Self-Harm v. Suicidal Thinking

Warning: This is a brutally honest description of some of my most destructive thoughts and behaviors. If you are in any type of emotional state right now that would leave you vulnerable to being triggered by this type of material, I’d recommend not reading this post. 

This post is something of an assignment, a question of J’s that I’ve been trying to develop an response to. How are self-harm and suicidal thoughts/gestures similar to me (if at all) and how are they different? I don’t even remember anymore why she asked, but I’m finally discovering my answer.

I find that it’s easiest for me to organize my thoughts by getting them down on paper. And now really seems like the best time to consider my response, considering in the past week I’ve had recurrence of both problems.

The way I experience it, my self-harm and my suicidal thoughts/behaviors are similar because they both reflect a high level of distress. For me to actively engage in either, my negative emotions will typically be at highest intensity and it will feel to me like those emotions are endless. In both cases, pain is often exacerbated by negative filtering, in the sense that I cannot seem to hold on to the experience of feeling well.  I am resistant to entertain any positive thoughts, especially those about myself.  I struggle greatly to recognize the progress I’ve made.

Hence, all that pain.

Self-harm is typically a reaction to something in the past that has created emotions of shame/guilt, worthlessness, or self-directed anger. I feel ashamed of something I have done wrong, angry at myself for a mistake I have made, so I think “I deserve to be punished.” Alternatively, I may think “I need to escape my pain” or “I need my pain to be visible” and if I’m feeling incredibly worthless I won’t value myself and my body enough not to resist those urges.

For me, self-harm has never been a direct means to end my life. I have not actively hurt myself with the intention that it would kill me in that moment. If I were going to follow through on an end of life plan, cutting would not be my ideal choice of action. However, as difficult as this is to admit knowing that J will read this, there have been a few times where I have cut shallowly at my wrist to see if I could handle the pain if I were to cut deeper the future. Almost like a test.

Suicidal thinking and gestures are typically by-products of self-harm, which means they equally follow shame and self-directed anger for past mistakes. I experience suicidal thoughts more in reference to the future than the past. There are accompanying thoughts of “I can’t live with myself for my past mistakes” (shame), “I am fundamentally flawed and will never get better,” (worthlessness) or “I am and will always be a stupid, terrible person who deserves to die” (anger).

However, where they differ is that I also experience suicidal ideation and planning in response to feelings of emptiness, anxiety, and sadness. The associated thoughts there are those such as “I cannot handle to continue feeling this alone” (emptiness), “I have so much fear at the idea of continuing to handle difficult situations like a job or relationship that I could fail at” (anxiety), or “I am feeling so low it is not worth living” (sadness).

It was interesting to parse that out. While some emotions seemed to me at the outset of this post like they have contributed to me hurting myself, I realized that they only do so when followed up by the previously listed anger, shame, and worthlessness as secondary emotions.

What I mean is this: While suicidal thinking is automatic to me when I am feeling sad or empty, I am not likely to actually hurt myself (or want to) because of those isolated feelings, but rather because I feel such intense anger at myself for my own actions that created the emptiness or because of my intense shame over how I’m handling my sadness.

There are a wider range of emotions that trigger the desire to die. This is unfortunate, because it feels like almost every negative emotion has very automatic suicidal thoughts attached to it, whereas my desire to hurt myself by cutting is more situation specific.

As such, I’ve found that while self-harm is usually combined with suicidal thoughts, suicidal thoughts may occur without even the impulse to hurt myself. My thoughts about suicide are much more frequent, recurring nearly daily even in some small form.

Interestingly, I’ve noticed the a difference in thoughts vs. actions. Both types of thoughts are out of my control, but the suicidal ones are harder to fight back against than thoughts about self-harm. Are my suicidal thoughts more common because they have always been harder to fight? Or are they harder to fight because they have always been so common and thus I’m worn out from dealing with them? Which came first, chicken or the egg?

Anyone’s guess, really.

If you’re talking only about action, I have noticed the actual impulse to self-harm is harder to ignore than suicidal planning. That urge is more fervent and lasts for longer.  I will feel an impulse to do both, but can and do put the latter off for much longer. For example, during a very difficult week I thought both about burning myself and writing out suicide notes that I had typed. I did hurt myself, but I didn’t do the notes. While my impulse to hurt myself grew with space, the impulse to plan suicide fizzled out. My motivation just disappeared.

Why? I’m not completely sure, but the first I thought I had is I regard self-harm as less problematic in a sense. In my head, the scars are trivial. They will heal, so what’s the big deal if I slip up? Obviously this is isn’t true, but I’ve been engaged in this behavior for so long I’m almost desensitized to it.

With suicidal gestures, it feels more grievous. I’m intricately aware of how final suicide would be, so any steps I take toward it, even if I feel the urge to do so, are scary. It’s a weird form of ambivalence pulling me in two different directions.

Maybe the part of me that believes there’s hope for the future and staying alive is larger or stronger than the part that believes I’m not deserving of punishment. I can’t say for sure, because I just can’t make complete sense of how I feel.

Both of these things are dangerous to me. They are similar in that way. Whether I’m hurting myself now or planning to hurt myself later, they only escalate my feelings and cause more distress. They reinforce themselves and have become super super hard habits to break. I know that. I want to move past them, but when the minions take hold I often feel overpowered and give in the impulses. I let them control me. I’m not proud of it, but it’s where we are at right now.

I don’t know how writing all this out with help J in our work together. Like I said, I can no longer remember what part of our conversation sparked the question. But it was an interesting thing to consider, I’ll give her that. I understand my motives and behaviors a little better.

Am I doomed to these urges? Maybe. Maybe not. What I believe right now about how things will end for me might not be what I believe in one or three or six months. I’m working hard for it to be different.

One thing is for sure. These are difficult desires to deal with and I keep that struggle so close, concealed from others for fear of judgment or failure to understand. I just want to be free of them. I just want to know what it’s like to truly value myself and my life enough to protect them.

 

 

 

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A DBT Flowchart

A few weeks ago, I posted about my confusion and frustration with figuring out when to use the abundance of new skills I was learning through my Dialectical Behavior Therapy workbook. I have tons and tons of notecards that simplify all of the information the book is spouting at me, but I needed something more comprehensive so that I can have an idea of where to go in the moment when a wave of emotions hits me hard.

I’ve been in a wonky place again for the last couple days and have pretty much been withdrawn from the blog world and the real world whenever I have the choice. The positive thing about that is while I’ve been hiding away from people, I’ve put all my energy into developing that needed flowchart.

I’m pretty happy with the results. Obviously, this is not a perfect system, as no issue is so black and white that it can be resolved by some arrows guiding you. However, I feel that it’s a worthy starting point for me that can replace some of that helpless feeling.

Hopefully you can read my handwriting. It’s broken down into color by unit (the colors I used when highlighting my book). Green is distress tolerance, blue is mindfulness, purple is emotion regulation, pink is interpersonal effectiveness.

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As anyone using DBT knows, there are many things that crop up when you’re trying to use skills which block you from being successful. I couldn’t fit all of that in one diagram, so I ended up with a second flowchart that specifically highlights some of the issues I typically run into.

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I don’t know if these will be helpful for anyone, but I wanted to share them. In a very rocky period as I look towards the beginning of my first real job, this has brought me a sense of calm and peace. There’s something about getting organized that makes me feel so empowered.

Reducing Sessions

The last week in therapy has been good. Not easy by any measure, but I’ve felt safe and contained while in that room. J and I have been working well together, a true team effort. I have felt like she has been attuned to my needs and I’ve been making efforts to talk about things even when they are difficult.

There’s a change coming though.

I’ve been seeing J twice a week for about three months now. It was an increase I had been dying to make and I was so happy to be able to do it once the demands of internship died down.

The first week of September, I’m going to have to go back to once a week sessions. This is the give and take of me choosing to stay with the girls as their babysitter in the afternoons. My schedule just won’t allow for anything else but that one day.

To say I’m dreading going back to once a week sessions would be an understatement. Yesterday, J told me that she has a conflict in her Monday schedule next week, meaning she’s out of the office all day. I have a conflict at my normal Thursday time, so we managed to find time on Wednesday. You’d think that would be a relief to me to see her at all, but all I could think was that this was supposed to be one of my last two weeks of double sessions. I left her office near tears and had to take a few minutes to let the emotion dissipate.

The truth is, I’ve been spoiled with the ability to see her twice a week and get that extra dose of support. To know that she’d be there twice a week, in spite of every awful feeling, was a huge relief. Even when things were difficult between us, I kept going. Going is always better than not going.

One session a week just does not feel like enough time anymore.

An hour is not enough time. It was, for over a year and a half, but now I’ve seen what it’s like to get twice that. I’ve felt the effects of having enough time to consult the DBT workbook and delve into the other things that are bothering me. Now, I feel like I’ll constantly be focused on the clock, worrying about how to fit everything in to that short little time period. Do we talk about skills or do we talk about something pertinent in my life? How do we find the space to give every subject the time it deserves?

Plus ugh, just thinking about having to contain all those big feelings for seven whole days. To pack them away and leave knowing it will be a whole week before I can let it out again. That used to feel like a fairly manageable period of time for me, but now I’m used to only three or four days. By comparison, a week feels endless.

Thank you to my attachment issues for that difficult feeling.

I almost wish I’d never taken on double sessions in the first place. Obviously, I don’t really wish that, because I’m grateful for the extra time I’ve gotten with J to work on things. I’m grateful I had the opportunity at all and the financial means to make it happen. I see the fruits of all those bonus sessions we had.

It’s just very hard. What I really wish is that I didn’t have to make this change on top of an already very taxing transition into a new job. I need J by my side for that more, not less.

I’ve tried thinking about ways to make up for what feels like a deficit. Seeing if there’s a way to do 90 minute sessions instead of 60. Asking for a 10 minute check-in another day during the week and paying for that time. I’ve already asked that if she’s able and willing to extend her hours so could do a double even once a month to let me know. That doesn’t feel particularly likely, but I figured it was worth a shot since I’ve seen her take people in the session after me before.

I’ll have to deal, because it’s not like there’s any other choice. I survived off of one session a week for a long time, so I’ll adapt back into that place. I know that I’ll be okay. I’m strong and I can handle carrying this myself. I’m persistent and I can keep fighting, even when it’s tough. I work hard and that will get me through the transition. I can be kind to myself in each day to my next session.

I don’t necessarily want to do any of that, but I can. I will be okay. I will be okay. I will be okay. I’m repeating that more to convince myself then to convince all of you.

But right now, it still feels like a huge loss.

 

 

Receiving Pain

One of the many confessions I made to J when everything came flooding out last week was that I see self-harm as a way of communicating pain. As in, when I’m feeling really really awful, one of the reasons I feel desire quelling within me to hurt myself is that I feel it clearly shows to her just how much hell it has been to live in my own mind that week.

I’ve nearly removed self-harm from my list of habits in about the last 2.5 months. There have been some slips, and what might be categorized as an “almost” harming event, but on the whole I’m not grabbing for my razor every other day (mostly because I threw it out). I’m working really hard at making better choices.

As such, I’ve noticed that when I am really fighting the urge, one of my recurrent thoughts is that I have to cut myself because if I don’t, how else will J understand just how deep and intense my pain was over the week? It’s like I believe words will not be enough to truly tell the story.

I’m not sure exactly where this need comes from. It’s not like J does anything over the top when I admit to her I’ve hurt myself. Typically, she’ll ask when and what triggered the incident. She may ask where I’ve cut. Often, we talk about replacement behaviors. Sometimes, we discuss safety. These are all run of the mill and none of them feel particularly validating. Not that they’re bad strategies, just that they don’t support me in a way that would encourage me to keep cutting to receive the attention.

When I wrote about this before, a fellow blogger who I really respect left me a comment that stated she was in a similar situation. What she and her therapist decided was to replace self-harm as a means of expressing severe pain with the urge to self-harm as an indicator of the same level of pain.

This idea seemed remarkably simple, but effective. I shared it with J. That strategy had been her first recommendation too. However, she wondered if I would truly be able to feel like my pain was understood or if the distinction between cutting and wanting to cut would still feel obvious to me. Would cutting still rank highest no matter what?

She’s probably right, I’m sure it would be a process to make the shift. But obviously continuing to hurt myself isn’t an option, so I think that I’m willing to try using “tempted to hurt myself” as the high point on a continuum of describing emotional pain.

J obviously doesn’t want me to relapse back into self harm. She doesn’t want this to be another factor contributing to that behavior. So she asked me how she can receive the information from me that I wanted to cut in a way that feels as validating as if I told her I did cut?

I’m having so much trouble developing a response. Since I don’t know the source of the need, I don’t know what she can do to help me suppress it.

So what can she do? How can she make me feel supported and understood? I’m still not entirely sure. I don’t have an end-all, be-all solution.

Validation is the golden rule of working with people like me. When in doubt, find some way to legitimize my feelings. Make sure I know that you’re supporting me amidst them. Say it 10 different ways. Say it again and again and again until it sticks.

“I believe you when you tell me how intense your emotions are.”

“I hear that you are in a very difficult place right now.”

“I understand how much you feel you need to hurt yourself. I’m glad you’ve chosen to be safe, despite all that pain.”

“What do you need? How can I help you right now?”

“Tell me more about what’s going on. Let’s work through these challenging feelings together.”

“I’m still here.”

I need to hear the validation. I need to hear it 100 times, using the same calm patience and empathy with each repetition. I need to hear it from J, and I probably need to say things like this to myself. To believe myself when I’m tempted to dismiss my own pain, as if not cutting means that I’m somehow healed and not allowed to feel negative feelings.

I need to hear that she’s still there, because maybe there’s a part of me that thinks not hurting myself means I’m on a path to being better – but does being better mean an end to therapy?

Will this work? Once, I’m sure it will not be sufficient. Over time? I’m hopeful.

Because what’s the alternative? Hospitalize me? Refer me to an IOP? We’re in agreement that I don’t need a higher level of care. What I really want when the pain has been that bad is to be held, but that is unfortunately beyond the therapy relationship.  So in lieu of that, I just want to know that she believes me, that she has as much of an understanding as she can without living the experience.

That’s so, so hard when I can’t know for sure what she’s thinking.

Has anyone else been in a similar situation? How does your therapist convey to you that they recognize the  depths of your struggles in a way that makes you feel like they really get it? I’ll take any suggestions.

 

 

Gratitude Log: Strength

In a recent session, I asked J to provide me with a writing prompt. She assigned me another list. Lists are her speciality, if you didn’t know. This one was about gratitude. Why am I grateful for my positive qualities? How have they served me? My goal is to use this prompt as a new self-love challenge, by creating a post for as many of the reasons I listed in this post as possible.  

This is going to be the final post of my gratitude log. At this point, I feel like I’ve hit all the most important reasons from my original list and I’m comfortable leaving it at this. I’ve got so much written, so many examples of the good stored within me. So much evidence of how the person I am has served me in positive ways. I hope that being able to go back and read these will give me strength when it’s more difficult to see the good.

Fittingly, that’s what this post is all about. Strength.

I’m a strong person. Maybe not so much physically, but emotionally. Sometimes it’s difficult to give myself credit for that. I assume the presence of extremely intense negative emotions means I’m not strong, that strength would mean the ability to avoid them. But maybe strength just means the ability to withstand them. I’m grateful for my strength in that it helps me sail my ship through the storms, of which there are so many.

I’m grateful for my strength because it helps me set my pain aside sometimes to help others or to just be kind to them. It helps me focus on something I can control and fix, someone whose day I can change if only by a fraction. When H has a bad day at school, when my friend is having boy troubles, or when I see another blogger struggling, I can put my emotions on a shelf and be a comfort for them, a source of support.

I’m strong. Strong enough to push through pain. Strong enough to take a simple prompt given to me by my therapist and write 13 posts on it as a means of fighting back against minions who only have negative things to say. I’m grateful for my strength because it gives me those words to use as ammunition. It has helped me write so many posts of self-love.

I’m grateful for my strength because it helps me find joy even amidst the trying days. To laugh at a funny movie. To admire a beautiful day. To smile at a stranger and strike up a conversation. It’s what makes me willing to even try looking for the sunshine beyond the clouds. I’m having deja vu, so perhaps I’ve discussed joy before, in relation to another positive quality of mine, but it feels important to address here as well.

I’m grateful for my strength because it keeps me here. Despite every awful feeling that courses through my veins, despite every mistake of the past, I’m still here. Still alive.

I’m grateful. Period. For so much more than I ever realized until now.

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Gratitude Log: Honesty

In a recent session, I asked J to provide me with a writing prompt. She assigned me another list. Lists are her speciality, if you didn’t know. This one was about gratitude. Why am I grateful for my positive qualities? How have they served me? My goal is to use this prompt as a new self-love challenge, by creating a post for as many of the reasons I listed in this post as possible.  

Honest to a fault. That’s the line I use in my dating profiles. I’m not sure where it came from, but I’ve always been a “whole truth and nothing but the truth” kind of person. Lying, or lying by omission, does not come very easily to me with anyone. Not my parents, teachers, or even my therapist. It pains me to do it, because I feel that strong moral code pressing back at me. My face contorts into this weird look and I pretty much give myself away immediately. It’s better off to just be up front.

I am grateful for my honesty because it helps me stay true to myself as a person. I’ve long struggled with what the ultimate “truth” is in any situation, but I typically know very firmly what my truth is. If something is bothering me, if I really like something, or if I don’t agree with someone, these are things that I will voice to those around me. For example, I recently admitted to a friend that I’d felt isolated when she and her friend kept talking about their mutual history that I knew nothing about around me. It doesn’t always work out for me, I usually make the choice to share my truth, because I don’t like concealing who I am as a person.

My need to be honest also teaches me to respect myself. As I said, my truths are not always received well, but the fact that I am willing to communicate my opinions and my values means that I respect myself enough to risk it. Because I know I deserve to be heard. Case in point, my grandfather and I often go back and forth on political opinions. I know it’s never going to be a harmonious conversation, because we just don’t agree, but I respect myself enough to keep sharing my perspective. Doing so has helped me see that I have as much right to being honest about how I feel as he does and that we can survive differing beliefs.

I am grateful for my honesty because it makes accountable. When I do screw up or make a mistake, I will usually own up to it pretty quickly. Once, I was working for a family and I dropped the iron on the floor. Of course, the light began to flicker and I worried that I’d broken it. No one was home, so I could have easily shoved in back on the shelf and pretended to be ignorant to what happened. But I had to be honest to the mother about it. My conscious wouldn’t accept anything else. It would have eaten away at me. As much as that sucks, I am grateful for the push to be honest, because it helps me maintain an integrity I’m proud of.

Finally, I am grateful for my honesty because it helps me make ethical decisions. At my job, I practice within the scope of my competence. I don’t use assessment tools I don’t know or give parents data I’m not confident about. Doing so would be dishonest, reflecting my role in the school in an inaccurate way. I stick to doing what I’m trained to do, using the information and skills at my disposal.

Share your truths, people. Honesty shows that you value yourself and others. It’s a pain in the ass, and sometimes requires a lot of effort, but it pays off for you in the long run.

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Gratitude Log: Initiative

In a recent session, I asked J to provide me with a writing prompt. She assigned me another list. Lists are her speciality, if you didn’t know. This one was about gratitude. Why am I grateful for my positive qualities? How have they served me? My goal is to use this prompt as a new self-love challenge, by creating a post for as many of the reasons I listed in this post as possible.  

Yesterday, I posted about the importance of hard work. Today’s piece of gratitude lies on a parallel road: initiative. We can all work hard, and many of us do. But there’s an extra step you can add in there that will put you ahead of everyone else who works.

It’s called taking initiative. It’s an area I excel in. I work hard, I’m responsible, I’m reliable, and persistent. These are all good things that I’ve discussed. But I usually go the extra step and that is something to be grateful for in it’s own way.

Taking initiative has brought me many positive relationships. I struggle hard with relationships, I have for a long time. But I think that the tendency I have to go the extra step is what kept people around amid difficult times.

In high school and college, I’m thankful for the friends that being a person who went the extra mile got for me. I remember that I made homemade cards for my close friends on their birthdays in the shape of Spongebob and cars and whatever they liked most. I remember staying on the phone with a friend who was upset until she fell asleep. I made my friend a slideshow for her birthday one year with pictures that I’d gotten by reaching out to her mom and scanning them while she was away. I remember trying so hard to help a friend who was cutting, even from miles away at college. Nothing was ever too much. I wanted them to know that I cared, I wanted to show it however I could. I think it’s why I always had friends and positive connections at different points in my life, even if they ultimately faded out. So I’m grateful for my initiative, because I think it gave me the gift of those friendships even when I didn’t know how to exist within them.

I’m thankful for my initiative because it’s helped me cultivate the relationship I have with the girls I babysit and their family. My initiative isn’t the only thing, and I’ve mentioned babysitting numerous times already, but I think it played a huge part. A lot of babysitters don’t plan scavenger hunts or make photo books to surprise the kids they babysit for. They won’t spend hours on Pinterest looking for and testing out ideas to use with the kids. I do, and because of it those girls know without fail how much they are loved and cherished. And they love me back, saying things like “you” when I ask them what good things in life they have to be grateful for.

I’m grateful for being a person who takes initiative because it gave me a good relationship with the people I worked with during my internship. It was never enough to do what was merely expected of me. I wanted to do more. I’d ask people besides my supervisor what I could do for them, whether it be an observation or testing. They respected that and it made them want to help me and teach me in return. I tried to learn as many assessment tools as I could. And I read as much as I could, literature on legal cases and the administrative code. I rewrote it in my own words to make sure I understood it. How much I cared about my work and wanted to be good showed, and I hope that will be repeated in my relationships at the new district

This whole gratitude log represents initiative. J gave me a prompt for one post. In fact, I asked her for the prompt. I wanted another way to try to grow and then wasn’t content to leave it at just one post. I had to turn it into more love, more kindness than I could even think to project at myself.

So thank you initiative, for giving me a record of all the good things and how they’ve served me. The gift that keeps on giving.

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