In 2003 I was given the task of starting a brand new program from scratch. The purpose of the program was to help individuals with long term psychiatric hospitalizations to achieve the least restrictive community environment possible and provide them with the supports needed for them to be successful. I was given a $200,000.00 budget and sent out to set up the rest of the program on my own.
From the few directions I received it was my understanding that patients housed longest in the hospital were my target cases. The state hospital sent me a patient list from longest to shortest stay. I chose the top twenty as my client base. Every one of them had been in the hospital from just over a year to over eight years. This is how Brenda[i] became my client.
On my way to meet Brenda I reflected on her case. She apparently had a normal childhood until she was eight years old. On a cold December night her family – two brothers, father, mother, and herself – were in a terrible accident. A drunk driver coming at a high rate of speed crossed the yellow line and plowed head-on into their car. Brenda was the sole survivor. For her the pleasant and secure life she had known was now over.
With no surviving relatives Brenda was placed into the foster care system. Troubled by post-traumatic stress disorder (PTSD) and recurring depression she became a difficult child to care for. In the system she was moved from house to house and family to family. By the time she aged out she had gone through twenty-seven placements. The longest stay was nineteen months and the shortest less than a week. Some of the homes were great, but they were eventually overwhelmed by her myriad of issues. In other homes she was physically, emotionally, and sexually abused. She bore a scar from her left ear across her cheek to her nose where she had been slashed with a kitchen knife from an angry foster mother. On another occasion she was raped repeatedly by her drunken foster father and his equally drunken buddies. As a result she became pregnant. She was strongly urged by her social worker to have an abortion, which she did.
Besides the PTSD and depression she was later diagnosed with a border-line personality disorder. She started self-harming when she was twelve and at the time I met her fifteen years later she was still cutting herself and swallowing foreign objects. Brenda was considered to be the most difficult case in the state and she was now my client. I was just beginning my third year working in the mental health field.
When I met with her it was hard not to notice the amount of scarring on her arms. (I was told that her inner thighs were nearly as bad.) There was not a place on either arm where she had not cut herself from her biceps to her wrists. This alone was unusual since most cutters use their dominant hand to cut their non-dominant arm. Because there were so few places left to safely cut she had begun to swallow. Hair brush handles, knives, and spoons were the most common things she forced into her esophagus. Her stomach was grossly distended from the multiple surgeries undergone to remove what she had swallowed. Soon after becoming my client a surgeon told her that if she required another surgical procedure he could not guarantee that she would survive. Thereafter, she quickly told someone when she had swallowed in order that she may be scoped instead of subjected to the scalpel.
Few people understand the pain that the Brendas of this world experience. An event like witnessing the unnecessary death of your parents and siblings and being left to wonder why you survived is extremely traumatic. Ripped from all you know you live the rest of your childhood without a real home and a forever family. Raped, abused, and discharged from what security net you have when you reach the age of majority you are left to your own devices. You barely know how to function in the world and you live from one disaster to another. Every relationship you have starts intensely and ends chaotically. You are a frequent visitor to your local psychiatric hospital. Finally, the court takes away your rights and once again the state becomes your guardian. No one wants you. You such a danger to the safety of yourself and others that not even local and regional mental health agencies will serve you. So you live in a locked facility for over three years. Is it any wonder you hurt so deeply?
On one occasion I was with Brenda immediately after she had cut herself. I got some antiseptic spray, a sanitary wipe, a topical antibiotic ointment, and some gauze to treat her wound. While tending the wound I began to speak to her in a low, calm, and sympathetic tone. I said to her that she must hurt an unbearable amount to harm herself in this manner. That she was trading her internal pain that she could not see and was helpless to do anything about for an external pain that she could both see and treat. I went on to say how helpless she must feel about her personal trauma that it was actually a relief to have an injury she could put a Band-Aid on. When I finished she looked up from under her hair that hid most of her face and said, “How do you know?” We had quite a long talk after that.
Self-harm is trading one pain for another, persistent for temporary, unseen for seen, and emotional for physical. It is not an attempted suicide or a scheme to get attention. It is a response to crushing internal conflict. It is repeated when one is under stress, in a difficult situation, or when certain dates and months come. Brenda self harmed during December, the month of the accident that stole her family from her, and the days surrounding July 4, the date she was raped. The memories were too excruciating to bear so she turned to the only coping mechanism she knew.
For three years I worked with Brenda until I was asked to assume a supervisory position. I passed her case onto another very capable mental health worker. The last I heard, she was living in a stable home and had ceased self-harming. She taught me a great deal about pain.
It is hard to pin down exact figures for those who self-harm. It is estimated that 20% of females and less than 15% of males engage in self injury. The age of inception is generally pre-adolescence to early teens. In more recent years cutting has become “popular” with endorsements by celebrities and instructional web sites. It makes it more difficult to separate those with a mental illness from those who do it for entertainment. Although self-harming is a symptom of borderline personality disorder, it can accompany eating disorders, depression, anxiety disorders, substance abuse, and conduct and oppositional disorders.[ii]
No one needs to be left in this kind of agony. If you or someone you know is self-harming, tell someone and seek help from a professional who is familiar with self injurious behavior. If appropriate, get medication to address the underlying mental illness. As one identifies the core issues s/he can become more aware of triggers and learn how to better cope with stress and emotions, boost self-image, improve relationships and social skills, and learn problem-solving skills.[iii] There is hope.
“I instantly realized that everything in my life that I’d thought was unfixable was totally fixable – except for having just jumped.” Ken Baldwin, Golden Gate Bridge jump survivor.
[i] This is a compilation of stories made into one in order to protect the confidentiality of the original clients. Names have been changed.
[ii] Source: Healthy Place.com
[iii] Source: Mayo Clinic.com