Scraping by Self-care writing for nonsuicidal self-injury: An exploration through fiction and social media Belinda Hilton BA, BA (Hons) School of Humanities Arts, Education & Law Griffith University Submitted in fulfilment of the requirements of the degree of Doctor of Philosophy June 2015
Abstract This project focuses on the confronting and often misunderstood behavior of self-injury. In various professional communities, multiple terms describe the behaviour including but not limited to: self-harm, deliberate self-harm (DSH), self-mutilation, self-injury, and nonsuicidal self-injury (NSSI) while definitions and classifications also vary. Awareness and understanding of the behaviour are growing: nonsuicidal self-injury was included in the DSM-V as a condition for further study (American Psychiatric Association 2013) providing guidelines for a possible diagnosis. The International Society for the Study of Self-Injury defines self-injury as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned (ISSS 2007/2015). However, ISSS and the DSM-V still note that self-injury can be a predictor of suicide risk (ISSS 2007/2015; American Psychiatric Association 2013). Self-injury is a maladaptive coping method employed to manage overwhelming emotions including sadness, anxiety and numbness (ISSS 2013) and has an average onset of mid-adolescence but can last well into adulthood (ISSS 2013). The behaviour remains stigmatised and as a result many individuals who self-injure may remain silent and not seek support. Therapeutic writing has been examined by researchers in the social sciences, creative arts and humanities. It is said to be a cost effective, readily available and accessible treatment option for a range of emotional, physical and mental health issues. Therapeutic writing is also said to return a sense of agency to the individual as they play a key role in their own treatment. This PhD submission asks: can a therapeutic writing process be devised that can assist those who self-injure in developing a system of self-care and support? This thesis investigates contemporary research into self-injury from selected psychology, sociology, cultural anthropology, communications and humanities perspectives and seeks to make sense of the behaviour through creative and academic approaches, research and practice. Drawing from the work of Hunt, Pennebaker and Murphy & Neilsen, it explores how a creative writing methodology and self-care process might be devised specifically to 1
aid self-injurers. As a creative writer with a history of nonsuicidal self-injury, I examine how my own creative practice can play a role in my on-going self-care. By fictionalising my experiences with both nonsuicidal self-injury and the underlying issues and experiences that motivate the behavior, in the novel Faint Impacts I aim to counteract the internal dialogue that leads to my self-injury and develop an increased sense of self-efficacy. The work seeks to devise not only a personalised and sustainable system of self-care for me as an individual but also to present a possible process for others to enact self-care writing as a practice. While exploring autobiographical fiction as an approach to self-care writing for NSSI, the project also investigates the possibilities of social media blogging. Contemporary research into the relationship between self-injury and the internet is examined to address issues that might arise for self-injurers when engaging with the medium and precautions that need to be taken when participating in online environments that discuss self-injury. In reflecting on my practice in utilising writing as self-care for NSSI as well as my understandings of my own experiences and self-injurious behaviour, the work seeks to address self-injury from an insider perspective, highlighting the potential for further research into self-care writing practices for NSSI, and discussing the need for further collaboration between different disciplines, mental health professionals and creative arts practitioners in addressing mental health issues. 2
Statement of Originality This work has not previously been submitted for a degree or diploma in any university. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made in the thesis itself. (Signed) Belinda Hilton 3
Contents Abstract 1 Statement of Originality 3 Acknowledgements 5 Publications arising from the dissertation 7 Exegesis 8 1. I want to hurt myself the experience of Nonsuicidal Self-Injury 8 2. Making sense of self-injury 12 3. Writing as self-care for NSSI 24 4. Creating Faint Impacts: an exploration of writing as self-care 36 5. With my finger on the trigger: writing with dangerous caution 44 6. Concerns over connect and share culture: NSSI-online 54 7. From scraping by to self-efficacy 66 List of References 70 Directory of self-injury and mental health online resources 82 Author s note 85 Creative product: Faint Impacts 86 4
Acknowledgments Discussions surrounding mental health issues often touch on feelings of loneliness and isolation, and raise the necessity for support from professionals, friends, family, work places and institutions alike. The same can be said of undertaking a PhD (and writing a novel). A PhD that discusses and reflects on one s own mental health can only be completed with a strong team of supporters with strong empathy, aptitude and patience. In the final year of my bachelor s degree I asked a lecturer a question about postgraduate study. That lecturer took the time to answer my question frankly and encouraged me to make it happen offering his service as a supervisor. Professor Nigel Krauth, my principal supervisor has continually offered me his frank advice, time and encouragement throughout my postgraduate studies. His wit, tolerance of panicked emails, keen eye for unnecessary full stops combined with his wealth of knowledge and experience have been indispensible throughout the PhD. Thank you Nigel for knowing when to nudge me in the right direction and when to let me find my own way. Many thanks must also go to my associate supervisor Dr Jason Nelson who has provided candid advice and unique encouragement during the PhD process. Thank you Jason for telling it like it is, asking the right questions and for giving your insights to academic life as a creative practitioner. Beyond my supervisory team there are numerous other staff members from Griffith University s School of Humanities (past and present) who have guided me, cheered me on and inspired me over the years. Firstly I must express my gratitude to Professor Stephen Stockwell and Dr Christine Feldman-Barrett for giving me the opportunity to teach within their courses. It has been a joy to sit in on your lectures and learn the ropes from you both. I also will be eternally grateful for the kindness, enthusiastic support and reassurances of Dr Stephanie Green and Ms Christina McKinley. Mentions must also go to Dr Amanda Howell, Associate Professor Patricia Wise, Associate Professor Ian Woodward, Dr Peter Denney, Dr Sue Lovell, Professor Paul Taçon, Dr Anthony Lawrence, Associate Professor Sarah Baker, Dr Sally Breen, Dr Marcus Waters, Professor Glen Finger, and Ms Lynn Canning for their helpful feedback, advice and friendliness over the years. I m grateful for the experiences I ve had attending conferences both in Australia and overseas and the many brilliant minds that I ve encountered while doing so notably the many members of the Australasian Association of Writing Programs (AAWP) as well as Professor Kerstin Shands and Guilia Grillo Mikrut from the Autobiography International conference 2014. Many thanks also go 5
to the associated peer reviewers, conference chairs and organising committees who have been instrumental in providing safe spaces and critical feedback for my work. My many thanks go to the PhD candidates now early career researchers who have left me breadcrumbs to follow: Dr Brady Robards, Dr Adele Pavlidis, Dr Chika Fujimoto and Dr Raphaël Nowak. To the numerous members of the School of Humanities HDR and creative writing communities it s been lovely to be part of such a vibrant environment! A huge teary thank you, a thousand hugs and my deepest gratitude go to Chantelle Bayes, Craig Garrett, Stefano Barone, Veronika Folkmanova and Robert Haubt who have been key supporters, amazing colleagues and dear friends... you are brilliant scholars who have kept me motivated and your support and friendship during this time has been awe inspiring. I look forward to cheering you all on as you cross the PhD finish line and to many future drinks, meals and good times shared. A thank you must go to emjaysquared aka, my parents, who have done well to both tolerate and indulge me (in general) but particularly over the past six years. Thank you to my friends (both long standing and recent) for their support and belief in me: Sam (and Harley), Renata, Georgia, Lauren, Joey, Zoe, Kylie and Krystle, you re all magic. I d also like to acknowledge those who have offered their support online through kind words, likes, follows and clicks. Thank you to Polly Chester for being a sounding board for my ideas and providing me insight from a human services perspective. To Erin and Jase, you have both been absolute champs in getting me through the fog thank you so very much for looking out for me. I m also thankful to the individual who has put a smile on my face for the last few months, kept me calm and taken my world in his stride you are appreciated. It is integral that I acknowledge the support that I have received from the Griffith University Counselling Service. This has been my best experience with professional mental health support to date. The skills that I have learnt and support that I have received from my counsellor here have been integral to both my well-being and my research and creative practice. Keep up the excellent work! Finally, to those who understand my experiences all too well, I hope you can find the kind of support that I have. I hope you can find what works for you, find clarity, and find a voice. I hope that you can take some comfort in my words. Take care of yourselves... you are worth it. 6
Publications arising from the dissertation Hilton, B. (2015). With my finger on the trigger: writing with dangerous caution. In G. Pittaway, A. Lodge, & L. Smithies, (Eds.), The minding the gap: writing across thresholds and fault lines papers the refereed proceedings from the 19 th conference of the Australasian Association of Writing Programs, 2014, Wellington NZ. Retrieved from: http://www.aawp.org.au/publications/minding-the-gap-writing-across-thresholds-andfault-lines/ Hilton, B. (in press). Expressing nonsuicidal self-injury: using creative writing and autobiographical fiction as self-care. In. K. Shands, G. Grillo Mikrut, D. Pattanaik, & K. Ferreira-Meyers, (Eds.), Writing the Self Approaches to Autobiography: English Studies 5. Södertörns hogskola, Stöckholm, (n. pag). 7
Exegesis 1. I want to hurt myself the experience of Nonsuicidal Self-Injury It was a craving so organic it seemed to have arisen from my skin itself. Imagining the sticky-slick scarlet of my own blood soothed me. This made no sense, yet it was the truth. (Kettlewell 1999, p. 13) The last two decades have seen a growing body of research into, and awareness of, self-injury, culminating in nonsuicidal self-injury (NSSI) being included as a condition for further study in the DSM-V (American Psychiatric Association 2013, p. 803). The inclusion marks a potential shift towards greater understanding of behaviour which has long been misunderstood. Self-injury has been historically interpreted as a suicide attempt and for some time was considered only a symptom of other mental illnesses such as Borderline Personality Disorder (Favazza 1998, p. 1). Accounts of self-injury were rarely discussed or represented in the media before the 1980s (Purington & Whitlock 2010, p. 12), and since then popular culture references have often resulted in the behaviour being viewed as a sub-cultural fashion statement and ridiculed as emo (Niwa & Madrusiak 2012 p. 12). Within society self-injury has often been interpreted as attention-seeking behaviour (Favazza 1987/1992, p. xxvi) further adding to the stigma surrounding it. Given the sense of misunderstanding that encircles self-injury, individuals who self-injure may not receive adequate support from family and friends (Murray & Fox 2006, p. 2) or may choose to keep their behaviour hidden from others (Hill & Dallos 2011, p. 466). It has been found that only a small percentage of those who enact deliberate self-harm willingly present at hospitals or mental health services (De Leo & Heller 2004, p. 140) be that due to fear of stigma or poor treatment or simply from shame or a lack of necessity on a practical level for medical interventions in wound care. The condition may continue for many years (American Psychiatric Association 2013, p. 804), meaning 8
long term support may be required which opens up questions as to the availability of support options, cost of access, types of support available and willingness of individuals to seek treatment. Our current clinical approach to treating self-harm is not enough. Too little is understood about the attitudes, practices, and daily lives of those engaged in self-harm and a cliniccentric approach to intervention fails to help those who are unwilling to seek help. (Boyd, Ryan & Leavitt 2010, pp. 28-29) Individuals who self-injure may find that they need to develop their own systems of self-care as they work towards seeking more positive and sustainable coping mechanisms. Taking into consideration that self-injurious behaviour can be associated with a sense of urgency and craving (American Psychiatric Association 2013, p. 804), creative or therapeutic writing may provide an immediate outlet to express negative emotions, such as tension, anxiety, and self-reproach (American Psychiatric Association 2013, p. 804) that influence self-injury and concededly reveal patterns of problematic thinking that need to be addressed. Writing is pretty nearly free; can be undertaken by anyone with ordinary writing skills, at any time of life, day or night; and, unlike physiotherapy or penicillin, does not need a professional to dispense or administer it. (Bolton 1998, p. 78) Writing may not be a cure-all, but can provide those who self-injure an additional outlet to enact self-care and bridge the gaps left from other forms of treatment and support. My research and writing on this topic are influenced by the fact that up to the present there have been two periods of my life where I have regularly employed self-injury as a coping mechanism, with the behaviour lasting for two or more years each time. The first period was during my late teens; the second began at the age of thirty during my first year of postgraduate study. It was the re-emergence of the behaviour after many years that led me to question the treatment options and recovery approaches offered to me earlier, and the shifts in perception of the behaviour in the near decade since I d first experienced it. 9
In Skin Game, Caroline Kettlewell s memoir about self-harm, she writes: I can no longer tell if I have/had real emotional troubles or if it is/was merely melodrama, I wrote in my journal, genuinely uncertain, as always, of the truth or fiction of my own feelings. (Kettlewell 1999, p. 138) When I began self-injuring yet again in my thirties, I struggled with the sense that I should know better. Like Kettlewell, I was unsure which thoughts and feelings were legitimate and which were fictions. Several months after I re-started self-injuring, despite having consulted with several health professionals and being medicated, I finally found a therapist who presented an alternative approach to my treatment. This therapist used the term stories to refer to the thoughts that led me to self-injure. It was the magic word to offer a creative writing academic struggling with her thinking. Acknowledging that the dark thoughts that entered my mind didn t necessarily need to be believed and acted upon, gave me a greater sense of agency to re-write my stories of self. With the therapist s support, as well as my supervisors, my PhD then became a concerted effort to investigate how I could use writing to cope with my coping mechanism. Beyond merely investigating the possibility of using writing as a therapeutic modality, being in the position of a postgraduate researcher has also enabled me to have access to more information on self-injury than I ve had previously. In section 2: Making sense of self-injury I take a closer look at self-injury, how it is defined including the variety of labels for the behaviour, and I seek to consolidate some of the available research to reach a better understanding of the behaviour. I will also share how my experiences parallel some of the research I ve encountered. Section 3: Writing as self-care for NSSI discusses why writing may be a useful practice for individuals who selfinjure. Here I look at research on therapeutic writing from a range of perspectives within the Humanities and Social Sciences. I discuss creative works from life-writing to fiction that tackle self-injury or mental health more broadly. Then I theorize my concept of writing as self-care specifically for self-injury. Section 4: Creating Faint Impacts: an exploration of writing as self- 10
care is where I discuss some of the choices I have made and experiences I have had in writing the creative project component of the PhD, Faint Impacts. I outline how I attempted to enact self-care writing in my practice and evaluate the success or benefits of the approach. Section 5: With my finger on the trigger: writing with dangerous caution raises some ethical considerations to writing about a sensitive topic in examining how the work may impact on the reader and how digital spaces approaches to self-injury may need to be considered by creative writers handling the topic. In section 6: Concerns over connect and share culture: NSSI-online I investigate self-injury on-line and look at why those who self-injure have long turned to the World Wide Web to discuss their behaviour. I look at some of the contemporary research into self-injury and social media, and I theorise how self-care writing may be applied to new communication technologies. Finally I reflect on my PhD experience investigating my own self-injury and NSSI more broadly in section 7: From scraping by to self-efficacy. While all care has been taken to handle the topic of self-injury carefully and sensitively it should still be noted that some readers may find this material upsetting or even triggering. At the end of the exegesis I have included a list of organisations which offer support or guidance for self-injury and mental health issues. The list contains a mix of government, volunteer, research-based and community outreach organisations. While many of the organisations are Australian operated, there are also several international organisations that can be found on-line. If you need immediate/crisis support please contact Lifeline Australia on 131114 11
2. Making sense of self-injury In 2012 I began self-injuring again. The following excerpts (as written, with spelling mistakes, etc included) are taken from my personal diary and refer to my return to the behaviour: May 16 th - I just self harmed. Scrapped nail scissors and made a scrap about inch long on my left ankle. Have put a bandaid on it was red but not quite bleeding. Stinging a little. May 18 th - Harmed last night successfully busted a razor out of a lady shave. Sliced three cuts on my left upper thigh. Also did a scissor scrape on my right ankle. Have covered all with bandaids. May 23 rd - Cut my legs and lower torso. Nine wounds all covered with bandaids. June 1 st - I bought a box cutter today. June 13 th - Harmed, worse than I have been. Four on the right ankle too large for bandaids [...] ugh its back. I can t cry the meds make you numb which aids the harm. [...] Cuts are stinging. Hope I don t get blood everywhere. Finding the right words Self-injury can be difficult to talk about not only due to the stigma attached to the behaviour but also because there are a barrage of terms and varied definitions used to describe it. Most mental health organisations within Australia use the term self-harm. Beyond Blue, Headspace, Reach out, Lifeline and Sane all use self-harm, however Beyond Blue includes the term self-injury in the title of its factsheet. Deliberate self-harm (DSH) is the term used by Australian academics such as De Leo & Heller (2004). However in 2013 the DSM-V proposed nonsuicidal self-injury (NSSI) as a condition for further study (American Psychiatric Association 2013) and the International Society for the Study of Self-injury which formed in 2005 uses both the terms self-injury and NSSI (ISSS 2015). When I first sought a label for my behaviour in the late nineties, self-mutilation was predominately used. Self-mutilation is the term used in Favazza s seminal work Bodies Under 12
Siege: Self-mutilation in Culture and Psychiatry (1987/1992), Strong s A Bright Red Scream: Selfmutilation and the Language of Pain (1998/2003) and Levenkron s Cutting: Understanding and Overcoming Self-Mutilation (1998/1999). During the course of my research I also came across the terms self-inflicted violence (SIV), self-injurious behaviour (SIB) and self-abuse. In less formal circles one may hear the behaviour referred to as cutting (as seen in the Levenkron title). The definitions listed for each term can vary slightly. The labels are used interchangeably by some and seen as uniquely different by others. Throughout the course of my research I have come to favour the terms nonsuicidal self-injury (NSSI) and self-injury. The International Society for the Study of Self-Injury defines self-injury as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned (ISSS 2007/2015). I favour the term nonsuicidal self-injury (NSSI) as it excludes behaviours involving the intent to die (ISSS 2007/205) and is the term and definition that I feel most closely relates to my own behaviour. The distinction refers to either an expressed absence of suicidal intent or understanding that the behaviour will result in only minor or moderate injury (American Psychiatric Association 2013). Researchers In-Albon, Ruf & Schmid state that NSSI differs from attempted suicide in the intent of the act, the methods and level of severity, and in the frequency of the action (In-Albon, Ruf & Schmid 2012, para. 3). Boyd, Ryan & Leavitt state the term self-harm is often used to refer to a category of practices that cause the body harm regardless of intention (e.g., cutting, eating disorders, and suicidal behaviour) (Boyd, Ryan & Leavitt 2010, p. 6). Martin, Swannell, Hazell, Harrison & Taylor note that: Many studies combine self-injury and suicide attempts together as deliberate self-harm. However, recent research suggests that there are clear differences between these behaviours in their correlates, responses to therapy and long-term outcomes. (Martin et al 2010, p. 506) 13
It is important to note, however that those who engage in NSSI are at an elevated risk to consider or attempt suicide (ISSS 2007/2015), and that NSSI and acts of self-injury can be a predictor of later suicide intent (In-Albon, Ruf & Schmid 2013, para. 3; American Psychiatric Association 2013, p. 805). While the term self-mutilation has fallen out of favour due to the extreme implications of the label, the differentiation between the terms self-harm/deliberate self-harm and nonsuicidal self-injury is important for greater understanding of the motivations behind the behaviour as well as for treatment approaches. In-Albon, Ruf & Schmid highlight the need for clarity in diagnosis for NSSI: Currently many patients with NSSI are officially diagnosed with their comorbid diagnoses or with BPD even without fulfilling all required criteria, although, NSSI is their main problem and therefore the main goal of psychotherapy should focus on NSSI. However, without an official diagnosis there is a discrepancy and intransparency between communication to the patient and the health insurance companies. (2013, para. 1) The Australian healthcare systems do not have the same issues regarding diagnosis and health insurance but the need for clarity in terminology and diagnoses remains in order to offer more tailored support to individuals exhibiting self-injurious behaviour. Self-injury: beyond sharp objects Different people have different ways of hurting themselves, and even those who cut themselves don t all do it the same way. There are many different techniques. (Leatham 2004, p. 31) Not all individuals who self-injure cut themselves, despite this being a well-known form of the behaviour (ISSS 2007/2015). The definitions refer to damage of bodily tissue or the skin s surface (ISSS 2007/2015; American Psychiatric Association, 2013). This damage may be done through cutting, hitting, burning, self-bruising, stabbing, scraping, rubbing, bone breaking, scratching and 14
so on (American Psychiatric Association, 2013; ISSS 2007/2015; In-Albon, Ruf & Schmid 2013, para. 30). In the study by Martin et al, half of the participants used one method of self-injury while other participants used two or more (2010, p. 508). The proposed criteria for Nonsuicidal Self- Injury as included in the DSM-V states that the damage may be likely to induce bleeding, bruising, or pain (American Psychiatric Association 2013). Self-harm and Deliberate Self-harm definitions often include a broader range of behaviours. The research conducted by De Leo & Heller into Deliberate Self-harm included behaviours such as overdose of medication, illicit drugs, hanging and sniffing/inhalation (2004, p. 141), while Failler noted that self-harm definitions may also include substance abuse and eating disorders (2008, p. 13). The DSM-V-proposed criteria suggested that Trichotillomania/hair-pulling disorder, Stereotypic self-injury such as head banging and self-biting associated with developmental delay, and Excoriation/skin-picking disorder should be considered as differential diagnoses along with Borderline personality disorder and Suicidal behaviour disorder (American Psychiatric Association 2013, pp. 805-806). The DSM-V also notes that the behaviour does not occur exclusively during psychotic episodes, delirium, substance intoxication, or substance withdrawal (American Psychiatric Association 2013, p. 803). Both Strong (1998/2003) and Favazza (1987/1992) cover broader forms of self-harm in their aforementioned books, with Strong s work featuring a chapter on eating disorders (pp. 114-135) and a chapter titled A walk on the wild side which discusses various forms of body modification as related to cultural practice as well as some discussion of sadomasochism relationships (pp. 136-157). Favazza s work documents cultural, religious and clinical forms of self-harm/self-mutilation. The DSM-V-proposed criteria for Nonsuicidal Self- Injury as well as the ISSS definition excludes behaviour which is socially sanctioned (e.g. bodypiercing, tattooing, part of a religious or cultural ritual) (American Psychiatric Association 2013, p. 803; ISSS, 2007/2015). So while an individual who self-injures may also be tattooed or engage in other socially sanctioned forms of bodily acts, the activities are undertaken with different 15
intentions. Likewise an individual who self-injures may be at risk of suicide but NSSI may not be undertaken with that intention. During my first period of self-injury the will to hurt myself became a regular part of life. I progressed from blunt, dull objects to razors and began scratching the blades against my skin until I bled. I did this frequently. My arms were the main body part upon which I inflicted damage but my thighs, calves and torso were also utilized. The injuries would be created slowly and steadily: I carved words into my skin, sometimes I pressed paper against my blooded skin to make butterfly prints of my body fluid, other times I photographed the wounds and used the imagery in my art. I knew what I was doing was unusual, it was different, but it also seemed to make sense to me. The use of sharp objects is listed under diagnostic features in the DSM-V proposed criteria, as are superficial burns from hot objects (e.g. cigarette burns) and friction rubbing. It is noted that A single session of injury might involve a series of superficial, parallel cuts separated by 1 or 2 centimetres on a visible or accessible location (American Psychiatric Association 2013, p. 804). The ISSS states that Hands, wrists, stomach, and thighs are commonly affected areas, though selfinjury can happen anywhere on the body (ISSS 2007/2015) while the DSM-V proposed criteria reference the frontal area of the thighs and the dorsal side of the forearm (American Psychiatric Association 2013, p. 804) as sites where NSSI occurs. My personal experience parallels these findings. NSSI has taken place on my arms including my wrists, dorsal and ventral forearms and upper arm; my legs including frontal and inner thighs, lower legs, ankles and the tops of my feet; my torso, hips and hypogastria region and underneath my breasts. The conscious decisions I make about where on my body to enact injury relate to my ability to conceal the wound, the sensation felt (i.e. some areas may be more painful), as well as how the wound will react (i.e. if the wound will bleed, scar, heal quickly, pull with movement). Glen & Klonsky studied the desire to see blood during NSSI and found that seeing blood served to relieve 16
tension (2010, p. 471). They theorised that the site of blood may enact physiological changes possibly in heart rate deceleration and that the desire to see blood may be linked to a marker for increased psychopathology, a more persistent course of NSSI, and consideration of more aggressive treatment strategies (Glen & Klonsky 2010, p. 471). NSSI thoughts can build over time. The DSM-V-proposed criteria note that there may be a period of preoccupation with the intended behaviour that is difficult to control or that NSSI thoughts may be repeatedly present without being acted upon (American Psychiatric Association 2013, p. 803). Such thoughts are often referred to as urges. LifeSIGNS, a user-led voluntary organisation based in the UK, use the term to describe NSSI thoughts: The Urge to self-injure builds up over a period of time, short or long. It builds up and up and crashes upon us, Urging us to seek relief (LifeSIGNS 2002/2015c). While the behaviour may be associated with urges and a recurrent desire that is hard to ignore, LifeSIGNS also notes that while self-injury can become habitual, it is generally driven by a psychological rather than a biological desire as in addiction, and that the use of the word addiction may complicate approaches to recovery (LifeSIGNS 2002/2015b). Reoccurring urges and NSSI-related thoughts can be very difficult to deal with. While the act itself is confronting, the desire to self-injure can be pervasive and impact daily function. As someone who experiences these thoughts, I can say that their occurrence can be alarming, upsetting but also quite simply strange. When NSSI thoughts are building, objects encountered in daily routines become considered for their sharpness or edges, there can be a sensation of tension under my skin, and I can at times visualize graphic images of the damage I would like to enact upon my body. These thoughts can be complicated to navigate, particularly when they are focused around an object. There have been times when I was able to see an object which is related to an urge, and wanted to hide the object from my view, but worried that touching the object would result in an act of self-injury. This becomes particularly complicated when the object serves a practical purpose or is in a communal or public space. The recurring desire to physically hurt your own body is in 17
conflict with general ideas of self-preservation. However, to those like me who self-injure rather than commit a wholly destructive act, self-injury is utilised as a way of coping. Understanding the motivations behind the act Most research suggests that NSSI begins in mid-adolescence (ISSS 2007/2015). Despite commonly held myths about gender predisposition, [t]he findings indicate that NSSI thoughts and behaviours are equally prevalent in young men and women, underscoring the importance of examining the predictors of NSSI in both genders. (Levesque, Lafontaine, Bureau, Cloutier & Dandurand 2010, p. 479) The International Society for the Study of Self-Injury state that on average the behaviour commences between the ages of 12 to 15 years (ISSS 2007/2015). Martin et al found a mean onset age of 17.2 years but also found participants who reported an onset after the age of 40, (2010, p. 508). My first occurrence of NSSI was at 15 but the behaviour didn t become habitual until I was 17 years old. At that stage I didn t know anyone else who hurt themselves for the same reasons that I did. In school I was aware of people branding themselves with heated disposable lighters, scratching designs into their skin with sharp objects then rubbing pen ink into the skin to create a tattoo, or piercing their ears with thumb tacks. All of these acts however were done with the clear intention of altering the body in an aesthetic way and were not repeated. During my first period of NSSI I met only one other individual who intentionally injured themself when upset, a male of the same age who had cut himself with razors on a couple of occasions. By the time I met him I had been injuring myself for several months. For me at least, self-injury was not learnt from friends. 18
Nor do I believe that it was it learnt from cultural influences. I liked music, clothing and movies that featured dark themes but these cultural products only spoke to pre-existing feelings within me. I felt like an outsider, I felt angry and upset and my taste in cultural products reflected these preexisting feelings. My self-injury was not a fashion choice or something I did to belong to a subculture. Why I was so unhappy, I m unsure. My senior years at high school saw a few incidents that may have contributed to my decline difficult social situations that led to a stressful school intervention, changes in my home life, the pressures of the final year of school and the anxieties of university applications. While the combination of these tensions was taxing, they were also no greater than any of the other hurdles being faced by my peers. For whatever reason though, I struggled to cope, and the way I chose to deal with my feelings of anger, isolation and unhappiness was to inflict injuries upon my body. Expectations motivating the engagement in self-injurious behaviour, as listed in the DSM-V s proposed criteria are: 1. To obtain relief from a negative feeling or cognitive state. 2. To resolve an interpersonal difficulty. 3. To induce a positive feeling state (American Psychiatric Association 2013, p. 803). Favazza states that an individual who practices NSSI seeks to feel better (1998, p. 4). The paradox of self-injury as a way to induce a positive feeling or obtain relief may be theorised as creating a physical wound that one can care for more easily than one s emotional distress (Klonsky & Glen 2009, p. 218). Physical pain and damage is seen as a more tangible and acceptable problem (Chandler 2012, p. 451). Physical wounds may provide a visible representation of healing. Much of the earlier literature I read on self-injury or self-harm more broadly discussed a relationship with traumatic childhood experiences. Books on the subject by Levenkron (1998/1999), Strong (1998/2003), Wegscheider Hyman (1999) and Miller (1994) contain case 19
studies and references to self-injury related to childhood sexual or physical abuse with part one of Miller s book titled: Traumas Reenacted (1994, p. 1). Failler discusses self-harm as an effort to manage the deep pain associated with trauma locally (Failler 2008, p. 16). Levesque, Lafontaine, Bureau, Cloutier & Dandurand discuss the theories of Interpersonal and Developmental models. Interpersonal models relates to early relationship disturbances such as maltreatment or inconsistent care-giving can contribute to the behaviour which may be provoked by any present interpersonal stressors such as relationship conflict or rejection (2010, pp. 474-475). The Developmental models relate NSSI to adverse childhood experiences, such as maltreatment and parental deprivation (Levesque et al 2010, p. 475). So while both models highlight problematic childhood experiences as contributing factors only one examines relationships and attachment issues as an ongoing factor. While traumas and maltreatment may feature in the personal histories of many documented case studies of self-injury they are absent from others. The trauma models do not fit my experiences of the onset of NSSI. The notion that I have no valid reason to justify my NSSI is something I have struggled with at times. In her memoir Skin Game, Kettlewell writes about her own experiences with this concern: Well, how many troubles should equal a legitimate reason for self-mutilation? Ten? Twenty? One hundred? And how monumental must these troubles be? There s probably no critical mass beyond which cutting yourself would ever seem, to most people, like a reasonable choice. (Kettlewell 1999, p. 60) LifeSIGNS states that anyone who has anything distressing to cope with might potentially turn to self-injury (LifeSIGNS 2002/2015d). Participants in the study conducted by Martin et al reported they used self-injury to manage emotions or to fulfil a need to self-punish (2010, p. 508). Chandler found that release, relief (from difficult emotional states) and control (of emotions) were terms used by participants in relation to their motivations for self-injury (2012, p. 448). Victor & Klonsky found that their participants exhibited a strong dissatisfaction with self (2013, p. 9). Beyond a 20
history of trauma and/or abuse, LifeSIGNS notes that individuals who self-injure may have difficulties related to low self-esteem, poor body image and/or pressure related to perfectionism and high achievement (LifeSIGNS 2002/2015d). My experiences with NSSI relate to feelings of inadequacy, a perceived need for self-punishment, control of emotions, as well as a sensation of numbness. Hyperstress and Dissociation are listed by LifeSIGNS as precursors to self-injury, with Hyperstress being related to overwhelming emotional states and Dissociation related to feelings of detachment from emotions, life, one s body, etc (LifeSIGNS 2002/2015a). Dissociation may be learnt from a need to detach from traumatic experiences (LifeSIGNS 2002/2015a). Strong writes about Dissociation and numbness associated with pent-up emotions: As kids, by and large, self-injurers were not allowed to have or express their own feelings especially anger (1998/2003, p. 44). In relation to my own NSSI, while at times the behaviour has been a reaction to Hyperstress-type situations, I more commonly experience feelings of numbness, flatness and a sensation of being detached emotionally prior to NSSI. I experience the behaviour as calming when it is a reaction to Hyperstress. When the behaviour is a reaction to numbness, it serves as a reminder of feeling. Both serve a purpose of getting on with it, which may relate to growing up in an environment and culture that (at one point in time at least) valued stoicism. Treating NSSI I can t remember what, at age seventeen, triggered me to tell a GP that I was hurting myself. For whatever reason, I did, and I was given a referral to a psychiatrist. While some self-injurers may need to seek medical assistance for wound care, in many studies research participants reported that they did not seek medical treatment. Solomon & Farrand note that seeking hospital treatment does not imply that the behaviour is out in the open, and may still be kept secret from friends and family 21
members (1996, p. 112). Martin et al found that only a third of their research participants had sought help despite talking about their behaviour with someone else: Although only a small percentage received medical help and very few were admitted to hospital, we estimate that, in the 4 weeks before our survey, more than 200 000 Australians self-injured, more than 30 000 sought medical help, and almost 5000 were admitted to hospital (assuming our sample is representative of the Australian population). (Martin et al 2010, p. 509) While I ve been fortune not to have negative experiences with treatment, I ve certainly had some that I remain neutral about. My first visit to a psychiatrist was underwhelming. The psychiatrist pointed to a glass of water on her desk and asked me if it was half full or half empty. I responded that there was half a glass. She repeated the question and I continued to give the same answer. The psychiatrist prescribed Fluvoxamine which I took in a liquid form as I was unable to swallow tablets. I had to keep a graph of my mood levels giving each day a score out of ten. We discussed alternative actions to self-injury like snapping a rubber band on my wrist or ripping up pieces of paper. I continued to see the psychiatrist and continued to take Fluvoxamine. I was already petite when I started taking medication and then experienced weight loss as a side effect. My collection of scars grew and my psychiatrist was discussing the possibility of putting me on Lithium alongside the Fluvoxamine. She offered me little explanation as to why I did these things, or why I felt the way I did; she simply focused on getting me to stop. Eventually I did (while the circumstances surrounding this were, on reflection, not an indication of recovery) and I thought I was better. I wasn t self-injuring. I didn t self-injure for approximately eight years, but then the NSSI thoughts started to build. By 2012 I had returned to self-injury behaviour. For many, self-injury is a maladaptive coping method that is periodically relied upon for a period of months or years, though for some it is used well into adulthood. (ISSS 2007/2015) 22
I have consulted with eight different health professionals about my mental health in the past fifteen years and have been medicated with antidepressants on three separate occasions. Since 2012 my longest period with an absence of NSSI has been five months. I have been un-medicated for the past two years. While the behaviour still feels like a possibility, I have a greater sense of agency over my behaviour and my mental health now than I have previously. There are two major reasons I attribute to this: first, finding the right mental health professional support; and second, the decision to not avoid thinking about NSSI or talking about NSSI, but instead to focus intently on doing the thinking and talking. I have been actively seeking out new ways of coping and working to better understand what feelings and beliefs I struggle to cope with. Andrews, Martin & Haskings suggest that treatment approaches to NSSI should take on a prevention and early intervention role where young people can be taught to manage negative emotions and develop improved coping skills (2012, p. 63), and Solomon & Farrand note that effective treatment requires an understanding of the meaning and context of the act of self-injury itself (1996, p. 112). This exegesis and the accompanying creative work seek to find an approach to coping with the coping mechanism. I am not looking for an alternative treatment that casts professional support or medical intervention into the wayside, I m not proclaiming that writing will replace self-injury, rather I am seeking an additional treatment that can bridge the gap when my therapist is not available and I don t feel up to calling a friend, or to postpone and minimize the act of self-injury. I m seeking not to replace these systems of coping but instead to provide an extra layer of support that is self-driven. 23
3. Writing as self-care for NSSI How much of the way we end up seeing ourselves is shaped by our own interpretations? When you construct a worldview on a series of misunderstandings, it s like building a skyscraper with the foundation out of plumb: a fractional misalignment at the bottom becomes a whopping divergence from true by the time you get to the top. (Kettlewell 1999, p. 23) Treating NSSI may involve a combination of medication and talking therapy of varying approaches. Replacement or placebo harms, such as snapping a rubber band against the wrist or holding ice cubes in the hand, may be suggested as ways to react to self-injury urges in an effort to replicate sensations without causing lasting damage. Individuals may sign no-cut contracts with their family or professional support systems. Temptations may be removed and triggers avoided in an effort to reduce the behaviour. However, medication can be fraught with side effects, while professional support can be costly and requires waiting time. Avoidance strategies that aim to replicate the sensation of the act do little towards moving beyond the behaviour. Removing triggers or adding additional pressure to cease the behaviour deliver little agency to the individual s abilities to cope without injury. With these limitations in mind, therapeutic writing may provide a suitable additional treatment option. A therapeutic writing practice may offer a readily available, cost efficient process of coping that returns a sense of agency to the individual to regulate their emotion affect without resorting to physical harms. Writing should by no means be considered a substitute for professional support or an alternative to taking medication. Writing may, however, be able to fill the gaps found in these forms of support. The writing cure 24
The therapeutic benefits of writing have been attested to, explored and researched by creative writing practitioners, social scientists and humanities scholars alike. Comprehensive reviews of the available literature have been published by Murphy & Neilsen (2008), Wright & Chung (2010) and Neilsen (2016). Neilsen (2016) surveys the literature associated with creative writing and recovery from severe mental illness where the construction of narrative might be central to the value of writing in recovery of identity (p. 78), writing as a means of repairing a fundamental flaw in symbolic functioning particularly examining the work of Lacan (p. 78), and writing as a form of cognitive remediation, where: The beneficial effects on cognition then flow through to functional advantages, which in turn yield benefits with respect to self-esteem and an enhanced sense of personal agency. (p. 79) He goes on to state that [t]he benefits of writing are likely to depend on the characteristics of the individual engaged in writing (p. 80). Wright & Chung describe approaches within the humanities as verging on the evangelical (2001, p. 278) while observing that the health sciences take the approach of trying to measure and control writing s affects (2001, p. 278). Murphy & Neilsen note that the theory and practice of writing as therapy presents a fascinating challenge for the discipline of creative writing (2008, p. 19), given its close relationship to what they refer to as the helping professions (2008, p. 7). The alignment they write on sees therapeutic writing approaches that are highly structured, based around writing exercises, guided by trained facilitators in workshops or in clinical contexts. Structured approaches are understandable when writing is employed as a therapeutic modality within a structured situation where evidence of its success may be necessary to justify financial investment or fulfil a controlled outcome and would also be beneficial within a class room scenario. However, for the individual creative writing practitioner, or more specifically for the individual seeking to utilise writing for some form of therapeutic benefit, such structured approaches may be at odds with the appeal of therapeutic writing in the first place. 25
Embarking upon an individual pursuit of writing with therapeutic purpose while perhaps less structured than formal, group-based or collaborative approaches still requires careful consideration. Professor of Psychology James W. Pennebaker has conducted extensive clinical research about writing s influence on health, and has published numerous works on his findings. Pennebaker s research found that despite the long term benefits to health, writing about difficult experiences left many participants feeling upset and anxious immediately following the act (2000, p. 6). He writes: These emotions, in many ways, can be viewed as appropriate to the topics the individuals are confronting (2000, p. 6). Any individual embarking on a self-practice should take the likelihood of ill-feeling seriously. They will need to consider if they have adequate support to cope with this discomfort, be that from a mental health professional (recommended) or socially from friends, family and loved ones. As previously stated, writing is not an alternative to a strong support base. When embarking on a writing practice for therapeutic purposes, professional support does not refer to a guided practice, but instead to a support figure with whom the writer can discuss any difficult feelings or confronting memories brought up by the practice. So, rather than being an alternative to professional support, the form of writing practice I m describing might be used to bridge the time between sessions with a therapist. Bolton states: Reflective and expressive writing is private and self-directed, and in principle available at any time to anyone with basic writing skills (1998, p. 79), and it is this ready availability that is particularly useful for individuals who self-injure. Another consideration for an individual embarking on their own therapeutic writing practice is how they will approach the work. Will they carefully construct fictional narratives, channel their emotions into poetry, write a daily journal, or pen a personal essay? Regardless of the format their words may take, according to Murphy & Neilsen, the importance remains on the process of writing, rather than the end product (2008, p. 16). Pennebaker discusses the basic considerations in developing an individualistic approach to writing for therapeutic benefit. He notes that when 26