My thoughts for this editorial come from paying attention to the wording of requests that I recently received for presentations. I was intrigued by their language. It is not uncommon to be asked “Can you come do a presentation about cutters?” and “Do you do trainings on managing borderlines?” I’ve become more aware of how often slang terms are used to discuss people who live with Self-Inflicted Violence (SIV). The words “cutter,” “self-injurer,” “borderline,” and “self-mutilator” seem to be the most common labels I hear. I realized that it is important to consider the meanings of these words most commonly used to describe people who live with SIV, and to consider the impact of their usage. I also gave more thought to several opinions that I’d received from some young readers of the newsletter. They didn’t care for the word “violence” in the term “SIV,” strongly stating that what we do to our bodies is often misperceived, that the behaviors of SIV are helpful and not harmful, and that the use of the word “violence” can misrepresent what we do. So I’ve been reflecting about the thoughts that led me to the creation of the phrase “SIV” and how I hoped it would be understood.
The Cutting Edge was first published early in 1990, and I struggled with language in writing the first issue. I’d spent a few years looking for people like myself, people who had lived with the need to cut or burn or bruise themselves (or other forms of SIV, some of which are described in the prose and poetry of this, and the previous, issue). As I came to know more people, and to listen to their stories and opinions, I realized that the things we did to our bodies—to cope with times of intense emotions, dissociation, disconnection—had very little to do with the language that typically described them. We all universally agreed that being referred to as “self-mutilators,” the most common label used to describe us, was demeaning and inaccurate. So I began my search for other terms used to describe us, didn’t find anything that felt accurate or respectful, and eventually realized that I wanted to create one myself. This editorial is a description of that process and I am eager to hear your opinions and suggestions on this topic of language.
Of the terms most frequently used to describe SIV, the most commonly used label is “self-mutilation.” This word has its origins in psychiatric literature. Self-mutilation is listed as one of the symptoms that characterize “Borderline Personality Disorder,” the most frequent psychiatric label given to people who live with SIV (the shortcut way of referring to someone with that diagnosis is to call the person “a borderline”). The word “self-mutilation” implies that the goal of the actions is actual disfigurement of the body, and that damage needs to result. This descriptor therefore does not include people whose forms of SIV do not result in scarring, such as people who punch themselves. It also suggests that those who live with SIV are masochistic, but that concept is oppositional to the purpose that SIV truly serves, which is as an action of self-help.
There can be no discussion of this “highlight” symptom of Borderline Personality Disorder (BPD), self-mutilation, without mentioning the destructive consequences of the label of “borderline.” This diagnosis has become mental health code for “this patient is a manipulative, self-mutilating, attention-seeking and extremely frustrating woman—protect yourself and try to get rid of her.” I recall one psychiatrist actually writing the word “exasperating” to describe “borderlines.” This sort of unprofessional, brutal judgment was not confronted by her peers. The exception to this image of a typical “borderline” is an increasing amount of men who are receiving this label, due largely to their living with SIV. Although technically this diagnosis cannot be given to persons under the age of 18, it is becoming more common to find adolescent girls and boys who’ve been labeled with it because of their SIV. As BPD is the only diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as the “DSM,” the book mental health professionals use to give diagnoses and bill for treatment), which includes “self-mutilation” as part of the diagnostic criteria, it is not surprising that most people who live with SIV and come in contact with the mental health system receive this label. Not surprisingly, people labeled as “borderline” typically experience patronizing, demeaning, or even abusive and coercive reactions from the professionals who are expected to be helpful to them. Fortunately, and thanks to the efforts of consumers and some insightful clinicians who are aware of the typical reactions to this label, there is now an increasing movement to eliminate this diagnosis. It is not possible to salvage this diagnosis, regardless of how accurate a clinician might perceive it to be. The diagnosis of BPD has become the dumping ground for clients that clinicians are fearful of or frustrated by and, ultimately, it is the persons who are labeled BPD who are blamed for the reactions that professionals have to them. A powerful action a compassionate and aware clinician can take is to remove the diagnosis of BPD from the client to lessen the impact of extreme prejudice that this term brings.
Other psychiatric terms used to describe SIV include “parasuicidality,” “delicate skin cutting,” and “deliberate self harm.” The first, parasuicidality, suggests that the actions of SIV are minimalistic, sometimes pathetic, suicide attempts. This further confuses SIV with suicide. The danger of this is that the reactions of professionals to people they perceive as suicidal often include coercion, such as forcible medication or hospitalization or other traumatizing reactions. Many people remain unaware that SIV is distinct from suicide, although it is not unusual that people who are in enough distress to need SIV sometimes live with thoughts of suicide as well. What is crucial to know is that SIV often brings a person profound relief from extreme discomfort and therefore can serve as a tool to prevent suicide. While SIV is not a permanent solution for intense pain and disconnection, it is useful in the moment. It is, therefore, an option that can make the difference for someone who is considering death as a solution to pain, helplessness, hopelessness, or despair. To remove SIV as a potential coping mechanism is to actually increase the chances that someone will consider death as an option.
“Delicate skin cutting” was a term found in the psychiatric literature with the beginning of awareness of self-cutting by adolescent girls. It disregards many other forms of self-injury and is therefore too narrow of a term to be effective. What was useful about this term, however, was the absence of implied intention about the behavior. The creator of this terminology didn’t suggest, in this phrase, why delicate skin cutting existed, just that it did.
“Deliberate self harm” is a label created by a psychiatrist who attempted to create a new diagnostic descriptor “Deliberate Self Harm Syndrome,” and get it included in the ever-present DSM. This phrase, like “self-injury,” is too broad and implies that the primary intention of the behavior is to harm the body. Fortunately this idea of a new “syndrome,” which would have led to a new diagnostic code, did not succeed, as it would have added yet another diagnosis that labeled a person based on only one component of their lives. It would have provided clinicians with an easy code with which to label people living with SIV, and therefore they could have avoided addressing the underlying trauma in the lives of people with SIV, as well as the purposes that SIV serves.
Typically, the media refer to SIV as “self-injury,” which is a more appropriate perception, although, as with “self-mutilation,” the word implies that injury needs to occur, and that the purpose of the behavior is to injure. The word “self-injury” is also very broad and therefore includes not only the behaviors of SIV but others as well, such as substance abuse, workaholism, and overeating. While all of these, and more, could be described as self-injurious, SIV has needed a place of its own, mostly because of how misunderstood and inappropriately reacted to it is.
So this leaves me to tell the story of why I use the words “Self-Inflicted Violence.” While I don’t think they are perfectly accurate, I do believe that they are more useful than the others. The words “SIV” are meant to be descriptive, without suggesting any particular meaning. They do describe acts of violence, such as cutting, punching, burning, scalding, and others. They do not attempt to imply the reason for these acts, especially avoiding the suggestion that the goal of SIV is mutilation, injury, or death. While many of us abhor violence, we also can understand that, in an imperfect world, violence is sometimes necessary. We understand that sometimes people use violent means as acts of self-defense. That’s how I describe SIV, as an act of self-defense, rather than self-aggression. SIV defends us from overwhelming emotions and experiences that seem intolerable. It buys us time while we learn to understand the roots of our struggles, build relationships with ourselves and others, and discover how to allow our most difficult emotions to flow. Perhaps the most important part of discussing this topic, however, is in making sure to say that it is people who live with SIV. We are not SIV. SIV is only a part of our lives.
What is the impact of labeling? What does this shortcut do to our humanity? I believe it does more than we realize. When people become “cutters” or “burners” or “borderlines” then we think we know them as a result of the label. We actually know very little about them. We know that they sometimes cut themselves, or burn themselves, or that they have been around mental health professionals enough to be labeled with BPD. But what else do we know? If we ourselves live with SIV we might feel a sense of kinship with others who live with SIV, just by knowing that SIV is part of their lives. But what really builds the connection with others, for me, is in the sharing of what SIV means to us, how it helps, how it hurts, where the pain and numbness come from, how to soothe them.
In prison you are known as a number; in psychiatric hospitals you are often referred to as a diagnosis. This process of objectification and dehumanization mimics that which occurs with bigotry and experiences of abuse, especially sexual abuse. Think of the labels, the slang terms, that you’ve heard that objectify different types of people. Does this serve those people, or you? Of course not, people are not objects to be categorized. When people are objectified they almost always end up dehumanized. The use of labels conveniently allows us to classify whole groups of people, usually in ways that disregard them as individuals and diminish their humanity. That’s what I realized when I found myself reacting to the words I was reading, the ones I mentioned at the beginning of this editorial. Though the discomfort I felt about the language was subtle, it was there. So, do I do presentations about cutters? I do presentations about the reasons people need SIV and how they heal. Do I do trainings on managing borderlines? I do trainings on the impact of the diagnosis of BPD, and this includes how people with SIV live and heal as well.
I am not a label. You are not a label.
How do you choose to describe yourself? As for me, I’m Ruta. I was named after a small plant from the country, Lithuania, where my parents were born. I’ve had an incredible life thus far, full of intense joys and almost insurvivable pains and losses.
I’ve lived through many ugly abuses, and the horrors I survived left me partly disabled. I’ve not been able to work as a therapist for many years, but I cherish the work I do have—editing this newsletter and teaching and consulting on issues of trauma and healing. I’ve survived the psychiatric system, the misunderstanding and labeling, hospitals and seclusion rooms. I’ve found many ways to survive and heal, including dear friends, sports, nature, music and authors, food, cigarettes, and, of course, SIV. I no longer need to comfort myself with food, smoking, or SIV, and I’m glad for that, but I’m also glad that I had those things that got me through the hardest times. I delight in my cabin home in the hills of eastern Ohio. Although I lost the love of my life quite tragically, it led me to discover how much I like to live alone. Well, not really alone as there are three dogs (Buddy, SweetPea, and Murphy) and three cats (Smudge, Punkin, TaterTot) that live with me. They are all survivors and strays like myself, so we get along amazingly well.
Oh, and I’ve been called a cutter and a burner and a borderline.
Who are you?