08/12/16

When Pain Feels Good

© sapegina |stockfresh.com

© sapegina |stockfresh.com

Counter-intuitively, self-harm or self-injury is best seen as an attempt to relieve pain than to cause pain. An NPR program, “The History and Mentality of Self-Mutilation” noted that in the late 19th century, two American doctors described a strange phenomenon. Women were puncturing themselves with sewing needles. The practice was so common, that doctors began to refer to the so-called “hysterical” women who did this as “needle girls.” Hysteria was the “it” psychiatric condition of the time. Sigmund Freud’s first published book was one he co-authored with Josef Breur, Studies on Hysteria. But self-harm has a longer history, dating back even to the time of the Greeks.

Self-harm is found in situations as wide ranging as monasteries, nunneries and modern-day prisons. Within a religious context, the practice is called flagellation. The practice of mortifying the flesh for religious purposes within the Roman Catholic Church dates to 1054. Within Roman Catholic ritual, the fourth of the modern Stations of the Cross is the Flagellation of Christ. This station is based upon the scourging of Christ, just before he was delivered up to be crucified (Mark 15:15). Typically occurring before a crucifixion, scourging was with a cattail whip that had pieces of bone or metal tied into it.

In the 14th century, the Flagellants were condemned by the Roman Catholic Church as a cult. But a mild form is still practiced within a few strict monastic orders. And some members of the Catholic lay organization, Opus Dei, use a “discipline” during prayer. This is a cattail whip of knotted cords, which is repeatedly flung over the shoulders during private prayer. Reportedly, Pope John Paul II practiced this discipline regularly.

Armando Favazza, who has studied self-injury for several years, said its practitioners use it as a way to silence a swirl of pain and anxiety. “They describe it as popping a balloon. All the anxiety just seems to go away.” A 19 year-old woman interviewed in the NPR story said she has her own “kit”, consisting of a new pack of razors, a pair of scissors and a pink towel. Whenever she was stressed, she turned to her kit. Before cutting her mind is exploding. But when she feels pain, there’s a kind of peace. “I’ll just be really calm and my thoughts will finally kind of be making sense, instead of them like racing through my head and nothing quite clicking. Just kind of centralizes my thought on one thing.”

A 2010 article, “Self-Injurious Behavior in Adolescents” by Janis Whitlock defined self-injury or non-suicidal self-injury (NSSI) as “the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned.” Most often, it is not a suicidal gesture, while it can result in severe harm or death. Studies tend to find what is referred to as common NSSI in 12% to 37.2% of American high school-aged individuals and 12% to 20% of late adolescent and young adult populations. “Overall, about a quarter of all adolescents and young adults with NSSI history report practicing NSSI only once in their lives.” The available evidence suggests that 40% of repeat NSSI report stopping within the first year, and 79.8% report stopping within 5 years of starting.

Unpublished data indicates females are slightly more likely to practice self-harm than males. In my counseling experience, I’ve talked with both males and females who attempted NSSI. This is also not an isolated American phenomenon. NSSI is present in a variety of countries and cultures globally. “Although most widely investigated in industrialized regions such as Europe, North America, Australia, and New Zealand, NSSI also occurs with some regularity in other industrialized and non-industrialized countries as well.”

Self-injury is strongly linked to childhood abuse, especially childhood sexual abuse; eating disorders, substance abuse, PTSD, depression and anxiety. While it is common among adolescents, NSSI often goes undetected. Some signs can include wearing long sleeves or pants during hot weather; constant use of wristbands/coverings, unwillingness to participate in activities with less body coverage, like swimming or gym class; and frequent bandages. Whitlock also highlighted what she saw as five key studies of NSSI. See her linked article for the details.

Moran et al. published a natural history study of self-harm in the British journal The Lancet in 2012. More girls (10%) than boys (6%) reported self-harm in adolescence. There was a substantial reduction of self-harm during late adolescence. During adolescence, self-harm was associated with depression and anxiety, antisocial behavior, high-risk alcohol use, cannabis use and cigarette smoking. While most adolescent self-harm resolved spontaneously, when mental health issues are associated, treatment mat be needed.

Most self-harming behaviour in adolescents resolves spontaneously. The early detection and treatment of common mental disorders during adolescence might constitute an important and hitherto unrecognised component of suicide prevention in young adults.

A Cochrane study by Hawton et al. in 2015 looked at pharmacological treatment for self-harm. The conclusion was: “There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH [self-harm].” They found no significant treatment effect for newer antidepressants, fluphenazine (an antipsychotic), mood stabilizers or natural products. While a significant reduction in self-harm behavior was found with flupenthixol (an antidepressant), the quality of the evidence for the study was very low. No data on adverse effects, other than the planned outcomes related to suicidal behavior, were reported.

We have reviewed the international literature regarding pharmacological (drug) and natural product (dietary supplementation) treatment trials in this field. A total of seven trials meeting our inclusion criteria were identified. There is little evidence of beneficial effects of either pharmacological or natural product treatments. However, few trials have been conducted and those that have are small, meaning that possible beneficial effects of some therapies cannot be ruled out.

In a 2004 article in The Journal of Biblical Counseling, “Self-Injury: When Pain Feels Good,” Ed Welch said anything that arouses unwanted emotions can trigger the self-harm cycle. Trouble in relationships or anything that can provoke shame could be triggers. Beliefs that you have violated a personal, cultural or religious taboo can initiate it. “Perhaps you just don’t tolerate your own humanness with its imperfections, weaknesses, dependencies and sins.” Welch described the cycle of self-harm as following the pattern in this graphic: self harm

These beliefs, personal experiences, and external circumstances mix into a stew of raw emotions that can include anger and frustration, anxiety, or a jumping-out-of-your-skin agitation. Without alternatives, self–injury gradually becomes the preferred response to these feelings because it works. You regain control. Your emotions are back in check. The screams within have been temporarily silenced.

Welch is approaching the issue of self-harm from a biblical, religious perspective. So his advice and action steps will include addressing the spiritual side of self-harm: “Self-injury is, at its root, about God. Avoid Him, and we miss true hope.” In order to address self-injury: 1) Allow other people in; ask for help. 2) Grow in honesty; don’t hide your behavior. 3) Feed yourself with Scripture; the Psalms are a good place to start. 4) Write out the meaning and purpose of your self-injury. 5) When you fail, don’t give in to hopelessness. “All human beings sin and fail. It is what we do!” 6) If you keep moving back into self-injury, notice the intentionality of your behavior. Are you putting barriers between yourself and your self-abuse strategies?

If you are interested in the complete article by Ed Welch, you can purchase it in booklet form on Amazon or at the Christian Counseling and Education Foundation (CCEF). The booklet is $3.99, but if you purchase it in its original form in The Journal of Biblical Counseling, you can purchase the full digital issue it appeared in (JBC Volume 22:2) for $4.99.

03/6/15

One Day at a Time

© Field of tiger lilies by elwynn | stockfresh.com

© Field of tiger lilies by elwynn | stockfresh.com

“There may be greater sins than worry, but very certainly there is no more disabling sin.”  (William Barclay)

In his book Running Scared, Ed Welch pointed out how many psychiatric conditions have to do with fear. There was a time, he said, when you were either psychotic or neurotic. “Psychotic meant that your were out of touch with reality and afraid; neurotic meant that you were in touch with reality and afraid.” Today there are many more shades of fear and anxiety. Within the DSM-5, there are 22 distinctly coded conditions just within the section on Anxiety Disorders.

Welch observed how various medications or psychological treatments, such as systematic desensitization, focus on thinking or bodily responses to fear and anxiety. But he suspected there was a deeper reality to our fears and worries. “Listen to your fears and you hear them speak about things that have personal meaning to you. They appear to be attached to things we value.” So to understand fear and anxiety, we have to look at ourselves, and the way we interpret our situations.

Within the short space of nine verses in the Sermon on the Mount (Matthew 6:25-34), there are three commands for us to not be anxious. We are encouraged to not be anxious about our life or about our future. Jesus underlines the pointlessness of anxiety here, while providing good reasons for trusting God. The Theological Dictionary of the New Testament put it this way: “Worry is unnecessary. God has lifted it from man.”

There are also three “therefores” that initiated those commands, whose purpose was to connect the paragraph or passage to what was just said. So the command to not be anxious about our life in verse 25 connects back to what Jesus said in verse 24: “You cannot serve two masters”—God and money. Verse 31’s “therefore”—don’t be anxious about what to eat, drink or wear—proceeds from the discussion in verses 26 through 30 about how God provides for the birds, flowers and grasses.

Look at how God provides for the insignificant things of his creation. The birds never go hungry or thirsty—yet they cannot sow, reap or gather into barns. The wild flowers, which cannot clothe themselves in finery, are more beautiful than King Solomon in all his glory. If God is careful to provide for them, will He not do much more for you? “Therefore do not be anxious, saying, ‘What shall we eat?’ or ‘What shall we drink?’ or ‘What shall we wear?’”

These worries are what drive the “Gentiles,” those who don’t know or trust in God. When you are anxious, you are forgetting the one whom you serve. Robert Mounce said in his commentary on Matthew: “Worry is practical atheism and an affront to God.” Verse 33 is then the climax of the passage: our first priority should be to seek out the kingdom of God and his righteousness. As Craig Blomberg said: “When priorities regarding treasures in heaven and on earth are right, God will provide for fundamental human needs.”

Worry does not accomplish anything. Anxiety is futile. It cannot add a single hour to your life. The future we try to provide for is not in our hands. “Whatever happens will be under God’s control.”

The final “therefore” then leads us to the logical inference from previous ones. If we aren’t to be anxious about our life, what we are to eat, wear or drink, then we aren’t to be anxious about the future. “Sufficient for the day is its own trouble.” In other words, live one day at a time.

This advice is heavily steeped within the culture and life of recovery. An early AA Grapevine article  (“Yesterday … Today and Tomorrow,” July 1942, vol.2, no. 2) commented that it was not the experience of today that drove people mad. Rather, it was remorse for something that happened yesterday and the dread of what will come tomorrow. “Let us, therefore live but one day at a time.” In “Garden Variety” Sara S. said she was a garden-variety alcoholic. “I know that one day at a time my life is becoming all that God intended it to be.” J. S. R. of Philadelphia commented in “Sidebar,” published in the October 1954 (vol. 11, no. 5) issue:

When I decided to stay sober one day at a time, I had no idea what an impact this would have on my life. As time progresses it becomes obvious that I live one day at a time. This is a very great consolation. No longer do I project bridges into the future, nor am I particularly concerned about yesterday. I do concern myself about today’s effort and sometimes it isn’t a very pretty picture; however, with proper training along simple lines as advocated in the very essence of AA, I have no fear.

Leon Morris observed that when an individual lives one day at a time, they defeat anxiety. A shallow thinker might conclude from Matthew 6:33 (But seek first the kingdom of God and his righteousness, and all these things will be added to you.) that a believer will have a smooth path through life. But that is not what Jesus is saying. All people have trouble. But there is “all the difference in the world between facing the problems we meet with firm faith in our heavenly Father and facing them with anxiety.”

This series is dedicated to the memory of Audrey Conn, whose questions reminded me of my intention in seminary to look at the various ways the Sermon on the Mount applies to Alcoholics Anonymous and recovery. If you’re interested in more, look under the category link “Sermon on the Mount.”