The rules of the award state that I should share seven things about myself, and pass the award on to 15 recently discovered blogs that I enjoy reading. However, Sara from The Bipolar Project chose to bend the rules a little and give the award only to Sirius, making it all the more special for us. I have decided to follow her lead because 15 is an overwhelmingly large number of blogs, especially if you adhere strictly to the ‘recently discovered’ part!

Therefore, the one blog that I’ve chosen as most deserving of the Versatile Blogger award is:

Blooming Lotus by Faith Allen

Faith blogs about her own journey to recovery from childhood sexual abuse, post-traumatic stress disorder and dissociation. Her courage and honesty is inspirational and she is always quick to share the things that have helped her with others – something that’s very in line with our own ethos, of course. Congratulations, Faith!

Now to list seven things about myself:

1. I founded Sirius Project back in 2003. At the time, there weren’t many good websites or forums focused on recovering from self-harm (the situation has changed a lot now), so when I realised I wanted to stop cutting I also decided to create a safe place to share with others in the same boat.

2. Also in 2003, my GP told my employer that I would never recover from depression or self-harm. Last summer, I celebrated seven years SH-free and although I still have episodes of depression, I have learned to manage them and lead a rewarding and relatively ‘normal’ life in between. There’s nothing quite like proving a pillock wrong.

3. SIRIUS originally stood for Self-Injury Resources, Information, Understanding and Support. I have to admit that one of my favourite Harry Potter characters may also have played a role! Now that we’re about mental health recovery in general and not just self-harm, I like the fact that Sirius is the brightest star in the night sky.

4. Outside mental health, I love choral music, cooking, poetry, foreign languages and being my own boss.

5. They say you should never talk about religion and politics, but I’m going to anyway. I’m a very liberal Christian and an extremely angry and disillusioned Lib Dem voter.

6. I’m a self-help junkie and must have devoured thousands of books about coping with depression, self-harm, trichotillomania, social anxiety, fatigue and more. You can find some of these on my Good Reads bookshelf, but I tend to only remember the ones that are either really good or really bad.

7. Despite my self-help leanings I’m also a big fan of psychotherapy and medication where appropriate, and I can be quite outspoken about the NHS’s use and abuse of CBT. I don’t think there’s anything wrong with CBT per se, but it’s not the right option for everyone, and in my experience the NHS’s approach to it is often over-simplistic.

If you haven’t already done so, you might want to update your bookmarks from http://siriusproject.org to http://sirius-project.org (the old URL will continue to be used for our forums, which have yet to be converted and updated).

We’re now ready for submissions from guest bloggers who would like to contribute to Sirius. If you have personal experience of a mental health problem, or of caring for someone who does, and you have something you’d like to say about recovery then we’d love to hear from you. You don’t have to be ‘recovered’ in the sense of no longer living with your condition or no longer experiencing symptoms; it could be that you’d like to write about learning to manage your condition, or you’re in the very early stages of recovery but would like to discuss something that has helped you so far. The idea behind Sirius is for people to share the things that have helped them, whether that’s through a personal account, a ‘how-to’ type post, a review of a resource or something else.

Please note that all the blog posts on Sirius so far have been written by me, and most have been adapted from pages I’d written on the old site, so please don’t feel you need to be guided by these in terms of style and/or content. I want to make the Sirius website into a much more collaborative place where anyone can share what has worked for them.

If you’d like to contribute, please just get in touch with a few sentences on what you’d like to write about.

Finally, we’re also looking for suggestions of resources – websites, organisations and books – to add to the site. If there’s something you’d like to recommend, guidelines are available on our how to contribute page.

When I founded Sirius Project back in 2003, I was a passionate advocate of this type of CBT. It was empowering to take charge of my own recovery and some of the techniques really did seem to make a difference to the way I felt. However, as time has gone by I’ve become increasingly disillusioned with the approach. Although CBT thought records do provide some temporary relief from the symptoms of depression and have been a useful coping skill for me, they haven’t been able to help me recover or stop me from relapsing. Worse, I’ve come to realise that the CBT I’ve had was actually feeding into some of the factors which were making me ill in the first place, such as perfectionism, pushing myself too hard and difficulty turning to others for support.

In this post, I’m going to share some of the CBT information and resources from the old Sirius Project website, but also inject a note of caution and talk a little about when CBT-based self-help might and might not be appropriate.

The Theory

Cognitive behavioural therapy is a practical treatment based on the theory that our thoughts, behaviours, emotions (mood) and some physical symptoms all influence each other. It is therefore possible to change the way you feel by changing your thoughts and behaviours.

For example, if you feel depressed, you’re likely to have all sorts of negative thoughts about yourself and other people. These make you feel even worse. Then you might stay in bed all day because you can’t face the world, and you hate yourself because you didn’t do any of the things you were supposed to do. Physical symptoms like trouble sleeping and loss of appetite (so not eating properly) can also feed into the cycle. You’re trapped in a vicious circle where you just go on feeling worse and worse.

Similarly, if you’re afraid of public speaking, you’re likely to feel very anxious or even panicky at the thought of doing this. You might find yourself thinking, “I’ll mess it up. Everyone will laugh at me.” Then you might get physical symptoms like shaking hands or trouble concentrating, and these make it more likely that you will make a mistake, deepening your fear. You might start avoiding situations where you have to speak in public, but the longer you put it off, the more terrified you feel – and you never have an opportunity to build up your confidence or learn how to cope. Again, you’re trapped in a cycle.

However, if you can break the cycle at any point, you can start to feel better. CBT teaches you to identify the thoughts and behaviours that feed into the cycle and change these so that your mood and other symptoms will improve.

The Reality

In my experience, the way we think and how we behave absolutely do affect our mood and can feed into the symptoms of mental health problems such as depression and anxiety disorders. I have experienced it myself that when I challenge the negative, distorted thoughts that are part and parcel of depression, and come up with more rational, balanced alternatives, my mood does lift – temporarily.

The problem I have with CBT-based self-help is that it often takes a fairly simplistic view of mental health problems and focuses on addressing symptoms rather than the underlying causes. At best, this means a lot of hard work constantly having to practise CBT skills because – as one popular self-help book admits – you are doing the equivalent of trimming back weeds rather than pulling them out at the root. (This is particularly frustrating when you have been promised by the NHS that CBT will cure you.) At worst, you might find that the programme doesn’t work or even makes your symptoms worse because the factors that make you depressed or anxious and keep you that way are different from the ones assumed by whoever designed the programme. For example, most CBT-based self-help for depression encourages you to become more active, yet my depression tends to be triggered by pushing myself too hard and I find that spending a lot of time resting is actually what I need.

You might think that having individual CBT would help to avoid these pitfalls. Yet even when I was referred to an NHS CBT service providing individual therapy for “complex and difficult-to-treat” patients, I got little more than formulaic, guided self-help that failed to acknowledge the complexity of my issues. It’s important to acknowledge, however, that CBT doesn’t have to be like this. I have it on good authority (from a friend who is training to be a therapist) that in its full form, CBT works on the root causes of mental health problems and is very different to the ‘sticking plaster’ version typical of the NHS.

One final potential issue with CBT-based self-help is that it places a lot of responsibility on the patient (or client, or service user – whatever you like to be called). This can be empowering, but I feel the idea of ‘becoming your own therapist’ is often abused by the NHS as an excuse for not providing appropriate help and support. Similarly, some CBT-based resources seem to imply that ‘twisted thinking’ and unhealthy behaviours are the cause of any emotional or mental health problem, ignoring the effect our emotions  have on how we think and act, as well as the roles of biology, life experiences and other factors. In my opinion, ‘good’ CBT should always acknowledge the way these factors feed into one another, and be focusing on thoughts and behaviours because these are the things we can change directly; it should never imply that the patient is to blame for all their problems.

When Is CBT-Based Self-Help Appropriate?

I think CBT-based self-help is worth a try if:

• Your mental health problems are mild and not particularly complex OR you’d just like to learn some coping skills. (I personally feel that CBT thought records saved my life when I had no other healthy ways of coping with depression, so I’m not knocking it as a self-help technique – I just have problems with the way the NHS uses and abuses it.)
• The theory behind the CBT makes sense to you and seems to correspond with your own experiences. (Some CBT-based self-help resources, such as the books in the Overcoming… series, start off with a lot of information about the problem they’re designed to treat and this is really worth reading to see whether your particular flavour of depression/anxiety/whatever is likely to be helped.)
• You’re willing to change the way you think and behave, and won’t feel overly invalidated or triggered by an approach that asks you to do this. (See also my comments above about resources that imply if you feel crap it’s all your own fault!)

It’s also worth looking out for CBT resources that seem to target your underlying problems rather than the surface symptoms. For example, I’m finding a CBT-based guide to overcoming perfectionism far more helpful than one about beating depression. Resources which target ‘core beliefs’ – the longstanding views we hold about ourselves, the world and other people – are definitely worth a look, although I’ve personally found that I need professional help with this.

CBT-Based Self-Help Resources

If you haven’t been put off by all of the above and would still like to give CBT-based self-help a go, here’s some further information and resources.

Challenging Thoughts

This part of CBT is very similar no matter what your problem is. It involves identifying thoughts that are causing you distress or feeding into your issues, and then challenging them with an alternative, more balanced way of looking at things. There are two main ways of doing this that I’ve come across. One involves writing out all the factual evidence for and against your most distressing thought in a ‘thought record’. I’ve written a post about how to do this, with examples from one of my own thought records, here. The other involves learning about common types of distorted thoughts and how to spot these in your own thinking. This is covered in detail by David Burns in his book The Feeling Good Handbook, and his ‘ten forms of twisted thinking’ are available online at BPDRecovery.com.

Changing Behaviour

The behavioural side of CBT-based self-help varies depending on what your problems are. It involves identifying the behaviours that feed into your cycle and finding ways to change them. For example, for a phobia, it could involve gradual exposure to the things that make you anxious. For BPD, it could involve learning healthier and more effective ways of coping, so that you don’t swing from crisis to crisis and end up feeling more and more distressed (that’s what DBT aims to do, although it takes a more validating approach than CBT). If your main problem is primarily a behaviour, for example an eating disorder or self-harm, CBT-based self-help will of course involve tackling this.

Here are a few resources that focus on changing behaviours for specific problems:

CBT for Depression
An example of the approach that does not work for me!

Using Rational Emotive Therapy to Control Anger
Good for all forms of freak-out – anger, panic or just feeling like you can’t cope.

The Five Steps
A simple coping technique for people who tend to make impulsive decisions.

Thoughts and Behaviour: Comprehensive Resources

Living Life to the Full
An online, CBT-based life skills course that aims to help people suffering with depression and/or anxiety among other issues.

Self-Help Leaflets
CBT-based booklets covering a range of specific problems from depression and anxiety to self-harm and hearing voices. Available in PDF or audio format.

Sources

My understanding of the theory behind CBT-based self-help is drawn from the books Mind Over Mood by Greenberger and Padesky and Feeling Good by David Burns.

(Image: Graur Codrin / FreeDigitalPhotos.net)

Thought records are supposed to help with all kinds of negative emotions, whether that’s depression, anxiety, anger or something else. Of course, if your thoughts are already balanced and rational then they’re unlikely to make a difference – not all negative emotions are a result of or linked to ‘twisted thinking’. I tend to use a thought record when I know or suspect my thinking has gone a bit screwy. I also find the first step can be helpful if I feel crap but don’t know why; it gives me a chance to understand why I feel the way I do and decide whether continuing with a thought record is appropriate.

Tip: It’s a good idea to rate your mood (e.g. on a scale of one to ten) before and after doing this exercise so you can judge whether it’s helped.

Step One

Take a sheet of paper and divide it into four columns. In the first column, write down all the negative, distressing or anxiety-provoking thoughts that are going through your head.

If you just know you feel bad and are not sure what you’re thinking, these questions may help:

• What was going through my mind just before I started to feel this way?
• What does this say about me? What does it say I can/can’t do?
• What does this mean about me? My life? My future?
• What am I afraid might happen? What is the worst thing that could happen if this is true?
• What does this mean about what other people might think/feel about me?
• What does this mean I should/shouldn’t do?
• What images or memories do I have in this situation?

Source: Overcoming Weight Problems by Gauntlett-Gilbert and Grace

Read through your list of thoughts and circle the one you find most distressing. This is the thought you’re going to challenge. (You can always repeat the exercise for other thoughts later if you like.)

Step Two

In the second column, write down all the factual evidence that suggests your circled thought is true. Be as specific as possible, and only include facts, not opinions. For example, if your friend Sally said a particular dress made you look a little fat, don’t write, “I look fat” (this is just Sally’s opinion). Don’t write, “Sally says I look fat” (this is overgeneralising). Write something like, “Sally said I looked a little fat in the green dress.”

Here’s an example from one of my own thought records:

Thought: I’m a useless, weak, pathetic person who can’t cope with ordinary life.

Evidence for thought: I only managed about 2/3 of the work I should have done today.
I couldn’t concentrate well and didn’t notice several typos – I’m not sure I did a good job.
The house is a mess.
I haven’t cleaned out the guinea pigs for 2-3 weeks.
The broadband company made a mistake with my bill months ago and I still haven’t contacted them about it.
I feel like I can’t cope and want to hide.

Step Three

In the third column, write down any factual evidence that suggests your circled thought is not 100% true. To do this, you can ask yourself the following questions:

• Have I had any experiences that show that this thought is not completely true all the time?
• If my best friend or someone I loved had this thought, what would I tell them?
• If my best friend or someone who loves me knew I was thinking this thought, what would they say to me? What evidence would they point out to me that would suggest that my thoughts were not 100% true?
• When I am not feeling this way, do I think about this type of situation any differently? How?
• When I have felt this way in the past, what did I think about that helped me feel better?
• Have I been in this type of situation before? What happened? Is there anything different between this situation and previous ones? What have I learned from prior experiences that could help me now?
• Are there any small things that contradict my thoughts that I might be discounting as not important?
• Five years from now, if I look back at this situation, will I look at it any differently? Will I focus on any different part of my experience?
• Are there any strengths or positives in me or the situation that I am ignoring?
• Am I jumping to any conclusions that are not completely justified by the evidence?
• Am I blaming myself for something over which I do not have complete control?

Source: Mind Over Mood by Greenberger and Padesky

You might also find it helpful to look at the Ten Forms of Twisted Thinking (which help you spot flaws in your negative thoughts) and Ten Ways to Untwist Your Thinking for further ideas.

Thought: I’m a useless, weak, pathetic person who can’t cope with ordinary life.

Evidence against thought: Depression is an illness. It’s recognised as a disability under UK law.
I did do some housework yesterday and at the weekend.
I give the guinea pigs a loving home.
I know many people with depression who deal with these problems and I don’t think they’re pathetic, weak or useless.
People in my support system are impressed by how much I’m getting done despite the depression.
Many people get behind on housework etc and I wouldn’t say they’re not coping with life.
I’ve been busy with work, Sirius Project and driving lessons.
I can cope with work fine when I’m not depressed.
I’m under extra stress with the housework at the moment because of my partner’s RSI.
I may not be on the best meds for me right now.
B says I come across as someone who makes every effort to deal with problems and work at it.
I’ve helped myself cope by being open with my employer about my depression.
I’m putting a lot of effort and energy into my recovery right now and have developed new ways to help myself.

What if your thought is true? Before you come to this conclusion, I would recommend asking someone you trust for their opinion. However, sometimes a distressing thought can be accurate – for example, if you’re in serious danger of losing your job and your thought is, “I could get fired!”

If this is the case, instead of trying to challenge the thought, it can be more helpful to take practical steps to address the problem. You might want to discuss your concerns with your boss, start looking for other jobs, come up with a plan for how you’ll cope financially, and so on. You can find more advice on problem-solving techniques on page 9 of this PDF booklet.

Step Four

In the final column, try to come up with some “alternative” or “balanced” thoughts that are more factually accurate than those in the first column. These should take into account all the evidence you’ve just gathered. You can ask yourself the following questions:

• Based on the evidence I have listed, is there an alternative way of thinking about or understanding the situation?
• Write one sentence that summarizes all the evidence that supports my thought and all the evidence that does not support my thought.
• Does combining the two summary statements with the word “and” create a balanced thought that takes into account all the information I have gathered?
• If someone I cared about was in this situation, had these thoughts, and had this information available, what would be my advice to them? How would I suggest that they understand the situation?
• If my thought is true, what is the worst outcome? If my thought is true, what is the best outcome? If my thought is true, what is the most realistic outcome?
• Can someone I trust think of any other way of understanding this situation?

Source: Mind Over Mood by Greenberger and Padesky

And here’s my example:

Thought: I’m a useless, weak, pathetic person who can’t cope with ordinary life.

Alternative thoughts: I’m finding “ordinary” life quite hard to cope with right now, but this is understandable given I’m depressed. It’s not a judgement on me as a person.
I’m not weak – I’m actually working very hard on recovery!

If there is any truth to your circled thought and it requires some kind of action, I also like writing a brief to-do list in this column. For example, “I am in danger of losing my job, but I can improve my situation by taking the following steps…”

Source

This exercise is a simplified version of the technique described in the book Mind Over Mood by Greenberger and Padesky.

(Image: Idea go / FreeDigitalPhotos.net)

I have never had formal DBT therapy, but a few years ago I took part in an online class which teaches the skills. Here I’m going to share a summary of the main DBT skills with links to further help and information.

I know not everyone is a fan of DBT. Some of the skills can seem a bit patronising, and it can feel like the emphasis is on coping better on the surface without addressing the reasons why you’re struggling in the first place. My personal experience is that DBT and similar skills (together with meds) have helped stabilise me enough that I’m able to work on the underlying stuff without self-destructing. I also view the DBT skills as a toolbox with a wide range of options: you don’t have to use every single skill, just figure out what works for you and under what circumstances. Finally, there’s more to DBT than just self-help techniques, and I have found its philosophy on emotions and suffering (which is drawn from Buddhism) makes a lot of sense.

If you’re interested in learning DBT skills, I highly recommend two websites which explain them far better than I ever could. The first is the free online DBT Class run by BPD from the Inside Out which takes you through one skill each week with a short homework assignment. The other is DBT Self-Help which provides lots of information on all the skills.

Mindfulness

Mindfulness is the art of paying attention to your thoughts, actions and experiences in the present moment without judging. I’ve found that mindfulness is grounding, reduces my stress levels and makes it easier to cope with any problems in life, so that I’m less likely to self-destruct.

What to do (summary)

• Observe
• Describe
• Participate

How to do it (summary)

• Non-judgementally
• One-mindfully (one thing at a time)
• Effectively (focus on what works)

DBT also teaches that there are three states of mind: reasonable mind, which is rational and logical; emotional mind, when emotions control or influence our thoughts and behaviour; and wise mind, which is a healthy balance of the two.

Getting Through a Crisis

Distress tolerance skills are skills for coping with distressing emotions, events and crises. Once learned, these skills can be used in the heat of the moment as an alternative to self-harm, bingeing, getting drunk or whatever your personal flavour of self-destruction is.

Distraction techniques can be remembered with the acronym ACCEPTS:

• Activities
• Contributing (helping others)
• Comparisons (with other people) (everyone I’ve spoken to hates this one. I don’t use it)
• opposite Emotions (e.g. watching a film or listening to music that will trigger a different emotion)
• Pushing away (mentally blocking the situation)
• Thoughts
• Sensations

Self-soothing techniques focus on the five senses and have to do with nurturing, comforting and being kind to yourself. These are some of my favourite skills.

IMPROVE the moment is an acronym for a set of skills:

• Imagery (e.g. create an imaginary “safe place”)
• find Meaning in the crisis
• Prayer (feel free to ignore this one if you’re not religious)
• Relaxation
• One thing at a time
• Vacation (take some time out)
• Encouragement (talk to yourself in an encouraging way)

Pros & cons involves weighing up the advantages and disadvantages of different courses of action.

Radical acceptance involves accepting reality as it truly is. That doesn’t mean you have to like or approve of the situation, but it means you stop fighting reality. Radical acceptance can be a way to avoid unnecessary suffering.

Managing Your Mood

Emotion regulation skills help you to understand the way you feel and manage your emotions. DBT teaches that emotions are not right or wrong – they just are. It places a lot of importance on validating the way you feel, while also teaching ways of reducing negative emotions and increasing positive ones.

Describing Emotions and The Function of Emotions explain the DBT perspective and can help you understand and validate your feelings. I recommend reading these before you try any of the other skills.

PLEASE Master is an acronym for a set of skills that can make you less vulnerable to negative emotions:

• treat Physical iLlness
• Eat healthily
• Avoid mood-altering drugs
• Sleep well (suggestions here)
• Exercise
• Mastery – do something every day that gives you a sense of competence or achievement

Increasing positive emotions does what it says on the tin! This involves doing more enjoyable activities and also making changes in our lives that will lead to more positive experiences.

Being mindful of your current emotion is a way to reduce unnecessary suffering when you are feeling bad.

Acting opposite is a way of changing unpleasant emotions by doing the opposite of the way you feel – for example, doing something that scares you, or finding compassion for someone you are angry with.

Relationship Skills

In DBT, relationship skills are known as “interpersonal effectiveness” skills. This basically means being able to meet your goals in your relationships with other people. DBT teaches that there are three types of goals in relationships:

• objectives (getting what you want or saying no to what you don’t want)
• relationship goals (keeping or improving the relationship)
• self-respect goals (feeling good about your behaviour and respecting your own values and beliefs)

DEAR MAN is an acronym of the skills needed for objectives:

• Describe the facts
• Express your feelings or opinions
• Assert your wishes
• Reinforce the positives (how the other person will benefit if they do what you need/want)
• stay Mindful
• Appear confident
• Negotiate

GIVE is for keeping or improving the relationship:

• be Gentle
• act Interested
• Validate
• use an Easy manner

FAST is for self-respect:

• be Fair
• no Apologies
• Stick to values
• be Truthful

Obviously, you can use more than one set of skills at a time if you have more than one type of goal. However, it can be helpful to prioritise what is most important to you in a given situation – getting what you want, the relationship, or your self-respect.

The following links may also be useful:

• When to use interpersonal effectiveness
• Factors reducing interpersonal effectiveness
• Myths about interpersonal effectiveness
• Cheerleading statements
• Intensity options (how firm do you want you be?)
• Suggestions for practice

Other Stuff

Behaviour chain analysis
You can do this exercise after you’ve self-destructed to help you understand all the factors that led up to it, and to look at what you could have done differently or can do differently in future. It can be used for any problem behaviour – self-harm, abusing drugs or alcohol, binge-eating, fighting with your partner, and so on.

Flash cards
Handy reminders of all the main DBT skills.

(Image: Felixco, Inc / FreeDigitalPhotos.net)

If you’re interested in drawing up a crisis plan, this page gives some suggestions of what to include.

First of all, here are some questions to think about:

• What have you found helpful in the past? Jot these things down and make sure you include them.
• Where are you likely to need your crisis plan and which format(s) will work best? For example, you could have a detailed plan in your bedroom and a condensed version on a card in your wallet.
• Will you want as many options as possible on the plan, or would a very long list be too overwhelming?
• Do you find it hard to make decisions in a crisis? If so, you might find it helpful to number the list in a fixed order that you’ll work through, or make it a flow chart.
• How would you like to decorate your list? You could include colours and pictures that you find soothing, uplifting or even humorous.

Now here are some categories to include on your plan.

Sources of Help

These are people or services you can contact in a crisis. It’s a good idea to write down their phone numbers and other contact details in your plan, so they’re easily at hand.

Try to cover all hours of the day – for example, if your CPN is only available during office hours, include a helpline that’s open in the evenings, overnight and at weekends. It’s also a good idea to think about how you’ll be able to contact people. If you find telephoning difficult, include some people or services you can contact by text, IM or in person.

Here are some suggestions:

• your GP and out-of-hours service
• helplines
• any mental health professional you’re seeing
• any crisis service you know of in your area
• friends and family who are happy to support you in a crisis
• contacts from self-help or support groups (with their permission)

Activities

These are things you can do by yourself that may help to get you through the crisis. The ideas below are just suggestions – the important thing is to include activities that you’d be willing to try and feel may help.

• journalling
• other creative activities e.g. painting, singing
• ideas from our alternatives page
• DBT coping skills
• challenging negative thoughts
• exercise
• hitting pillows or a punch bag
• brainstorming solutions to whatever problem you’re facing
• distracting yourself with a favourite TV programme
• aromatherapy or pampering yourself

Happy Boxes

You might also find it helpful to create a crisis box or “happy box” containing items that will help get you through the crisis. You could keep your plan in the box, or include the box as an item in your plan. Here are some suggestions:

• essential oils, bubble bath, hand cream
• favourite books, CDs and DVDs
• self-help resources
• relaxation CDs
• photographs
• letters from friends
• teddy bears
• art supplies
• henna tattoo paste, red pens or anything else you use as an alternative to self-harm
• any PRN medication you’ve been given for a crisis (in small quantities)

(Image: Salvatore Vuono / FreeDigitalPhotos.net)

Surfing the Urge

UK charity FirstSigns observe that the urge to self-harm is a bit like a wave, which builds to a peak but eventually diminishes again if you’re able to wait it out. I’ve certainly found this to be true of my own urges. One way of surfing the urge is to practise the 15-minute rule: commit to holding off for 15 minutes, and when this time is up, if you still feel like self-harming you can. (Of course, the time frame doesn’t have to be 15 minutes. It can be as short or as long as you like.)

Physical Barriers

If you tend to hurt yourself on impulse, if your self-harm is likely to seriously endanger your health or life, or if you just want to reduce temptation, then you might consider some sort of physical barrier which makes self-injury more difficult. Here are some suggestions:

• It sounds obvious, but throw away anything you use to self-harm that you don’t strictly need for other purposes. If you feel unable to throw something out, put it somewhere that’s difficult or time-consuming to get at.

• Try to minimise the dangers from items you use to self-harm but also need for other purposes. For example, only keep a couple of painkillers in the house rather than a whole box.

• If you’re on medication and overdosing is an issue, talk to your doctor or pharmacist about dispensing your pills in smaller quantities, or ask a friend or family member to look after them for you.

• If you self-harm without implements – picking at yourself, scratching, pulling out hair, etc – try placing a physical barrier between your hands and the area you usually harm. For example, keep it covered with clothing, use KY Jelly to make it slippy, or wear cotton gloves. Or keep your hands occupied with stress balls or tangle toys in trigger situations.

• If your self-harm is putting your health seriously at risk, consider going into hospital or to another safe place such as a crisis house. You don’t have to wait for someone else to suggest this – if you think hospitalisation would help, talk to your doctor or therapist about it.

The Butterfly Project

RecoverYourLife’s Butterfly Project suggests covering areas where you would normally self-harm with a temporary tattoo that will remind you not to.

Avoiding Triggers

Think about the situations where you usually self-harm, and about the things that trigger you. Write these situations and factors down, then divide them into three categories:

1. things that can always be reasonably avoided, e.g. drinking alcohol (I’m envisaging a situation here where drinking is a trigger, but where you don’t have an addiction-type problem that would make giving up alcohol extremely difficult)
2. things that can sometimes be avoided or can be avoided in the short term, e.g. being at home alone
3. things that can’t reasonably be avoided, e.g. other people criticising you

To decide whether something can be “reasonably” avoided or not, think about what your quality of life would be like without it, as well as the lengths you would have to go to to avoid it. It’s important to bear in mind here that you can never control someone else’s behaviour. You can ask them not to behave in a way that triggers you, and they may agree, but ultimately you might want to focus on ways of protecting yourself. Bon Dobson has a good article on what boundaries actually are which might be helpful.

Having drawn up your list, you could aim to avoid everything in the first category, and you might want to avoid things in the second category at times when you feel particularly at risk, or where practical.

A word of warning: Most triggers can’t be avoided forever, so in the long run you may need to be prepared to learn to cope with them. To help you cope with those triggers you can’t avoid, take a look at our Mental Health section, or ask for a therapist’s help.

(Image: Nathan Rogers / FreeDigitalPhotos.net)

If you’re trying to stop self-harming, you might find this list of distractions and alternatives useful. They are all things you can do right now instead of hurting yourself. Even if you feel you can’t cope without self-harm, many people find it helpful to try at least one thing on this list before allowing themselves to self-injure. That way, there’s not too much pressure on you to give up your way of coping, but you learn what else works for you and in time you’ll hopefully build up a long list of healthier alternatives.

How are you feeling right now?

• Angry, frustrated, restless
• Sad, soft, melancholy, depressed, unhappy
• Numb, unreal, craving sensation/pain, dissociating
• Wanting focus
• Wanting to see blood, scars, or pick scabs
• Wanting the familiar ritual of self-harm

Find more alternatives

If your SI is so impulsive that you find you’ve done it before you’ve even thought about this list, take a look at the prevention strategies.

Angry, Frustrated, Restless

Try something physical and violent, something not directed at a living thing:

• Slash an empty plastic soda bottle or a piece of heavy cardboard or an old shirt or sock.
• Make a soft cloth doll to represent the things you are angry at. Cut and tear it instead of yourself.
• Flatten aluminium cans for recycling, seeing how fast you can go.
• Hit a punching bag.
• Use a pillow to hit a wall, pillow-fight style.
• Rip up an old newspaper or phone book.
• On a sketch or photo of yourself, mark in red ink what you want to do. Cut and tear the picture.
• Make Play-Doh or Sculpey or other clay models and cut or smash them.
• Throw ice into the bathtub or against a brick wall hard enough to shatter it.
• Break sticks.

I’ve found that these things work even better if I rant at the thing I am cutting/tearing/hitting. I start out slowly, explaining why I am hurt and angry, but sometimes end up swearing and crying and yelling. It helps a lot to vent like that.

Crank up the music and dance.

Clean your room (or your whole house).

Go for a walk/jog/run.

Stomp around in heavy shoes.

Play handball or tennis.

Sad, Soft, Melancholy, Depressed, Unhappy

Do something slow and soothing, like taking a hot bath with bath oil or bubbles, curling up under a comforter with hot cocoa and a good book, babying yourself somehow. Do whatever makes you feel taken care of and comforted. Light sweet-smelling incense. Listen to soothing music. Smooth nice body lotion into the parts or yourself you want to hurt. Call a friend and just talk about things that you like. Make a tray of special treats and tuck yourself into bed with it and watch TV or read. Visit a friend.

Numb, Unreal, Craving Sensation/Pain, Dissociating

Do something that creates a sharp physical sensation:

• Squeeze ice hard (this really hurts). (Note: putting ice on a spot you want to burn gives you a strong painful sensation and leaves a red mark afterward, kind of like burning would.)
• Bite into a hot pepper or chew a piece of ginger root.
• Rub liniment under your nose.
• Slap a tabletop hard.
• Snap your wrist with a rubber band.
• Take a cold bath.
• Stomp your feet on the ground.
• Focus on how it feels to breathe. Notice the way your chest and stomach move with each breath.

Note: Some people report that being online while dissociating increases their sense of unreality; be cautious about logging on in a dissociative state until you know how it affects you.

Wanting Focus

Do a task (a computer game like tetris or minesweeper, writing a computer program, needlework, etc) that is exacting and requires focus and concentration.

Eat a raisin mindfully. Pick it up, noticing how it feels in your hand. Look at it carefully; see the asymmetries and think about the changes the grape went through. Roll the raisin in your fingers and notice the texture; try to describe it. Bring the raisin up to your mouth, paying attention to how it feels to move your hand that way. Smell the raisin; what does it remind you of? How does a raisin smell? Notice that you’re beginning to salivate, and see how that feels. Open your mouth and put the raisin in, taking time to think about how the raisin feels to your tongue. Chew slowly, noticing how the texture and even the taste of the raisin change as you chew it. Are there little seeds or stems? How is the inside different from the outside? Finally, swallow.

Choose an object in the room. Examine it carefully and then write as detailed a description of it as you can. Include everything: size, weight, texture, shape, color, possible uses, feel, etc.

Choose a random object, like a paper clip, and try to list 30 different uses for it.

Pick a subject and research it on the web.

Wanting to See Blood, Scars, or Pick Scabs

Draw on yourself with a red felt-tip pen.

Take a small bottle of liquid red food coloring and warm it slightly by dropping it into a cup of hot water for a few minutes. Uncap the bottle and press its tip against the place you want to cut. Draw the bottle in a cutting motion while squeezing it slightly to let the food color trickle out.

Draw on the areas you want to cut using ice that you’ve made by dropping six or seven drops of red food color into each of the ice-cube tray wells.

Paint yourself with red tempera paint.

Get a henna tattoo kit. You put the henna on as a paste and leave it overnight; the next day you can pick it off as you would a scab and it leaves an orange-red mark behind.

Wanting the Familiar Ritual of Self-Harm

Go through your “ritual” doing everything but self-injuring. This means that you go through the motions of preparing to self-harm, you unpack your tools, your bandages, you get the right music, or whatever it is you find yourself doing while you hurt yourself, and then, at the moment when you would normally start self-injuring, you pack it all away. You can do this again and again until the urge leaves you. (From FirstSigns: “Everything But” Rule.)

Some people also find it helpful to bandage themselves as if they’d self-injured.

More Alternatives

These pages also offer suggestions of things to do instead of self-harm:

Distractions
Techniques and strategies to help you distract yourself when you feel like self-harming.

Getting Through a Crisis
Ideas taken from DBT therapy.

Spank the Monkey!
Just for fun… but this and other games on AddictingGames.com can be an excellent way of distracting yourself from the urge to self-harm!

(Image: Francesco Marino / FreeDigitalPhotos.net.)

Many people who self-harm have no idea why they’re doing it. They just know they get uncontrollable urges to hurt themselves. They may worry that they’re “crazy”, or feel very upset and angry with themselves for not being able to control their behaviour. Friends and family members can also be baffled by self-harm, and not know how best to help.

This page looks at some of the most common reasons why people hurt themselves. It discusses the needs that self-harm might be meeting and how those needs can be met in other ways.

There’s Always a Reason

If you self-harm, you probably have good reasons for doing so. People don’t hurt themselves “just because”, or in order to be a nuisance to others. Self-harm is usually a way of coping with painful emotions. It may reduce those emotions, help you express them, or just help you function better in spite of them.

Below is a list of common reasons why people self-harm. Read through them, and see if any apply to you. If you’re not sure, think back to recent occasions when you’ve harmed yourself. What were the circumstances that lead up to the self-harm? How did you feel before and afterwards?

Common reasons why people self-harm

• to calm down when anxious, angry, overwhelmed, or tearful
• to replace emotional pain with something physical that you know how to deal with
• to release painful feelings, or take the edges off them, so you can function normally
• to prevent yourself from taking anger out on other people or hurting them
• to distract yourself from other problems in your life
• to slow things down when the world seems to be spinning too fast, or when your thoughts are racing out of control
• to help yourself focus
• to punish yourself, when you hate yourself or feel guilty, ashamed or inadequate
• to keep happiness under control, if feeling happy seems alien to you, or if you know there will be a come-down
• to feel something instead of being numb, to prove that you’re alive or make yourself feel real
• to get in touch with your emotions
• to stop yourself from dissociating
• to make yourself dissociate so you can escape from your problems for a while
• as part of a ritual that helps you feel safe
• to express or communicate how you’re feeling (to yourself or others)
• to prove to yourself or others that something is wrong
• to express how much you hate your body
• to help yourself get to sleep
• to prevent nightmares
• to stop flashbacks
• to stop hearing voices
• to take care of yourself by dressing the wounds afterwards – as an “excuse” to look after yourself
• to be taken care of by others (for example, when having your wounds treated)
• to make others notice you and your problems
• to be in control of something in your life, when everything else seems out of control
• to have a secret that others don’t know about, something that is just for you
• to prove that you can cope with the pain
• because you feel anxious or freaked out if you don’t do it regularly

Exercise: Print off the list of common reasons for self-harm, or copy it into your journal. Mark those items that you think apply to you. Now add anything else that you get out of self-harm. Try to be as specific as possible. For example, instead of “to help me cope with sexual abuse”, you might put, “to punish myself when I feel dirty”, “to stop flashbacks of the abuse” and/or “to be in control of who’s hurting me”.

What if you’re still not sure why you hurt yourself? Try not to worry about it too much. There are many things you can do to help yourself even if you don’t understand why you’re self-harming – take a look at our other self-help pages for ideas. You could also try keeping a self-harm journal where you make a note of what lead up to the self-harm and how you felt before, during and afterwards – this will help you spot patterns. A therapist might also be able to help you understand what you get out of self-harm.

Meeting Needs in Healthier Ways

Once you understand the reasons for your self-harm and the needs it meets, you can start to think about meeting those needs in healthier ways. Here are a few examples:

Exercise: Look again at the reasons why you hurt yourself. Now take one of those needs and brainstorm how you could meet it in other ways. If you get stuck, why not ask for help on our forums? You might also benefit from a therapist’s help.

Further Information

The cycle of self-injury Diagram and description of a typical self-harm “cycle”, from a UK expert.

Why is it so hard to stop? This article hopes to shed some light on the reasons it is so difficult to stop self-harming.

(Image: Graur Codrin / FreeDigitalPhotos.net)

Reproduced from Secret Shame (Self-Injury Information and Support).

If the whole concept of a disorder in which people deliberately inflict physical harm on themselves confuses you, or if you’ve been doing this for a while and never realized that it’s recognized as a valid psychological problem all by itself, then this page is a good place to start learning about self-injury.

What self-injury is — and isn’t

You’ll hear it called many things — self-inflicted violence, self-injury, self-harm, parasuicide, delicate cutting, self-abuse, self-mutilation (this last particularly seems to annoy people who self-injure). Broadly speaking, self-injury is the act of attempting to alter a mood state by inflicting physical harm serious enough to cause tissue damage to your body. This can include cutting (with knives, razors, glass, pins, any sharp object), burning, hitting your body with an object or your fists, hitting a heavy object (like a wall), picking at skin until it bleeds, biting yourself, pulling your hair out, etc. The most commonly seen forms are cutting, burning, and headbanging. “Tissue damage” usually refers to damage that tears, bruises, or burns the skin — something that causes bleeding or marks that don’t go away in a few minutes. A mood state can be positive or negative, or even neither; some people self-injure to end a dissociated or unreal-feeling state, to ground themselves and come back to reality.

It’s not self-injury if your primary purpose is:

• sexual pleasure
• body decoration
• spiritual enlightenment via ritual
• fitting in or being cool

The sort of self-injury this site discusses is repetitive self-harm. People learn that hurting themselves brings them relief from some kinds of distress and turn to it as a primary coping mechanism.

Calling it self-mutilation often angers people who self-injure. Other terms (self-inflicted violence, self-harm, self-injury) don’t speak to motivation. They simply describe the behavior. “Self-mutilation” implies falsely that the primary intent is to mark or maim the body, and in most cases this isn’t so.

Why does self-injury make some people feel better?

There are a few possibilities, and the answer is probably a mixture of them. Biological predisposition, reduction of tension, and lack of experience in dealing with strong emotions are all factors.

It reduces physiological and psychological tension rapidly.

Studies have suggested that when people who self-injure get emotionally overwhelmed, an act of self-harm brings their levels of psychological and physiological tension and arousal back to a bearable baseline level almost immediately. In other words, they feel a strong uncomfortable emotion, don’t know how to handle it, and know that hurting themselves will reduce the emotional discomfort extremely quickly. They may still feel bad (or not), but they don’t have that panicky jittery trapped feeling; it’s a calm bad feeling.

This explains why self-injury can be so addictive: It works. When you have a quick, easy way to make the bad stuff go away for a while, why would you want to go through the hard work of finding other ways to cope? Eventually, though, the negative consequences add up, and people do seek help.

Some people never get a chance to learn how to cope effectively.

We aren’t born knowing how to express and cope with our emotions — we learn from our parents, our siblings, our friends, schoolteachers, — everyone in our lives. One factor common to most people who self-injure, whether they were abused or not, is invalidation. They were taught at an early age that their interpretations of and feelings about the things around them were bad and wrong. They learned that certain feelings weren’t allowed. In abusive homes, they may have been severely punished for expressing certain thoughts and feelings. At the same time, they had no good role models for coping. You can’t learn to cope effectively with distress unless you grow up around people who are coping effectively with distress. How could you learn to cook if you’d never seen anyone work in a kitchen?

Although a history of abuse is common among self-injurers, not everyone who self-injures was abused. Sometimes, invalidation and lack of role models for coping are enough, especially if the person’s brain chemistry has already primed them for choosing this sort of coping.

Problems with neurotransmitters may play a role.

Just as it’s suspected that the way the brain uses serotonin may play a role in depression, so scientists think that problems in the serotonin system may predispose some people to self-injury by making them tend to be more aggressive and impulsive than most people. This tendency toward impulsive aggression, combined with a belief that their feelings are bad or wrong, can lead to the aggression being turned on the self. Of course, once this happens, the person harming himself learns that self-injury reduces his level of distress, and the cycle begins.

What kinds of people self-injure?

Self-injurers come from all walks of life and all economic brackets. People who harm themselves can be male or female; gay, straight, or bi; Ph.D.s or high-school dropouts (or high-school students); rich or poor; from any country in the world. Some people who SI manage to function effectively in demanding jobs; they are teachers, therapists, medical professionals, lawyers, professors, engineers. Some are on disability. Their ages range from early teens to early 60s, maybe older and younger. In fact, the incidence of self-injury is about the same as that of eating disorders, but because it’s so highly stigmatized, most people hide their scars, burns, and bruises carefully. They also have excuses to pull out when someone asks about the scars (there are a lot of really vicious cats around).

Aren’t people who would deliberately cut or burn themselves psychotic?

No more than people who drown their sorrows in a bottle of vodka are. It’s a coping mechanism, just not one that’s as understandable to most people and as accepted by society as alcoholism, drug abuse, overeating, anorexia, bulimia, workaholism, smoking cigarettes, and other forms of problem avoidance are.

Okay, then isn’t it just another way to describe a failed suicide attempt?

NO. People who inflict physical harm on themselves are often doing it in an attempt to maintain psychological integrity — it’s a way to keep from killing themselves. They release unbearable feelings and pressures through self-harm, and that eases their urge toward suicide. And although some people who self-injure do later attempt suicide, they almost always use a method different from their preferred method of self-harm. Self-injury is a maladaptive coping mechanism, a way to stay alive. Unfortunately, some people don’t understand this and think that involuntary commitment is the only way to deal with a person who self-harms. Hospitalization, especially forced, can do more harm than good.

Can anything be done for people who hurt themselves?

Yes. This site has a variety of self-help ideas, as well as some advice for family and friends of those who self-injure. Research into medications that stabilize mood, ease depression, and calm anxiety is being done; some of these drugs help people stop their self-harm. Many therapeutic approaches have been and are being developed to help self-harmers learn new coping mechanisms and teach them how to start using those techniques instead of self-injury. They reflect a growing belief among mental-health workers that once a client’s patterns of self-inflicted violence stabilize, real work can be done on the problems and issues underlying the self-injury.

This does not mean that patients should be coerced into stopping self-injury. Any attempts to reduce or control the amount of self-harm a person does should be based in the client’s willingness to undertake the difficult work of controlling and/or stopping self-injury. Treatment should not be based on a practitioner’s personal feelings about the practice of self-harm.

Self-injury brings out many uncomfortable feelings in people who don’t do it: revulsion, anger, fear, and distaste, to name a few. If a medical professional is unable to cope with her own feelings about self-harm, then she has an obligation to herself and to her client to find a practitioner willing to do this work. In addition, she has the responsibility to be certain the client understands that the referral is due to her own inability to deal with self-injury and not to any inadequacies in the client.

People who self-injure do generally do so because of an internal dynamic, and not in order to annoy, anger or irritate others. Their self-injury is a behavioral response to an emotional state, and is usually not done in order to frustrate caretakers. In emergency rooms, people with self-inflicted wounds are often told directly and indirectly, that they are not as deserving of care as someone who has an accidental injury. They are treated badly by the same doctors who would not hesitate to do everything possible to preserve the life of an overweight, sedentary heart-attack patient.

Doctors in emergency rooms and urgent-care clinics should be sensitive to the needs of patients who come in to have self-inflicted wounds treated. If the patient is calm, denies suicidal intent, and has a history of self-inflicted violence, the doctor should treat the wounds as they would treat non-self-inflicted injuries. Refusing to give anesthesia for stitches, making disparaging remarks, and treating the patient as an inconvenient nuisance simply further the feelings of invalidation and unworthiness the self-injurer already feels. Although offering mental-health follow-up services is appropriate, psychological evaluations with an eye toward hospitalization should be avoided in the ER unless the person is clearly a danger to his/her own life or to others. In places where people know that self-inflicted injuries are liable to lead to mistreatment and lengthy psychological evaluations, they are much less likely to seek medical attention for their wounds and thus are at a higher risk for wound infections and other complications.

Copyright 1998, Deb Martinson. Reproduction and distribution of this page is enthusiastically encouraged, especially distribution to medical personnel.

(Image: M Bartosch / FreeDigitalPhotos.net)