Cutting/self-harm comes up in crisis chat even more than borderline personality disorder, in part because cutting is common among both BPD patients, depressed teenagers, and depressed/anxious young adults. I have a lot of thoughts on cutting.

First, it is obvious to me that the shame around cutting is a million times worse for cutters than the actual cutting. I talk to so many kids terrified to reach out for help because people have or will judge them, shame them, or commit them for cutting. Even if they hide it perfectly, they know, and they know their support network doesn’t know, and they will never rid themselves of the fear that the support would be withdrawn if they knew.

Luckily my program gets that, and we’re at least allowed to be chill about cutting.  It doesn’t trigger an active rescue call, we’re explicitly supposed to reassure them it’s not shameful and we’re not judging, and we’re even allowed to praise it not as an alternative to suicide*, but as a coping mechanism that removes the necessity of it.

We are not, however, allowed to suggest it as an alternative to other popular coping mechanisms for the same problems, even to visitors already doing both. This confuses me.  Mental illness often leads to self medication through substance abuse**, eating disorders, social isolation, or simple inability to function in the world.  Done safely  (sterile instruments, proper care afterwords, incisions in safe areas- all of which can be taught) , cutting leads to… cuts.  Maybe some scarring if it’s really bad.  Cutters often report greater feelings of cope after cutting, and are able to invest that cope in other therapist approved things, like eating or seeking out a support network.

Not to mention the things you need to do to prevent people from self harming are incredibly intrusive (because everyone has finger nails), at a time when people most need to feel like their autonomy is respected.  Thin is a documentary about an eating disorder clinic, but a lot of the patients had self-harmed in the past (full disclosure: it’s been two years since I watched this and details might be fuzzy).   I’m sure the clinic had the best of intentions, but the section on the methods they used to prevent cutting left me screaming “do you not realize anorexia is about control?  I understand the feeding tube can’t wait till they get better, but is preventing cutting really worth triggering them like that?”.

In my perfect world, bystanders would treating cutting the same way participants do: as an external representation of an inner ugliness.  And then they would work on resolving that ugliness, rather than pushing away the evidence of it.  In a less perfect but still better than this world, cutting would qualify for the same harm reduction plans that drug addiction does, with health facilities providing sterile blades, bandages, and instruction of safe places to cut.  And then people would notice it is way, way less harmful than heroin or methadone*** and it would lose the stigma and now we’re back to my perfect world

*We’re allowed to praise a lot of things as alternatives to imminent suicide, up to and including later suicide.  It’s not often that “Why not see a doctor first and kill yourself if that doesn’t work out?”  is the right thing to say, but it’s not never either.

**Nothing like a depressant to chase the blues away

***Which is in fact significantly more dangerous than heroin, but less fun.

PS: If a patient or loved one of yours is cutting and you don’t know what to say, I have found “For a lot of people cutting is about releasing stored emotions.  Is it like that for you?”  to be a productive question.