The Realities of Self-Harm and Suicide
Featured Guest: Lori Vann
What can behavioral health providers do to better understand the realities of self-harm and to know how to respond when they spot the signs in their patients?
We’ll discuss this with non-suicide self-injury specialist, author and counselor Lori Vann on this episode of Recovery Unscripted.
For more about Lori’s work, visit http://lorivanncounseling.com/
Interviewer: Well, I’m here with Lori Vann, thank you for being with us.
Lori: Well, thank you for inviting me.
Interviewer: Absolutely, let’s start with having you tell us a little bit about your story, your background and how you became involved in the world of recovery?
Lori: Well, I’m a licensed professional counselor supervisor. I’ve been working with non-suicidal self-injury for about 20 years now, stumbled upon it. Just started with one client after another who did it and I just kept on going and it’s my real passion and the more that I’ve worked with it the more needs I see out there and my goal is to try to take a program I’ve developed the self-injury Prevention, invention program, get it into treatment centers on the national and international level and the programs based on four out of the five books that I’ve written.
Interviewer: Cool, and so you were already practicing in psychology and this is just something you saw was this self-injury?
Lori: Yes, I’m currently in private practice in a suburb of Dallas called Lewisville. I’ve been in private practice for a little over 10 years now, but I’ve practiced inpatient psych, nonprofit, outpatient clinics, school district. Sort of the whole gamut. It’s just a consistent theme that kept coming up.
Interviewer: You saw that it was a need then you responded to that need, developed a way you could help?
Interviewer: Here at the conference innovations and recovery you gave a presentation what you think you know about nonsuicidal self-injury, abbreviated NSSI, right?
Interviewer: So you’re looking at that versus the reality and how getting it right can make all the difference. I guess first of all to set the landscape for this could you give us an intro to what is nonsuicidal self-injury and what are some of the myths or misconceptions people have about it?
Lori: Well, nonsuicidal self-injury which previously had been referred to as self-mutilation, certain times erroneously referred to as cutting. You could say self-harm as well. How I’ve defined it over the years is pretty simplistic. It’s the intentional infliction of harm upon one’s body usually for emotional reasons and the things to focus in on it are the intentional part and that’s what separates it from suicide. Suicide the intent is to die self-injury the intent is to harm yourself to deal with your emotions, its perceived coping skill.
Some of the myths because it’s a really taboo topic a lot of people don’t even assess for it unfortunately especially since there’s such a strong correlation with suicide. I think self-injury should be assessed by everyone, every clinician, every treatment center. The myths it’s everything from– Well, some people think it is a suicide attempt and it’s not. Some people think it’s strictly for attention-seeking. It’s not.
Interviewer: Actually the way you described it, it’s very different from suicide. The whole motivation and everything is very different.
Lori: Yes. The intent really is such a key piece to assess for and oftentimes people don’t bother to ask they just assume. How you would treat a suicide attempt is very different than how you treat a self-injurious act. Now there’s a very strong correlation that- and I’ve worked with about 500 cases, consulted on hundreds more. At least 60% of cases I’ve worked with have a history of suicidal ideation or attempt, but one is not a guarantee of the other.
Obviously, they’re plant people they have attempted suicide that never self-harmed. You do need to assess for both parts because on self-injury it can possibly be a predictor of a later suicide attempt and tons of research I can point to goes with that. People do think well they’re just doing it to get attention. I would say even if someone did it for getting attention purposes, we really need to step back and have the compassion and really ask ourselves what drove a person to that point where they thought that’s the only way they can get attention?
To me that’s really a sad state of affairs that someone got to such a level they felt that was the only way that they could get someone to notice them or to help them is to harm themselves and then to “show it off”.
Interviewer: Even if it is that that’s a great example of where the treatment providers can step in and say, “Okay, this is still a cry for help and there’s reasons behind this.”
Lori: Yes, absolutely. I think unfortunately some people get a little jaded to it and they might be judgmental and they might react with a callous way. I’ve seen that in some treatment centers where they go, “Oh, well, what do you expect?” They’re a cutter or they’re this or oftentimes it’s tied into the diagnosis of borderline of, “Well, that’s just what they do,” is to get attention and you hear a lot of that frustration. My thought is, “Okay, is that coming out when you’re actually meeting with the client?”
It’s also how judgmental of you and how uneducated of you because you really don’t understand this behavior and we also- one of the myths is that you have to be borderline if you’re self-harming and that’s not the case at all it’s just unfortunately in the DSM one of the very few times self-harm is mentioned is with borderline personality. I can tell you for a fact that the majority of the cases I’ve worked with they are not borderline. If you work with it and again this is about assessment you catch your young enough age then you really intervene so that maybe they don’t become a full personality disorder.
Interviewer: You’ve gotten into this a little bit but guess what, why do people engage in NSSI? You say it’s like a coping mechanism so it’s similar to substance use, has some overlap with that kind of thing?
Lori: Absolutely. The first book I wrote on a caregiver’s guide to self-injury, I’ve collected 35 reasons why people self-harm and with that every time they self-harm it could be a completely different reason. It’s also to note that every time they harm it could be for multiple reasons. It could be while I was sad and I was also angry and I felt like I needed to punish myself. Sometimes it’s just a single reason everything fall out of control.
The number one by far, the number one reason people self-harm is that their emotional pain is so bad it’s so difficult to deal with the physical pain is just easier to cope with. It’s a distraction, some people they get the rush from X when you harm yourself it does release your body’s own natural opiates their own pain pill as it were. That gets a little–
Interviewer: In reaction to the pain.
Lori: People have this escape, this release from it they don’t have to focus on their emotions, it’s as if the injury purges it from their body which is some similarities with eating disorders too. It’s that part of what I’m really trying to help people in the substance treatment world understand that self-injury, one, should really be seen as an addiction and two, there’s a lot more similarities. With self-injury, that rush lasted for a couple of hours and then the cycle can start all over again much like substance use.
Interviewer: Yes, and then they have to feel like they have to keep coming back to that?
Interviewer: Again, similar to substance use. I guess like- you touched on this a little bit earlier a lot of clinicians feel uncomfortable about this, it’s a taboo thing. Why do you feel that the healthcare profession is so unaware or avoidant of this topic?
Lori: I think it’s just her own personal discomfort because it seems so counterintuitive to do that to one’s body and that’s where you get some of the shaming involved where people go, “Well, you must be crazy, you must feel this, you must be that in order to do that to your own body. People avoid pain you’re seeking it out.” Right there it’s just that mindset instead of stepping back and go, “Again, what’s going to cause someone to do this?”
I think the media is a factor because we’ve talked a lot more about substance. Substance has become for lack of a better way to put a little bit more socially acceptable, you’ve celebrities that come out and they talk about their history with addiction. It’s great, it’s wonderful where you are having these conversations and awareness and eating disorders is starting to get a little bit more out there in those discussions because of some celebrities and it’s not being ashamed as what it used to be.
Self-injury is still a huge taboo and it’s just so counterintuitive, it’s just hard for us to conceptualize why someone would do that, but if you see self-injury and substance being very similar in nature, substance use is a form of self-harm. You’re ingesting things that are toxic to your body. It’s just the scars are internal so no one sees them versus–
Interviewer: Even in the moment they understand if they’re thinking clearly that this is not healthy.
Lori: Yes. Absolutely.
Interviewer: Addiction keeps it going.
Lori: Maybe it’s because, in movies and TV, we see so many commercials for substances. We see it throughout movies of people using and it’s just more normalized. We just don’t have that same thing with injuring and we don’t want it to be a formalized process. We want to be seen as, “Hey, there’s help. This isn’t the best way to deal with life.” Instead of shaming and stigmatizing, it’s let’s just get those discussions going much like with suicide.
It’s just waiting for people to get on board with that because it’s so much more common than what people realize. I would say in the US, you’re looking at about 20% to 35% lifetime risk.
Interviewer: Really? 20% to 30% of Americans at some point would be at risk for this, is that what you mean?
Lori: When you get into clinical populations that’s where you’re really going to see it in that 30% tile and above. There are so many different studies that come out over the years of– One I think goes back to 2006 I think. It was a University study of students from top universities and 20% of them and this was 10 years ago or more that it was Columbia and I think maybe Princeton. About 17% to 20% of their student body had a history of self-harm. This was a long time ago. You can only imagine what the numbers would be like–
Interviewer: That’s a high achieving population that you would think should be confident and just successful and all that but there’s still that overlap.
Lori: That’s part of some of the myths too is that we see self-injury, it’s only this particular demographic. It’s teenage girls that are this, this and this. That’s not the case at all. Self-injury starts in elementary school. The Guardian had a study last year in 2018, they found it in kids as young as three years of age. That absolutely goes to adults. 10% of those in my studies started at 18 or later.
Interviewer: To 10% you said?
Interviewer: Still, most people would start younger but still a significant–
Lori: Yes. It’s still a significant number to pay attention to. Those are just the adults that come in and admit to it. Since so many people do assess for it, I mean who knows. Then people can return to it that they may have done it for a while as adolescents and they stopped. Maybe they did other stuff and then they came back to it as adults. There’s all sorts of interesting things there but it’s across all racial groups, it’s across all age groups, all financial groups is an international epidemic and that’s not an exaggeration.
Interviewer: Yet it’s still this dark corner of the room idea where that’s not something that people talk about.
Interviewer: Then because of that, because it is this taboo thing that leads to clinicians being uneducated, unaware. Then what are some of the negative consequences of that, that trickle down to the patients?
Lori: Well, when clinicians are uneducated about it and treatment centers don’t assess for it or know how to deal with it, it just reinforces the stigma. People usually aren’t just going to come out and say, “Hey, this is something I’m going to do.” It’s something that has to be assessed for. It has to be talked about. There has to be a trust there and when you don’t have education, it’s hard for you to feel comfortable in your own skin to talk about it, to assess for it.
Clients, especially if they’ve had poor treatment responses in the past where people have been judgmental and I’ve had so many of those cases where clinicians have said the wrong thing, that they’ve had a bad attitude, they’ve been judgemental, condescending. That’s why they switch counselors or they just stay away from mental health for a long time until they’re forced to get it again.
When I have these stories that come into me of practitioners that say the wrong things, say it’s for attention, say, “Well, why don’t you just stop it. Just quit doing it.” Something completely ineffective, then it closes the client off. Why on earth would they then be open with you? Why would they then share because you just showed you don’t understand it.
Interviewer: It’s hard enough to make that decision to seek help without all of that. You touched on earlier about the similarities between substance use and this. How can knowing those similarities like in this context where a lot of people are dealing with substance use. How can like knowing what to do with that when you come across somebody who’s also doing self-harm. How can that help treat another person?
Lori: Well, I think with all of these things I’ll say you can’t focus solely on the behavior. You’d have to get to the core issues. When I work with clients I’ve developed what I call this tree model and we’re all about getting to the root system, the actual poor stuff because whether it’s substance or eating disorder or injury or gambling report, these are all symptoms. They’re just symptoms of a deeper issue.
The concern I have is that so often we focus solely on the behavior and you can get rid of that behavior and then they’re going to flip-flop to something else. What people have talked with me about the substance realm is that they will get sober from a substance but now they’re self-harming. I’ve had plenty of clients that self-harmed and got stopped and then maybe they started to experiment with substances because the core stuff wasn’t addressed.
That’s where I’d love to get into treatment centers and really help them understand some of the techniques that I use and really understand how everything is so interconnected. The techniques really are applicable to whatever behavior may be present, but definitely, someone can stop with substance and then they go to self-harm instead.
Interviewer: Let’s get into what you’re hoping that people get out of it. What would be some do’s and don’t for clinicians, therapists that kind of thing when it comes to addressing this issue with their patients?
Lori: First, never make assumptions. Always ask. Always be open and assumptions or don’t assume that it was a suicide, don’t assume they do it for attention, don’t assume that they must be psychotic and that’s why they do it. Always ask. What was your intent behind this? What was your desired effect? What continues to keep you going in doing this? What would you like to see go differently?
A lot of times people actually know the answers, it’s just no one ever asks them. Ask what is your perfect situation? What is that you desire to get out of treatment? Do you even want to work on this behavior? We can know something isn’t healthy but until the client is really at the spot where they understand it’s not healthy and they have the desire to work on it, sometimes you’re going to just be stuck.
That’s where you have to have some of that patience and what I call the back door method. When I work with my tree model, it’s you know what, we don’t have to talk about so much the self-injury right now. Let’s just look at other things that might be going on in your life. As we’re dealing with all the core stuff, invariably the need to do the other behavior starts to go away. It’s just been so consistent and I have a 90% success rate with it.
Interviewer: With the tree model?
Lori: Yes, with the tree model and that’s 90% for the self-injury side and it’s 90% for just my general population clients.
Interviewer: Is there anything that you haven’t said about the tree model that would help describe it? How does that work?
Lori: Well, visualizing a tree, it’s a really great picture. The root system are the beliefs we have about ourselves. Obviously, when someone is doing harmful behaviors, low self-esteem is going to be a really big factor. Where does low self-esteem come from? Well, it comes from the beliefs we have about ourselves. That’s influenced by people throughout our history, people that are currently in our life.
It’s getting into what I call a bill of rights and there a lot of versions out there of this. When you don’t believe you have certain rights, then how do you set boundaries with people? If you don’t set boundaries, which is like the trunk of the tree, then it’s going to lead to other symptoms. Like core symptoms of depression and anxiety and anger and all the rest of it. All of those have to go somewhere and that’s where you go onto the behaviors.
That’s a very simplistic way of describing it. There’s a lot more detail and nuances, but that’s really the basics. We’re always about we’re going to get into that root system because if you don’t have a healthy root system, if all those different beliefs aren’t healed, you don’t really have a good shot of having a healthy tree.
Interviewer: Yes. What’s maybe one or two things that you wish more clinicians understood about self-harm, NSSI?
Lori: Well, first, I’d say, it’s completely treatable.
Interviewer: Wait. Let’s wait till the announcement is over.
Interviewer: All right, go. What do you wish more clinicians understood about this?
Lori: First and foremost, it’s treatable. It’s completely a treatable behavior. Yes, you do have to have the motivation of the client because if the client’s not motivated, again, you’re stuck at times, but it’s a 100% treatable behavior. There’s absolutely help. There’s help. There’s solutions out there. Two, it’s much more common than what most clinicians think, and because of that, we really have to start assessing, we really need to start those discussions, we need to start the education programs because so many people are dismissive of it. I’ve had parents that said, “Well, they’re just experimenting. They’ll grow out of it.” You don’t know that.
Interviewer: There’s still something causing them to do that even if it’s a phase and they move on to something else.
Lori: Yes. It’s like, “Why would you want your kid to move on to something else? Wouldn’t you want to deal with whatever this issue, trigger, et cetera is?” I mean, that’s just– It’s also clinicians. I would want them to just learn to start to be comfortable with, what I sometimes call, as the NSSI or the SI question, the S words, be comfortable talking about suicide, be comfortable talking about self-injury.
That’s just part of our field. It’s not saying you have to treat it, but you have to comfortable enough to ask about it and assess for it, and then you can always refer out, but you have to do your due diligence, your ethical responsibility to do those assessments.
Interviewer: Because if we don’t ask them, maybe no else will.
Interviewer: Just to wrap up, everyone who works in this profession, it can be hard at times, it can be heavy at times, especially dealing with suicides, self-injury, but people keep getting up and fighting this fight. Could you end by summing up why this mission is so important to you?
Lori: It was something I stumbled into 20 years ago, and it’s just different passions for different people. This is absolutely my passion. I’ve seen the success. I’ve not healed every person that I’ve worked with. I mean, no clinician can say that. Sometimes, it’s about the right fit. Those that have gotten better, when I’ve seen some of the extremely difficult cases, and I see them graduating from high school, I see them going to college and getting married, I see them hitting their sobriety dates of years and years, and it’s just inspiring.
To me, it’s a completely preventable behavior, and I sort of have the nickname of “I’m a savior of lives and limbs,” and I want to continue doing that and eradicate self-injury, so to speak.
Interviewer: Absolutely. Well, keep up the good work. Thank you for being with us, Lori.