Peace and quiet are important for mental and physical health.
Here are a few links to references:
http://www.ncbi.nlm.nih.gov/pubmed/14757721
http://www.ncbi.nlm.nih.gov/pubmed/15936421
(A 2005 study published in Lancet which showed that noise causes increased irritability, and a negative impact on cognitive development in school-aged children)
On a related note, the use of music players such as iPods can cause permanent hearing loss, particularly if people have the volume turned up very high. People are more likely to use higher iPod volumes if the background noise level is also high. Here are some links to information and evidence:
http://www.hearinglossweb.com/Medical/Causes/nihl/mus/ipod/ipod.htm#fast
http://www.ncbi.nlm.nih.gov/pubmed/19124629
http://www.ncbi.nlm.nih.gov/pubmed/17430434
http://www.ncbi.nlm.nih.gov/pubmed/17711774
Also, the sound volume at a rock concert or a nightclub is sufficient to cause hearing damage, especially if this is an activity done regularly without hearing protection. I recommend using earplugs at rock concerts (yes, I'm serious!) Here is some evidence:
http://www.ncbi.nlm.nih.gov/pubmed/8499785
http://www.ncbi.nlm.nih.gov/pubmed/16825883
http://www.ncbi.nlm.nih.gov/pubmed/12176760
Monday, February 9, 2009
Friday, February 6, 2009
Imaginary Numbers - a metaphor
One of my favourite mathematical metaphors comes from an area called "complex analysis".
I can't resist the metaphor, because of the nature of the mathematical language involved.
I've always loved mathematics. It is enchanting, beautiful, yet infinitely challenging. There is no area within mathematics that cannot be developed into an almost impossibly esoteric branch of its own. Its theoretical abstraction must surely exceed the complexity of the physical universe (unless we consider abstract mathematical ideas to actually be part of the physical universe).
The appreciation of mathematics as an art form or as a form of esthetics has, unfortunately, been hampered by an educational approach which often leads people to experience mathematics with dread, anxiety, or despair.
Anyway, here is the mathematics:
1) A "square root" of a number is another, smaller number, which, when multiplied by itself, gives the first number. So, for example, the square root of 25 is 5--since 5 times 5 equals 25. I suppose we could add that 25 in fact has 2 square roots, since (-5) times (-5) also equals 25. This idea of a "second" square root already involves a higher degree of abstraction.
2) There are some numbers which do not seem to have any possible square root. For example, what would be the square root of (-25)? There does not seem to be any number which, when multiplied by itself, yields a negative number.
3) So, how about if we create such a number, imaginatively? Such a number has been invented, and it is called the "imaginary number", signified as "i". The imaginary number i is an abstraction, with the property that i times i equals -1.
4) What is the use of having such an imaginary number? What application could it have? Well, as it turns out, it is enormously useful in understanding and solving problems in physics and engineering. And, I think, it demonstrates a very beautiful link between phenomena that might initially seem completely different.
The exponential functions are phenomena which, if represented graphically, appear to represent rapidly accelerating growth. If something keeps doubling regularly, the growth is "exponential". Many phenomena in nature can be described using exponentials.
The trigonometric functions are phenomena which, if represented graphically, appear to represent waves, which oscillate regularly; in the case of the "sine" function, we have a "sine wave", which fluctuates, forever, between -1 and 1. Many other phenomena in nature can be described using the trigonometric functions.
There appears, at first sight, to be no obvious relationship between the exponentials, which represent unbridled growth (e.g. population growth); and the sine wave, which represents continuous, regular, well-bounded waves (e.g. the swinging of a pendulum).
But if we figure out a formula which can calculate an exponential, and a formula which can calculate a sine wave function, we find that if "imaginary numbers" are allowed, the two types of functions are variations of the same thing. Hence we have the mathematical fact:
exponential (ix) = cos(x) + i sine(x).
So here is the psychological metaphor:
The link between something which rises, escalates, explodes upwards towards infinity, and something which is stable, repetitious, and finite -- is "imagination". They are variants of the same, larger, thing, as long as you can expand your perspective of understanding.
The introduction of imagination may transform a problem of unbridled excess into one which could include stable regularity. Similarly, imagination could transform the monotony of a "sine wave" type of life into something more excitedly or wildly "exponential".
In approaching seemingly impossible life problems, I think it is important to be able to step back, and sometimes to allow an entirely new perspective or way of thinking.
I can't resist the metaphor, because of the nature of the mathematical language involved.
I've always loved mathematics. It is enchanting, beautiful, yet infinitely challenging. There is no area within mathematics that cannot be developed into an almost impossibly esoteric branch of its own. Its theoretical abstraction must surely exceed the complexity of the physical universe (unless we consider abstract mathematical ideas to actually be part of the physical universe).
The appreciation of mathematics as an art form or as a form of esthetics has, unfortunately, been hampered by an educational approach which often leads people to experience mathematics with dread, anxiety, or despair.
Anyway, here is the mathematics:
1) A "square root" of a number is another, smaller number, which, when multiplied by itself, gives the first number. So, for example, the square root of 25 is 5--since 5 times 5 equals 25. I suppose we could add that 25 in fact has 2 square roots, since (-5) times (-5) also equals 25. This idea of a "second" square root already involves a higher degree of abstraction.
2) There are some numbers which do not seem to have any possible square root. For example, what would be the square root of (-25)? There does not seem to be any number which, when multiplied by itself, yields a negative number.
3) So, how about if we create such a number, imaginatively? Such a number has been invented, and it is called the "imaginary number", signified as "i". The imaginary number i is an abstraction, with the property that i times i equals -1.
4) What is the use of having such an imaginary number? What application could it have? Well, as it turns out, it is enormously useful in understanding and solving problems in physics and engineering. And, I think, it demonstrates a very beautiful link between phenomena that might initially seem completely different.
The exponential functions are phenomena which, if represented graphically, appear to represent rapidly accelerating growth. If something keeps doubling regularly, the growth is "exponential". Many phenomena in nature can be described using exponentials.
The trigonometric functions are phenomena which, if represented graphically, appear to represent waves, which oscillate regularly; in the case of the "sine" function, we have a "sine wave", which fluctuates, forever, between -1 and 1. Many other phenomena in nature can be described using the trigonometric functions.
There appears, at first sight, to be no obvious relationship between the exponentials, which represent unbridled growth (e.g. population growth); and the sine wave, which represents continuous, regular, well-bounded waves (e.g. the swinging of a pendulum).
But if we figure out a formula which can calculate an exponential, and a formula which can calculate a sine wave function, we find that if "imaginary numbers" are allowed, the two types of functions are variations of the same thing. Hence we have the mathematical fact:
exponential (ix) = cos(x) + i sine(x).
So here is the psychological metaphor:
The link between something which rises, escalates, explodes upwards towards infinity, and something which is stable, repetitious, and finite -- is "imagination". They are variants of the same, larger, thing, as long as you can expand your perspective of understanding.
The introduction of imagination may transform a problem of unbridled excess into one which could include stable regularity. Similarly, imagination could transform the monotony of a "sine wave" type of life into something more excitedly or wildly "exponential".
In approaching seemingly impossible life problems, I think it is important to be able to step back, and sometimes to allow an entirely new perspective or way of thinking.
Thursday, February 5, 2009
Family Therapy ideas for Individual Therapy
Long ago I found that ideas from the theory and practice of family or group therapy could be well-applied to individual therapy.
In family or group dynamics, individuals can find themselves in particular types of roles (e.g. observer, leader, critic, outsider, social butterfly, scapegoat, etc.). Sometimes these roles can be "typecast", entrenched through repetition. Such entrenchment of roles may not allow a person's full range of emotion & personality to flourish.
Similarly, within one's own individual mind, it is possible to "typecast" oneself, through repetition of assumed roles.
The same tactics that can help in a group or family setting (e.g. encouraging a deliberate exploration of entrenched roles, and experimenting with taking on different role styles) could be beneficial for an individual.
Another dynamic which is explored in family therapy is the type of boundaries that exist between different members, in conjunction with the strength of the bond between each different member.
There may be "detached" relationships (a weak bond and little involvement), or so-called "enmeshed" relationships (in which people are extremely involved in each other's affairs, sometimes not allowing the individual to have an experience of autonomy).
Boundaries may be weak, absent, or atypical (in different cases, leading to different types of abuse, or to young children taking on the role of parent or confidante with their mother or father). Or boundaries may be extremely rigid, lacking flexibility (perhaps leading to an uncomfortable authoritarian atmosphere in the relationship or household).
In family therapy, reflection and work can be done on building healthy relationship bonds, encouraging a relaxation of enmeshments, so as to permit more individual autonomy. And work can be done to encourage healthy boundary formation.
Similarly, in an individual therapy setting, personal boundaries and "inner relationship bonds" can be a source of problems. "Enmeshments" may occur on an inner level, perhaps in the form of ruminative or obsessive preoccupations. "Detached" inner relationships may occur, in which parts of self or behaviour are held separate, and leading to a non-integrated sense of self, or a sense of self consisting of numerous independent facades or personas. Boundaries could be weak (perhaps leading to impulse control problems), or inflexible (perhaps leading to an inability to adapt easily, or to adjust to another person's style in a relationship).
In individual therapy, similar work can be done to build healthy "inner bonds", and healthy "inner boundaries".
I consider this comparison between family/group and individual therapy to be metaphorical. In the theory of so-called "object relations" such metaphorical ideas may be considered quite literally, i.e. that external relationships become literally "internalized" in the formation of a healthy self.
In practice, I think some of the ideas from family therapists can be imaginatively applied in an individual therapy setting.
As a concluding--but practical and concrete-- tangent, an exercise in one form of family therapy is to research your family tree, and to collect information about the life stories of different members of your family tree. This would include immediate relatives, but also more distant ancestors.
I think this is an interesting exercise in individual therapy for a variety of reasons:
1) because psychological symptoms, problems, personality styles, etc. are substantially influenced by genetic factors, it can be interesting to examine the life stories of those who are genetically related to you. It may also be true that the SOLUTIONS that work best for various life problems are also influenced by genetic factors (e.g. there is some evidence that a particular medication, if it works extremely well, has a higher chance of working extremely well for another person who is genetically similar). In a broader, "life story" sense, you may find stories in your family of various adversities that are similar to your own, and you may come to understand how these different ancestors coped. Some of these stories may be cautionary (i.e. warnings about how NOT to cope with certain problems), but some of the stories may be inspiring, and may guide or reassure you in your own pathway to solving your life problems.
2) the process of examining stories from family and ancestors can increase your sense of connectedness, identity, and meaning. Many families in our modern culture have become quite disconnected, and perhaps this disconnectedness fosters loneliness, materialism, or a cultural vacuum. As you gather information about these family stories, you may end up re-connecting with distant cousins, etc. and this could expand or enhance your network of friendships.
3) If many of the stories you find are very negative, this type of information could be upsetting, traumatic, or exacerbate more recent post-traumatic symptoms. If this is the case, such an exploration may need to be taken very slowly, if at all. But sometimes, if you feel ready, the process can become part of healing from the trauma. The exploration of a full story--even if the story is very negative--can sometimes be a prelude to healing. This task encourages the exploration of stories from distant relatives, as well as immediate relatives--this increases the likelihood that you will find some positive, inspirational stories, even if many of the stories are traumatic or turbulent.
In family or group dynamics, individuals can find themselves in particular types of roles (e.g. observer, leader, critic, outsider, social butterfly, scapegoat, etc.). Sometimes these roles can be "typecast", entrenched through repetition. Such entrenchment of roles may not allow a person's full range of emotion & personality to flourish.
Similarly, within one's own individual mind, it is possible to "typecast" oneself, through repetition of assumed roles.
The same tactics that can help in a group or family setting (e.g. encouraging a deliberate exploration of entrenched roles, and experimenting with taking on different role styles) could be beneficial for an individual.
Another dynamic which is explored in family therapy is the type of boundaries that exist between different members, in conjunction with the strength of the bond between each different member.
There may be "detached" relationships (a weak bond and little involvement), or so-called "enmeshed" relationships (in which people are extremely involved in each other's affairs, sometimes not allowing the individual to have an experience of autonomy).
Boundaries may be weak, absent, or atypical (in different cases, leading to different types of abuse, or to young children taking on the role of parent or confidante with their mother or father). Or boundaries may be extremely rigid, lacking flexibility (perhaps leading to an uncomfortable authoritarian atmosphere in the relationship or household).
In family therapy, reflection and work can be done on building healthy relationship bonds, encouraging a relaxation of enmeshments, so as to permit more individual autonomy. And work can be done to encourage healthy boundary formation.
Similarly, in an individual therapy setting, personal boundaries and "inner relationship bonds" can be a source of problems. "Enmeshments" may occur on an inner level, perhaps in the form of ruminative or obsessive preoccupations. "Detached" inner relationships may occur, in which parts of self or behaviour are held separate, and leading to a non-integrated sense of self, or a sense of self consisting of numerous independent facades or personas. Boundaries could be weak (perhaps leading to impulse control problems), or inflexible (perhaps leading to an inability to adapt easily, or to adjust to another person's style in a relationship).
In individual therapy, similar work can be done to build healthy "inner bonds", and healthy "inner boundaries".
I consider this comparison between family/group and individual therapy to be metaphorical. In the theory of so-called "object relations" such metaphorical ideas may be considered quite literally, i.e. that external relationships become literally "internalized" in the formation of a healthy self.
In practice, I think some of the ideas from family therapists can be imaginatively applied in an individual therapy setting.
As a concluding--but practical and concrete-- tangent, an exercise in one form of family therapy is to research your family tree, and to collect information about the life stories of different members of your family tree. This would include immediate relatives, but also more distant ancestors.
I think this is an interesting exercise in individual therapy for a variety of reasons:
1) because psychological symptoms, problems, personality styles, etc. are substantially influenced by genetic factors, it can be interesting to examine the life stories of those who are genetically related to you. It may also be true that the SOLUTIONS that work best for various life problems are also influenced by genetic factors (e.g. there is some evidence that a particular medication, if it works extremely well, has a higher chance of working extremely well for another person who is genetically similar). In a broader, "life story" sense, you may find stories in your family of various adversities that are similar to your own, and you may come to understand how these different ancestors coped. Some of these stories may be cautionary (i.e. warnings about how NOT to cope with certain problems), but some of the stories may be inspiring, and may guide or reassure you in your own pathway to solving your life problems.
2) the process of examining stories from family and ancestors can increase your sense of connectedness, identity, and meaning. Many families in our modern culture have become quite disconnected, and perhaps this disconnectedness fosters loneliness, materialism, or a cultural vacuum. As you gather information about these family stories, you may end up re-connecting with distant cousins, etc. and this could expand or enhance your network of friendships.
3) If many of the stories you find are very negative, this type of information could be upsetting, traumatic, or exacerbate more recent post-traumatic symptoms. If this is the case, such an exploration may need to be taken very slowly, if at all. But sometimes, if you feel ready, the process can become part of healing from the trauma. The exploration of a full story--even if the story is very negative--can sometimes be a prelude to healing. This task encourages the exploration of stories from distant relatives, as well as immediate relatives--this increases the likelihood that you will find some positive, inspirational stories, even if many of the stories are traumatic or turbulent.
Wednesday, February 4, 2009
Vitamin D & other vitamins
I'm re-posting this as a separate entry, because I think it's important.
I recommend multivitamin supplements as standard advice, because I think there is negligible evidence of risk (other than the effect on your wallet), and potential benefit.
The role of vitamin supplements ought not to be overvalued -- I think they are unlikely to cause a pronounced change in any symptom. But a vitamin deficiency could possibly prevent other treatments for depression from working optimally. Many people with psychiatric symptoms have less than optimal nutrition, for various reasons; therefore I feel that vitamin and mineral deficiencies are more likely.
There is some evidence of vitamin supplements being used to augment antidepressant medications, but the level of evidence is quite weak.
Vitamin D in particular is probably important to supplement, particularly for those of us who experience dark, cold northerly winters (vitamin D is normally produced in the body when our skin is exposed to the ultraviolet rays from direct sunlight). Furthermore, most of us wisely use sunscreen when it is sunny and warm, so most of us are getting less vitamin D from the sun. There is some evidence that the RDA for vitamin D (200-400 IU per day) is too low, particularly when we consider that brief whole-body skin exposure to sunlight generates an equivalent of perhaps 10 000 IU.
Here is a reference to a very interesting and promising recent study suggesting beneficial mood effects from higher-dose vitamin D supplementation (people received the equivalent of about 3000-6000 IU per day, for a whole year); the study is from a major, highly respected internal medicine journal:
http://www.ncbi.nlm.nih.gov/pubmed/18793245
Here is an excellent reference examining the issue of vitamin D safety, dosage, and toxicity:
Vieth, Reinhold. "Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety", American Journal of Clinical Nutrition 1999;69:842–56
A recent study by Bischoff-Ferrari et al. (2009) showed that elderly hip fracture patients given 2000 IU per day of vitamin D for 12 months, had a 60% reduction in fall-related injuries and a 90% reduction in infections leading to hospitalization, compared to a group given only 800 IU per day of vitamin D.
Here's a reference to a 2008 study from a clinical biochemistry journal showing toxicity from prolonged very high-dose vitamin D, of over 40 000 IU/day over several years. It concludes that the lowest dose at which hypercalcemia can occur is about 3800 IU per day:
http://www.ncbi.nlm.nih.gov/pubmed/18275686
Based on the evidence I recommend supplementing with an extra 2000 IU of vitamin D daily (possibly up to 3000 IU), in addition to the 400 IU that is present in most vitamin supplements, unless you have a medical condition associated with abnormal calcium metabolism or abnormal sensitivity to vitamin D (e.g. sarcoidosis).
If you are taking high-dose vitamin D you should have serum calcium levels checked periodically, and possibly a serum vitamin D level.
I do not recommend "mega doses" of any other vitamin, since I do not see a good evidence base for this being helpful, and higher doses of many such nutrients can be toxic or dangerous. A few recent studies have shown that people taking certain vitamin supplements, such as vitamin A or E, actually do more poorly than the control group.
I recommend multivitamin supplements as standard advice, because I think there is negligible evidence of risk (other than the effect on your wallet), and potential benefit.
The role of vitamin supplements ought not to be overvalued -- I think they are unlikely to cause a pronounced change in any symptom. But a vitamin deficiency could possibly prevent other treatments for depression from working optimally. Many people with psychiatric symptoms have less than optimal nutrition, for various reasons; therefore I feel that vitamin and mineral deficiencies are more likely.
There is some evidence of vitamin supplements being used to augment antidepressant medications, but the level of evidence is quite weak.
Vitamin D in particular is probably important to supplement, particularly for those of us who experience dark, cold northerly winters (vitamin D is normally produced in the body when our skin is exposed to the ultraviolet rays from direct sunlight). Furthermore, most of us wisely use sunscreen when it is sunny and warm, so most of us are getting less vitamin D from the sun. There is some evidence that the RDA for vitamin D (200-400 IU per day) is too low, particularly when we consider that brief whole-body skin exposure to sunlight generates an equivalent of perhaps 10 000 IU.
Here is a reference to a very interesting and promising recent study suggesting beneficial mood effects from higher-dose vitamin D supplementation (people received the equivalent of about 3000-6000 IU per day, for a whole year); the study is from a major, highly respected internal medicine journal:
http://www.ncbi.nlm.nih.gov/pubmed/18793245
Here is an excellent reference examining the issue of vitamin D safety, dosage, and toxicity:
Vieth, Reinhold. "Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety", American Journal of Clinical Nutrition 1999;69:842–56
A recent study by Bischoff-Ferrari et al. (2009) showed that elderly hip fracture patients given 2000 IU per day of vitamin D for 12 months, had a 60% reduction in fall-related injuries and a 90% reduction in infections leading to hospitalization, compared to a group given only 800 IU per day of vitamin D.
Here's a reference to a 2008 study from a clinical biochemistry journal showing toxicity from prolonged very high-dose vitamin D, of over 40 000 IU/day over several years. It concludes that the lowest dose at which hypercalcemia can occur is about 3800 IU per day:
http://www.ncbi.nlm.nih.gov/pubmed/18275686
Based on the evidence I recommend supplementing with an extra 2000 IU of vitamin D daily (possibly up to 3000 IU), in addition to the 400 IU that is present in most vitamin supplements, unless you have a medical condition associated with abnormal calcium metabolism or abnormal sensitivity to vitamin D (e.g. sarcoidosis).
If you are taking high-dose vitamin D you should have serum calcium levels checked periodically, and possibly a serum vitamin D level.
I do not recommend "mega doses" of any other vitamin, since I do not see a good evidence base for this being helpful, and higher doses of many such nutrients can be toxic or dangerous. A few recent studies have shown that people taking certain vitamin supplements, such as vitamin A or E, actually do more poorly than the control group.
Tuesday, February 3, 2009
Self-Injury
Self-injurious behaviour is common. Cutting skin is probably the most common specific behaviour, but there are many other varieties of self-injury.
There are different reasons why it might arise, or factors that might be motivating the behaviour.
Quite often self-injury leads to a feeling of relief, of focus, of emotional intensity, in the midst of deep anger or sadness. Sometimes a long-suffering person may feel as though the capacity to feel has been lost--he or she may feel numb or empty--and self-injury gives rise to some type of feeling for a moment. Also, an act of self-injury may cause someone to feel "in control" during that moment, while they may feel "out of control" in other parts of life.
Another common motivation is self-hatred. Physical pain may be desired. The sequence of self-hatred, leading to self-injury, leading to a sense of relief, leading perhaps to guilt or worsened self-hatred afterwards, can become a powerfully reinforced, self-perpetuating behavioural pathway.
Another motivation is a wish to experiment with the idea of suicide, perhaps with the thinking that cutting skin deeply enough could cause death, but then discovering that the act of non-suicidal self-injury creates a feeling of focus, control, excitement, or relief.
Self-injury can be a very private act, but sometimes can be an overtly interpersonal act, a type of non-verbal communication. Such communication can sometimes become part of an interpersonal dynamic. This dynamic can sometimes (but not always) be part of a vicious cycle, making symptoms worse (David Dawson's ideas, as expressed in Relationship Management of the Borderline Patient, can sometimes apply here).
Self-injury can become part of a person's sense of identity or personal culture, particularly if it has arisen during adolescence or young adult life.
Regardless of the various motivations, I believe that self-injury is an addictive behaviour. Just like alcohol or opiates, it may create some form of relief in the moment, with consequences to pay afterwards. The person engaging in it may recognize that it isn't "healthy" but may continue, or may feel unable to stop.
In the treatment of any addictive behaviour, I believe there are a number of therapeutic principles which can help:
1) If there are underlying problems which are driving the behaviour, or triggering it, then these problems may be addressed with whatever help is available. For self-injury, these problems may include depression, loneliness, irritability, boredom, struggling with issues having to do with identity, meaning, personal culture, etc. Sometimes addressing these underlying problems satisfactorily will solve the problem of self-injury.
2) The self-injury itself could be understood as a psychological defence. If a defence is to be lowered or set aside, it has to be with the will, motivation, and consent of the individual. Without the defence, there may be periods of more intense discomfort ("withdrawal symptoms"), at least initially . I do not believe that a person should be urged or told to "stop cutting". I do believe that a gentle, frank discussion about addiction, triggers, abstinence, etc. could be introduced, with the patient's consent. Addiction treatment programs have a stronger sense of the dynamics here -- a person cannot and should not be forced or "contracted" to stop something. Such a dynamic is unlikely to help, certainly not for very long.
The will to change has to come from the person seeking help, particularly if a strong theme for the person is having self-control, autonomy, freedom--and particularly if the person's problems have in part been caused by past trauma, in which self-control, autonomy, and freedom were oppressed.
3) Alternative strategies to deal with emotional distress can be found and practiced. Common triggers could be identified (e.g. feeling frustrated, feeling bored, feeling lonely, craving sensation of some type), and plans could be formed to negotiate through these moments. A cognitive-behavioural model could be useful (e.g. using journaling), and meditative practices could be helpful (e.g. mindfulness exercises).
Sometimes "substitute" activities such as rubbing ointment on the skin, snapping an elastic band on the wrist, marking the skin with an erasable pen, etc. can be part of a transition away from more harmful self-injury behaviours.
4) If there is guilt or secrecy around the behaviours, it can help to have a forum--such as psychotherapy-- to talk openly about the issue, without the fear of the dialog leading to a highly charged or panicked emotional exchange. The power of guilt or the power of secrecy can be perpetuating factors. In addiction treatment models, it is acknowledged that a person may not have the power within themselves to stop -- help may be needed -- acknowledgment of this fact may break the cycle of guilt.
In practice, I find that self-injury can gradually settle down as other problems settle. In many cases it may--ironically-- settle best when it does not become a primary focus of therapeutic dialog. It may resurface from time to time under stress. If the problem is very intense and acute, people may have a hard time making it through the day or the week, and may feel that the existing help is not enough (e.g. the therapy may feel inadequate). But I think that sticking to a very stable, regular, open-ended therapeutic framework is important.
There are different reasons why it might arise, or factors that might be motivating the behaviour.
Quite often self-injury leads to a feeling of relief, of focus, of emotional intensity, in the midst of deep anger or sadness. Sometimes a long-suffering person may feel as though the capacity to feel has been lost--he or she may feel numb or empty--and self-injury gives rise to some type of feeling for a moment. Also, an act of self-injury may cause someone to feel "in control" during that moment, while they may feel "out of control" in other parts of life.
Another common motivation is self-hatred. Physical pain may be desired. The sequence of self-hatred, leading to self-injury, leading to a sense of relief, leading perhaps to guilt or worsened self-hatred afterwards, can become a powerfully reinforced, self-perpetuating behavioural pathway.
Another motivation is a wish to experiment with the idea of suicide, perhaps with the thinking that cutting skin deeply enough could cause death, but then discovering that the act of non-suicidal self-injury creates a feeling of focus, control, excitement, or relief.
Self-injury can be a very private act, but sometimes can be an overtly interpersonal act, a type of non-verbal communication. Such communication can sometimes become part of an interpersonal dynamic. This dynamic can sometimes (but not always) be part of a vicious cycle, making symptoms worse (David Dawson's ideas, as expressed in Relationship Management of the Borderline Patient, can sometimes apply here).
Self-injury can become part of a person's sense of identity or personal culture, particularly if it has arisen during adolescence or young adult life.
Regardless of the various motivations, I believe that self-injury is an addictive behaviour. Just like alcohol or opiates, it may create some form of relief in the moment, with consequences to pay afterwards. The person engaging in it may recognize that it isn't "healthy" but may continue, or may feel unable to stop.
In the treatment of any addictive behaviour, I believe there are a number of therapeutic principles which can help:
1) If there are underlying problems which are driving the behaviour, or triggering it, then these problems may be addressed with whatever help is available. For self-injury, these problems may include depression, loneliness, irritability, boredom, struggling with issues having to do with identity, meaning, personal culture, etc. Sometimes addressing these underlying problems satisfactorily will solve the problem of self-injury.
2) The self-injury itself could be understood as a psychological defence. If a defence is to be lowered or set aside, it has to be with the will, motivation, and consent of the individual. Without the defence, there may be periods of more intense discomfort ("withdrawal symptoms"), at least initially . I do not believe that a person should be urged or told to "stop cutting". I do believe that a gentle, frank discussion about addiction, triggers, abstinence, etc. could be introduced, with the patient's consent. Addiction treatment programs have a stronger sense of the dynamics here -- a person cannot and should not be forced or "contracted" to stop something. Such a dynamic is unlikely to help, certainly not for very long.
The will to change has to come from the person seeking help, particularly if a strong theme for the person is having self-control, autonomy, freedom--and particularly if the person's problems have in part been caused by past trauma, in which self-control, autonomy, and freedom were oppressed.
3) Alternative strategies to deal with emotional distress can be found and practiced. Common triggers could be identified (e.g. feeling frustrated, feeling bored, feeling lonely, craving sensation of some type), and plans could be formed to negotiate through these moments. A cognitive-behavioural model could be useful (e.g. using journaling), and meditative practices could be helpful (e.g. mindfulness exercises).
Sometimes "substitute" activities such as rubbing ointment on the skin, snapping an elastic band on the wrist, marking the skin with an erasable pen, etc. can be part of a transition away from more harmful self-injury behaviours.
4) If there is guilt or secrecy around the behaviours, it can help to have a forum--such as psychotherapy-- to talk openly about the issue, without the fear of the dialog leading to a highly charged or panicked emotional exchange. The power of guilt or the power of secrecy can be perpetuating factors. In addiction treatment models, it is acknowledged that a person may not have the power within themselves to stop -- help may be needed -- acknowledgment of this fact may break the cycle of guilt.
In practice, I find that self-injury can gradually settle down as other problems settle. In many cases it may--ironically-- settle best when it does not become a primary focus of therapeutic dialog. It may resurface from time to time under stress. If the problem is very intense and acute, people may have a hard time making it through the day or the week, and may feel that the existing help is not enough (e.g. the therapy may feel inadequate). But I think that sticking to a very stable, regular, open-ended therapeutic framework is important.
Subscribe to:
Posts (Atom)