By Melanie Chung-Sherman, LCSW-S, CTS, LCPAA At the tender age of 5 years old, Rebecca* took a belt and attempted to hang herself in her foster parent’s closet. She talked about wanting to kill herself from a young age. She drew macabre pictures of death and dying at home, school, and with the many therapists she encountered. She was medicated and told to behave. Following her adoptive placement when she was 8 years old, she discovered that picking her scabs until they bled or pulling out her hair in clumps created a sense of release when she became upset or anxious. She did not believe that she would stay in any home permanently. She was keenly aware of other people’s exhaustion and frustration with her behaviors. She was even sent to her room or grounded from others in a failed attempt to discipline her — which only reinforced her isolation, sense of guilt and false script that she must solve this issue alone because it was too much for the adults. People looked at her funny when she would arrive to school with clumps of her hair pulled out. They even tried to coax her out of her shell and told her to “use her words.” However, they did not realize what she had already learned, that hurting herself was far more productive than any word could elicit. She also learned that words could be powerful weapons — resulting in losing her birth family, getting moved to various foster homes because her “words scared them,” and sending her abuser away to prison — driving her shame even further inside. She also realized that hitting herself would not only garner attention, it would stop adults from attempting to physically discipline her like they had tried to do while in foster care. There were times that she would hit herself until she bruised or bled. It became a “safe” way for her to receive attention from those she learned to mistrust — including herself. Multiple hospitalizations, muffled conversations between her adoptive parents and professionals about what they were “going to do with her” only fueled her assumption that they were eventually going to get rid of her. Threats and discipline produced little impact and reinforced that she was too broken, too shattered for redemption. Why, then, should she stop what gave her the only spark of feeling alive? She only learned to hide her harmful behaviors and emotions from those who professed that they wanted her to heal. She made a conscious decision to stop harming in places that her scars were visible, so she hid them away on her thighs, breasts, upper arms, stomach, buttocks and vagina. On the outside she appeared “perfect” — a straight-A student, cheerleader and the epitome of performance. But on the inside she struggled with her identity and attraction to other girls. She wondered who in her birth family might be bi-sexual or lesbian? She was so angry that she had one more thing that was different within her. Turning to her adoptive parents was too complex and risky because she felt she caused enough problems — and their spiritual beliefs would not allow grace or understanding of that issue. She needed to be perfect because life experience reinforced that people do not leave “perfection.” So she continued punishing herself privately. As she entered young adulthood, her pain threshold was not like everyone else’s. She needed more to induce the same release she felt as a young girl and began cutting deeper — brazenly defying the last cuts and all those who told her to stop. Sometimes she cut so deep — to the muscle — and felt a rush of euphoria. She did not intend to kill herself at first — just quell the pain. What did people really know of her pain? A pain so deep and dark that she needed to battle in isolation because if they really saw the “badness” inside her was too much for anyone to deal with. When everything else in her life was out of control, she blindly felt more empowered to harm herself and an expert in this aspect of her life. She became quite popular on underground chat rooms and websites discussing her risky behavior. Through friends, she learned that controlling food intake was also powerful and began to restrict her diet through binging and purging in high school. She realized that alcohol was a powerful elixir combined with starvation to douse the hurt and drive it deeper — yet, it was socially acceptable in college. Those close to her watched her shrink away, but she would casually share that she was fine and not to worry — some even praised her rapid weight loss as a symbol of self-control and strength. Little did they really know. Over time, her appearance began to match how she felt on the inside, but by that time, she was too exhausted to care anymore. She believed that if they really knew her, they would leave anyway . . . so she decided she would leave nothing behind. When she was 19 years old, Rebecca attempted suicide for the first time. (*Names, identities and case histories are fictional to protect the identities of clients served. Any representation in likeness is coincidental.) The number of children, adolescents and adults struggling with deliberate self-harm remains a subject that most parents, educators, religious figures and caregivers rarely address, let alone discuss openly. It is important to note that self-harm behaviors do not discriminate against ethnicity, culture, gender, socioeconomic, religious beliefs or even methods of placement into the home whether by birth, adoption, kinship or foster. Deliberate self-harm is when “one intentionally damages one’s own bodily tissue without intending to die” (Gratz & Chapman, 2009) to immediately release feelings of anguish and pain. It is important to determine what self-harm is not, though commonly categorized as self-harm, such as alcoholism, drug abuse, eating disorders or other destructive behaviors that develop and increase in intensity over time. For example, most people do not set out to drink him or herself into a coma on the first drink, but when a person chooses to purposefully cut skin — they are seeking immediate reaction. Thus, some examples of self-harm include, but are not limited to, burning, cutting, pulling out hair (Trichotillomania), excessive scratching, punching self, continuously picking at scabs or wounds, biting and suicide attempts. Self-harm is a coping mechanism to deal with intense emotions. Think of it as an immediate release with a slow-burn over time. Despite differing variables, there is a distinct connection between self-harm and suicide attempts. According to the U.S. Center for Disease Control (2012), approximately 70 percent of youth who engage in “repetitive self-harm also attempt suicide.” This behavior is more common among teenagers and young adults ranging in age from 13 to 35 years old (Gratz & Chapman, 2009). However, it is assumed that the younger a person is when he or she engages in harmful behaviors, the more complex and difficult it will be to stop. Many experts believe that with the immediate access of the Internet, self-harm, has become more normalized and socially acceptable. Are Adoptees at More Risk? There are unique factors that can put adoptees and foster youth at more risk for self-harm. Adoption is born of loss and grief. Grief can be connected to feelings of abandonment, rejection, difference and an unknown identity. Many adoptees and foster youth have limited, or inaccurate, medical and social histories creating a space for questions and assumptions related to inherited issues ranging from physical and mental health — as well as a missing connection to who an adoptee might look like, love or become. This can trigger feelings of depression, anxiety, anger, shame and helplessness. If acknowledgement of adoption-related loss within society, an adoptive family, or the adoptee is dismissed or minimized as legitimate, it can create a deeper sense of solitude. This sense of solitude and difficulty communicating feelings, coupled with adverse childhood experiences, can heighten overall risk (Slap, Goodman, & Huang, 2001). These adverse childhood experiences are noted in the longitudinal study by Kaiser Permanente and the Center for Disease Control that range from child abuse, neglect, domestic violence, multiple caregivers, war, chronic trauma, suicide in the family, mental health and more (Bynum, Griffin, & Riding, 2010). There is no statistical evidence in which adoption or foster care is the primary cause for self-harming behaviors any more than stating all animals with claws are bears. It is fair to say that most adoptees and foster youth have experienced at least one or more of those experiences prior to placement — and in some cases following adoption. Statistically, more adoptees and foster children enter into therapy programs based on unique circumstances than the general population. It is important to note that because an individual was adopted or fostered should not automatically suggest that he or she will self-harm or become suicidal. Therefore, a cautious awareness is realistic and healthy, rather than a pathological verdict, which can inadvertently reinforce an environment of mistrust and frustration. Formulating secure attachments early in development “does not simply improve the odds of intimate connections” (Powell, Cooper, Hoffman & Marvin, 2014), but reduces the long-term impacts of adverse childhood experiences. Many adoptees, foster youth and some adoptive parents have endured, at the least, relational trauma and separation, which significantly impacts their ability to feel worthy of love and reach out for help from loved ones. It can be argued that someone who harms does not necessarily trust him or herself — let alone other people to care for his or her needs. Attachment is a give-and-receive process between parent and child, thus, if clues or statements by adoptive parents or caregivers repeatedly go unnoticed or dismissed, the inadvertent message reinforces a sense of unworthiness, disconnect or guilt. At the core of this barrier is shame. This pattern creates a vicious cycle of self-harm and further detachment from those closest. In an attempt to alleviate the shame, self-harm becomes a form of punishing the “badness” that one falsely believes may have caused the abuse, abandonment, rejection or neglect. Sexual orientation is another distinct factor that raises the risk of self-harm and suicide. Adoptees and foster youth struggling with sexual orientation, such as LGBT issues, coupled with the differences associated with adoption, raises the risk. Gender and sexual orientation is intricately linked as individuals enter adolescence. If sexual differences are perceived as socially unacceptable or even intolerable within places that profess a foundation of trust and security such as schools, places of worship, the community and the adoptive family. It can become confusing and disheartening to those struggling — as places that are seen as both refuges and venues to promote adoption and fostering, yet not completely accept differences of an adoptee’s sexual orientation. This can be felt as yet another rejection and abandonment. Partial acceptance of an individual is not full acceptance, and adoptees know this, creating a fracture of trust and vulnerability — driving the need to punish further and keep even more secrets within. The term “birth mother rage” or the “primal wound” related specifically to self-harm and adoption issues has been suggested by professionals and adoption constellation members. Though, there are a variety of feelings related to relinquishment for some constellation members, more specifically adoptees, it is erroneous to assume that self-harm is directly related to birth parent driven rage or abandonment alone. Not only is that assumption potentially damaging to an adoptee’s narrative as well as demeaning to the role of the birth family, it limits the exploration of other issues contributing to self-harm that may stretch beyond adoption-related issues alone. Relating self-harm directly to adoption-related issues alone simplifies a complex issue. This assumption places false responsibility on the adoptee in which there will always be something inherently wrong with no chance for parole — based solely on the fact they were adopted. It does not take into account the many other factors that play a role beyond the identity of adoptee. If a person were to arrive at the emergency room with a broken arm after a skiing accident, what good would it do to merely treat for head injuries? Hopefully, everything would be evaluated, but the broken arm needs immediate attention. Let’s face it, self-harm behaviors such as cutting one’s self goes against social norms and tends to create an uneasy feeling in others. . . and for good reason. At the crux of self-harm is a deep-seeded need to momentarily halt powerful feelings of hurt, inadequacy and shame. Ultimately, self-harm works or individuals would not continue to do it. Though, it can provide immediate release, the release is only temporary and can quickly become an addictive behavior, in which a person has built a tolerance and needs each experience to be more intense and frequent in order to obtain the first “high.” Repeated experiences of self-harm tend to take place in isolation fueling feelings of dread and shame — creating a vicious cycle. In addition, “repeated self-harm is one of the best predictors of eventual death by suicide” (Gratz & Chapman, 2009, p. 27). As tolerance increases, inhibition and caution decreases, which can lead to unintentional suicide — or intentional. When words go silent and painful experiences hide away from light, our human nature reverts to survival and cowers in the dark. We hide, cover, punish and lie to beat away the rushing tides of shame, devaluation, pain and fear. Ultimately, self-harm is a choice. It does not relieve the pain, but only hides the underlying issues. It is not a phase that will just go away. It is not considered a normal or healthy behavior, but becomes a normalized way for the person to relieve themselves. Family members are typically the first line of defense. Self-harm is risky and dangerous — and in most cases professional help is warranted to intervene. There is always hope and a pathway toward recovery. The waves of self-punishment no longer have to eclipse the joy of living. The long road to healing is always worth the hard work — and breaking the bonds of silence, secrecy and shame. Melanie Chung-Sherman, LCSW-S, CTS, LCPAA, is the clinical director of post-adoption services at Christian Works for Children in Dallas, Texas. She is a board-certified clinical supervisor and licensed clinical social worker as well as a licensed child placing administrator through the State of Texas. She is a certified trauma specialist through The National Institute for Trauma and Loss in Children™. She is a practicum student through The Theraplay® Institute. She is the founder and owner of a private practice dedicated to providing adoption-competent counseling through the lifespan. She is an adjunct professor of social work at Collin College. She has spoken nationally and internationally regarding child welfare and mental health issues. She graduated from the University of Texas at Arlington with a master of science in social work. She and her younger brother were adopted from South Korea in the 1970’s. Her greatest joys are her children and spending quality time with her husband and close friends. Warning Signs of Self-Harm
- Obvious signs or actions of injury.
- Preoccupation with scars and wounds.
- Isolation from family and friends.
- Heightened defensiveness or denial when asked directly about scars or marks.
- Depression and anxiety.
- Lack of emotion or verbalization of feelings in a healthy way.
- “Sharps” found throughout personal belongings such as razors, string, scissors, knives.
- Missing sharps in the home.
- Websites and chat rooms devoted to self-harm (EMOs).
- Drastic change in appearance, dress and social circles in which cutting and risk-taking is applauded.
- Wearing clothes that are not congruent with the season or weather (attempting to cover scars).
- Giving away possessions.
- Suicide attempts or threats.
- Child abuse and neglect, including emotional neglect.
- Multiple attachment breaks.
- Unresolved trauma.
- Sexual orientation, particularly LGBT.
- Parental history of self-harm (birth or adoptive family).
- Mental health history (birth family or adoptive family).
- Addiction issues (birth or adoptive family).
- Suicide attempts by birth and/or adoptive family members in the past.
- Chaotic family life (birth and/or adoptive home) — domestic violence, divorce, separation, absent parent.
- Psychiatric hospitalizations.
What to do?
- Talk, talk, talk — acknowledging that your child or someone you love may be harming themselves can bring a sense of relief and understanding.
- Create a purpose-filled space of compassion — with a goal to connect despite the outcome. Ask about your child each day. Actively engage when your child appears to push you away . . . this is when he or she needs you the most.
- Do not judge — remember this is self-protective as much as it is a coping mechanism. Though, this is not the way you may deal with pain, it is how your loved one has.
- Do not try to solve or fix the problem — this will not be “cured” or solved by attempting to find a solution. Your loved one may not recognize the issue to be addressed — as there may be many.
- Do not assume that addressing the deep emotional issues must happen first before self-harm stops — self-harm is a form of dissociation, or a break with the here and now. Thus, one cannot necessarily traverse deeper emotional connections to the behavior without containment and healthier coping skills learned.
- Do not use threat, yelling, or coercion to stop the behavior — this will only drive the shame, fear, and guilt further into isolation. Offer support and an avenue that they can come to you when they need.
- Do not assist in the self-harm by buying or supporting the behavior — you can be compassionate without enabling.
- Relapse is not a weakness, but part of recovery — there will be moments of relapse and that is also a time that deeper connection and attachment can be reinforced — that regardless of the relapse, their loved ones are there by their side.
- Seek professional help immediately. This may be a life-long journey of recovery for some and a shorter recovery for others.
Resources to Consider:
- S.A.F.E. (Self Abuse Finally Ends): http://www.selfinjury.com/
- Local 12-Step programs
- Community services that offer recovery and accountability groups (i.e. places of worship, YMCA, etc.)
- Counseling programs and therapist specialized in self-harm
- CDC: http://www.cdc.gov/ViolencePrevention/Suicide/statistics/index.html
- Mayo Clinic http://www.mayoclinic.org/diseases-conditions/self-injury/basics/definition/con-20025897
References: Adverse Childhood Experience (ACE) Study (2014). (Graph illustration The Adverse Childhood Experiences Study). Retrieved from http://www.cdc.gov/violenceprevention/acestudy/ Bynum, L, Griffin, T., Riding, D. L., Wynkoop, K. S., Anda, R. F., Edward, V. J., Strine, T. W., Liu, Y., McKnight, L. R., & Croft, J. B. (2010). Adverse childhood experiences reported by adults: Five states, 2009. Morbidity and Mortality Weekly Report, 59(49), 1609-1613. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm Gratz, K. L. & Chapman, A. L. (2009). Freedom from self-harm: Overcoming self-injury with skills from DBT and other treatments. Oakland, CA: New Harbinger Publications. Powell, B., Cooper, G., Hoffman, K. & Marvin, B. (2014). The circle of security intervention: Enhancing attachment in early parent-child relationships. New York, NY: Guilford Publications. Slap, G., Goodman, E., Huang, B. (2001). Adoption as a risk factor for attempted suicide during adolescence. Pedatrics, 108. Retrieved from: http://pediatrics.aapublications.org/content/108/2/e30.full.html Swahn, M. H., Bina, A. H., Bossarte, R. M., Van Dulmen, M., Crosby, A., Jones, A. C., & Schinka, K. C. (2012). Self-harm and suicide attempts among high-risk, urban youth in the U.S.: Shared and unique risk and protective factors. International Journal of Environmental Research and Public Health, 9, 178-191.