Alternatives to SI

Many people try substitute activities as described above and report that sometimes they work, sometimes not. One way to increase the chances of a distraction/substitution helping calm the urge to harm is to match what you do to how you are feeling at the moment.

First, take a few moments and look behind the urge. What are you feeling? Are you angry? Frustrated? Restless? Sad? Craving the feeling of SI? Depersonalized and unreal or numb? Unfocused?

Next, match the activity to the feeling. A few examples:

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 aluminum 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.

Craving sensation, feeling depersonalized, dissociating, feeling unreal

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.)
• Put a finger into a frozen food (like ice cream) for a minute.
• 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.]

You want attention or people to focus on you:

• 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.

If you want to see blood:

• 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.

If you want to see scars or pick scabs

• 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.
• Another thing that helps sometimes is the fifteen-minute game. Tell yourself that if you still want to harm yourself in 15 minutes, you can. When the time is up, see if you can go another 15. I've been able to get through a whole night that way before.

I tried all of that. I still want to hurt myself.

• Sometimes you will make a good-faith effort to keep from harming yourself but nothing seems to work. You've slashed a bottle, your hand is numb from the ice, and the urge is still twisting you into knots. You feel that if you don't harm yourself, you'll explode. What now?
• Get out the questions below. It's a good idea to have several copies of these printed out and ready to use; you can also answer them online; your responses will be mailed privately to you and no one will see them except you.

Answer these as honestly and in as much detail as you are able to right now. No one is going to see the answers except you, and lying to yourself is pretty pointless. If, in all honesty, you see no other answer to #8 but yes, then give yourself permission, but set definite limits. Do not allow the urge to control you; if you choose to give in to it, then choose it. Decide beforehand exactly what you will allow yourself to do and how much is enough, and stick to those limits. Keep yourself as safe as you can while injuring yourself, and take responsibility for the injury.

The questions:

1. Why do I feel I need to hurt myself? What has brought me to this point?
2. Have I been here before? What did I do to deal with it? How did I feel then?
3. What I have done to ease this discomfort so far? What else can I do that won't hurt me?
4. How do I feel right now?
5. How will I feel when I am hurting myself?
6. How will I feel after hurting myself? How will I feel tomorrow morning?
7. Can I avoid this stressor, or deal with it better in the future?
8. Do I need to hurt myself?

Staying safe while hurting yourself

A few things to keep in mind should you decide that you do need to hurt yourself:

• Don't share cutting implements with anyone; you can get the same diseases (hepatitis, AIDS, etc) addicts get from sharing needles.
• Try to keep cuts shallow. Keep first aid supplies on hand and know what to do in the case of emergencies.
• Do only the minimum required to ease your distress. Set limits. Decide how much you are going to allow yourself to do (how many cuts/burns/bruises, how deep/severe, how long you will allow yourself to engage in SI), keep within those boundaries, and clean up and bandage yourself later. If you can manage that much, then at least you will be exerting some control over your SI.

What is "fake pain" and why does it matter?

The concept of "fake pain" helps to explain why distress-tolerance skills are so crucial. Observation of myself and interviews with others have convinced me that one of the reasons people self-injure is to deflect unknown, frightening pain into understandable, sort-of-controllable "pseudo" or "fake" pain. Calling this phenomenon "fake pain" is in no way intended to suggest that it doesn't hurt; it hurts like hell. When memories or thoughts or beliefs or events are excessively painful, instead of facing them directly and feeling "genuine" pain, we sometimes deflect distress into pain that seems understandable and controllable, like that of self-injury. The real feelings associated with the event you're avoiding get overridden by those of the situation you create to distract yourself. It still hurts like hell, but it's a controllable familiar hell, whereas the real pain you're avoiding seems scary and poised to take over your world like the monster who ate Detroit.

It's easy to revert to "fake" pain. Trying to find the source of your distress can be scary as hell, because you often don't know what you're going to unleash. Fake pain, although very painful and traumatic, is something that you understand and can control and can handle. It's familiar, not mysterious and scary like the real pain behind it. You might feel that if you ever exposed yourself to the real pain you'd lose control: "If I ever start crying, I'll never stop" or "If I let myself get mad about that, I'll never stop screaming."

Instead, you unconsciously deflect the distress away from the memories or feelings that generated it and into self-injury. SI is seductive: you control it. You know the boundaries, even when you feel out of control. It makes sense and it makes the distress go away, at least for a while. It's a clever mechanism -- it takes what seems unbearable and transforms it into something you can control. The only problem is that when you deflect pain, you never face up directly to what it is that has caused this much tumult in your life. So long as you channel distress into fake pain, you never deal with the real pain and it never lessens in intensity. It keeps coming back and you have to keep cutting.

You have to deal with the unbearable if you ever want to make it lose its power over you. Every time you can meet the real pain head-on and feel it and tolerate the distress, it loses a little of its ability to wipe you out and eventually it becomes just a memory. The process is like building tolerance to a drug. Narcotics users take a little bit more of their drug every day as tolerance builds, until eventually they're routinely taking amounts of drug that would kill an ordinary person. The poisonous events in your past work in a similar way. Exposure (with the help of a trained therapist) over time will build your tolerance to these events and enable you to lay them to rest. The key is learning to tolerate distress.

DBT-related skills

Marsha Linehan's Skills Training Manual has several helpful worksheets for getting through crisis situations. Though they are best used as part of a DBT program with a trained therapist, you might find some of them helpful.

Accepting Reality

This concept focuses on learning to accept reality as it is. Accepting it doesn't mean you like it or are willing to allow it to continue unchanged; it means realizing that the basic facts of the situation are even if they aren't what you'd like them to be. Without this kind of radical acceptance, change isn't possible.

Letting Go of Emotional Suffering

In this worksheet, you learn ways to observe and describe your emotion, separate yourself from it, and let go of it. One of Linehan's basic principles is that emotion loves emotion, and this worksheet is designed to help you experience your emotions with amplifying them or get caught in a feedback loop.

Distraction

Distraction is simply doing other things to keep yourself from self-harming. Most of the techniques mentioned above are distraction techniques; you bring something else in to change the feeling. Using ice, rubber bands, etc, is substituting other intense feelings for the self-injury. Other things Linehan suggest substituting include experiences that change your current feelings, tasks (like counting the colors you can see in your immediate environment) that don't require much effort but do take a great deal of concentration, and volunteer work.

Improve the Moment

This worksheet focuses on ways to make the present moment more bearable. It differs from distraction in that it's not just a diverting of the mind but a complete change of attitude in the moment.

Evaluating the Pros and Cons of Tolerating Distress

As the name implies, this worksheet leads you through an evaluation: what are the benefits of doing this self-harming thing? What are the benefits of not doing it? What are the bad things about doing it? About not doing it? Sometimes writing this down can help you make a decision not to harm.

Self-Soothing

This, like improving the moment and distracting, is a distress tolerance technique. It's pretty straightforward: use things that are pleasing to your senses to soothe yourself. Some people find that active distraction works better for violent angry feelings and soothing is more effective for soft, sad ones.

Reducing Vulnerability to Negative Emotion

Prevention of states in which you are likely to self-harm is covered in this worksheet, which suggests ways of taking care of yourself in order to minimize the times when you feel the urge to hurt yourself. If you're balancing eating, sleeping, and self-care, you're less likely to be overwhelmed by emotion.

Interpersonal Effectiveness

Being clear about what you want and about your priorities in an interaction are crucial to good communication, and this worksheet offers a series of questions and steps to follow to help you determine how to approach a difficult interpersonal interaction. It is truly amazing how much going through these steps can help.

More information about Dialectical Behavioral Therapy can be found at DBT-Seattle.

Bristol Crisis Service for Women

Bristol Crisis Service for Women is the leading UK (and as far as I know, European) support organization for women who self-harm. They offer a confidential help line, publications for self-harmers and for professionals, and other services. They're empathetic, dedicated and a valuable resource for women in the UK and Europe. Check out their Women and Self-Injury leaflet.

S.A.F.E.

In 1984 Karen Conterio (then of Hartgrove) established a support group for self-injurers called SAFE (Self-Abuse Finally Ends). SAFE groups were not like 12-step groups or most self-help groups; they were short-term groups run by a professional facilitator. SAFE no longer offers these groups, but they do have a 30-day inpatient program; more details are on the resources page. SAFE operates on the belief that the underlying emotional conflict is the primary problem, not the self-injury. More information about SAFE can be obtained at 1-800-DONTCUT.

I stopped a while ago, but I keep thinking about hurting myself. Help?

It's not uncommon for people to continue thinking obsessively about self-injury for a while after they've made the decision to stop. Hurting yourself has been a huge part of your life up until recently, and you're used to dwelling on it. You might think that you're supposed to be "cured" now and that all thoughts of SI should magically vanish from your head, so when you catch yourself thinking about that blade or lighter or whatever, you get angry and frustrated and shove the thought away.

Foa and Wilson (1991) deal with intrusive thoughts by a combination of giving yourself permission to think about it and exposure/habituation techniques combined with ritual prevention. Exposure refers to repeatedly presenting someone with the situation about which they obsess, and habituation happens when, after much exposure without resulting to usual actions, the person gets used to the situation and it no longer distresses them.

To adapt these techniques, first make yourself safe. If you're in a mind-set in which self-injury seems very very likely, it might be better to use distraction techniques to get past that place. Line up a support person whom you can call if you get overwhelmed by this technique. Try to tolerate it for as long as you can, even if you're uncomfortable.

First, designate two 10- or 15-minute time periods daily. Choose times when you will be alone and able to think without being interrupted. To begin, set a timer for the designated amount of time. Then obsess about hurting yourself. Think about what it would feel like, how you would feel afterwards, how much you want to do this -- all those thoughts you've been trying to suppress. Get as distressed as you can, and stay focused on the topic of injuring yourself. You may find, especially after the first few times, that you get really bored toward the end of your time period. That's a good sign -- you're becoming habituated.

When the time is up, stop thinking about SI. If thoughts of wanting to harm come into your mind at other times during the day, acknowledge them and remind yourself that you will think about them later, when it's time. Then let them go. If they come back, repeat the process. Don't shove them away or try to ignore them; just acknowledge, remind yourself they have their time soon, and let go.

After a week or so you will notice an improvement (maybe even after just a few days). One crucial thing: no matter what, do not act on the thoughts of SI. They are just thoughts, and you can use the skills that you used to stop harming to get through these times. In order for habituation to occur, you have to get through the exposure without resorting to the old behavior. Use distraction and substitution for SI (ritual) prevention.