend to tell them what happened to the cats prescription and support.

Remind yourself that nothing lasts forever, including overwhelming emotions.

After going through the stages, I was still angry and worried. But the intensity had subsided and I was able to think clearly without hurting myself. Best of all, the success confirmed that the skills work with practice.

Brandy E. Wyant is a Boston-area clinical social worker and author. You can find her on Instagram and Twitter at @bewyant.

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