Podcast: The Raw Reality of Self-Harm and Healing

Gillian C. Galen, PsyD, is a senior child and adolescent psychologist specializing in dialectical behavior therapy (DBT). She is the director of training for the 3East continuum, an array of programs for teens that use DBT to target self-endangering behaviors and symptoms of borderline personality disorder. She has extensive experience diagnosing and treating adolescents and young adults who struggle with emotion dysregulation, anxiety, depression, trauma, and self-endangering behaviors, such as self-injury and suicidal behaviors.

Dr. Galen has a particular interest in the use of mindfulness in the treatment of borderline personality disorder and psychiatric illnesses. She is the co-author of the books “Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy”, “Coping With BPD: DBT and CBT Skills to Soothe the Symptoms of Borderline Personality Disorder”, and “DBT for Dummies.”

Our host, Gabe Howard, is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author. Gabe is also the host of the “Inside Bipolar” podcast with Dr. Nicole Washington.

Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without. To book Gabe for your next event or learn more about him, please visit gabehoward.com.

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Hey everybody, welcome to the podcast. I’m your host Gabe Howard. Calling into the show today, we have Gillian C. Galen, PsyD. Dr. Galen is a senior child and adolescent psychologist specializing in dialectical behavioral therapy, or DBT. She is the Director of Training for the 3East Continuum. And please note that funding for today’s episode has been provided by McLean Hospital. So a big thank you to them. Dr. Galen, welcome to the podcast.

Gillian C. Galen, PsyD: Thanks. Thank you for having me.

Gabe Howard: Thank you so much for taking the time today. And today we’re going to be discussing how to navigate self-harm. Now let’s start off by discussing how urges to self-harm and really suicidal thoughts for that matter, they do change as we age. Is self-harm something that comes up at any age, like for example, do a do adults start self-harming whereas they don’t have a history of this behavior as children?

Gillian C. Galen, PsyD: Yes. So. So I think, you know, the brain is really different in adolescents and adults. I think in general, in my certainly in my experience treating many adolescents, young adults and some adults. There is or tends to be more self-injury and self-harm in adolescents. The prefrontal cortex is less developed, underdeveloped, which is natural, right? It’s really developing into your mid 20s at this point. And so you’re seeing self-injury happen more I think, in adolescence. There’s also nowadays a culture of self-injury. You’re seeing it in the movies. There’s blogs about it. There’s books about it. Huge percentages of kids will report trying self-injury as a form of emotion regulation. You tend to see over time any kinds of self-injurious behaviors, particularly people that struggle with extreme emotion dysregulation and symptoms of borderline personality disorder. You do tend to see those decrease over time, even with no with no treatment. So there are many fewer adults trying self-injury. It doesn’t mean that they’re not there, but it’s a more common trajectory tends to be that it’s starting in in adolescence.

Gillian C. Galen, PsyD: Or maybe it started in adolescence. It paused and then it reemerged later in sort of later adolescence or college age or post-college. And you’re seeing fewer of those more impulsive behaviors around emotion regulation like self-injury, just change over time. So there’s been studies done out of McLean and Mary Zanarini lab, which just show over time that that is just not one of the behaviors that people will use as they grow older for emotion regulation. You know, I also see it in my practice, right. You know, with treatment, as people develop, they tend to rely less on self-injury as a mode of emotion regulation went into adulthood. I think it’s also become a little bit more accepted. Not not accepted as like, you know, okay. Bas as part of in high schools, many kids are doing this. It’s much, you know, you can find communities of kids doing this. And even in college of kids doing this, it’s much harder to find that in adulthood. And a higher need to hide it in adulthood, I think, as well.

Gabe Howard: Just to make sure I’m wrapping my brain around this correctly. Is it possible for somebody? And I’m just I’m just arbitrarily picking a number, who is 40 years old and has no history of self-harm to start self-harming? Or is that something that that doesn’t occur too often?

Gillian C. Galen, PsyD: I think it’s possible, but I think it’s uncommon.

Gabe Howard: Oh, okay. Now one of the things that comes up that we see in pop culture is that self-harm is always a young person, almost always white, almost always female, and she has self-harming to handle some sort of trauma that has befallen her. Is that what self-harm actually looks like in real life?

Gillian C. Galen, PsyD: You know, so so that’s one version of what self-harm looks like. I think it’s certainly what we tend to see more, more of, in general you know, one of the misnomers about self-harm is that it’s linked with trauma and really the, the if you look, if you look at studies, if you look at groups of people that that use self-harm as emotion regulation, right. Because the predominant function of self-harm is to regulate emotion, there’s a very small percentage of people that self-harm to communicate, to make a communication about their distress. There’s another smaller percentage of people that self-harm around self-punishment. But the majority of people are using self-harm to function as emotion regulation. They’re often down regulating. They’ll tell you, I feel anxious, I feel overwhelmed, I can’t manage, I self-injure and then I feel relief. Or they’ll say, I feel nothing, I feel numb, I feel disconnected, they will self-injure, and then they’ll have that sort of surge of endorphin and emotion that is actually the most common now, certainly within those subsets. Right. There are people that have trauma and have PTSD. And are managing the emotion dysregulation related to trauma by using self-injury. But that’s not the majority of people, right? That’s one subset of people that are using it as self-injury. I think the majority of people that we kind of see in the world around self-injury is probably female.

Gillian C. Galen, PsyD: You’re seeing all the people in the movies are white adolescent girls. From my experience, you know, lots of boys self-injure many, many boys self-injure and men Self-injure you actually see a lot of self-injury in men in prisons, but there’s a lot of boys that self-injure. Now, sometimes the self-injury looks different right? You know there’s self-injury by cutting. There’s self-injury by burning. There’s there’s many different types of self-injury. Some people are carving. So, at some point there was a thought well maybe boys and young men tend to use things more, more burning than cutting. I think part of this goes to what, again, what you see, girls and women tend to be more help seeking. They show up more in treatment, and I think they tend to be the protagonists in the movies more than boys. I think in general, boys that struggle with emotion dysregulation can get more tracked in the juvenile justice system or defiance or aggressive behaviors. But many we see many, many boys that have very significant difficulties with self-injury.

Gabe Howard: It really seems like self-injury and self-harm is a maladaptive coping skill that they’re trying to resolve. One problem, and unfortunately, the way that they are resolving that isn’t the healthiest. But it does sound like it works. How do we wrap our heads around that idea, especially when we’re trying to help somebody?

Gillian C. Galen, PsyD: Yeah. Yeah. So I mean, so you’re exactly right. I think it’s you’re ahead of the game because most people I talk to, it’s too hard to wrap your mind around this, right? So one of the things that that happens with self-injury, right, is that providers and parents and family members, we identify this as a problem. Here is the problem behavior. The problem, the problem is self-injury. The person that is self-injuring that self-injury. It may be a problem, but it’s a solution, right? It’s a profoundly effective short-term solution to emotion regulation. Right. And that’s one of one of our biggest challenges. For those people in the behaviorism world, we talk about negative reinforcement, which is behaviors that we do, that produce powerful relief, that make us want to do them again. And this is how self-injury works. Self-injury works extremely quickly. It changes how you feel emotionally very quickly. Now it causes its own problems, right. Because people put you in therapy or it has social problems or, you know, it gets in the way at school or at work. But fundamentally, if you’re feeling like you are drowning in an emotion, it is a powerful, powerful, powerful, what we would call short term solution to a long term problem. Right. Because I’ll often talk with people and they’ll tell me how well it works, and I will agree with them.

Gillian C. Galen, PsyD: The problem is, if it really worked, I wouldn’t need to do it again. It would work one time as an effective solution, but it doesn’t. Right. You have to continue to do it to regulate your emotions. And often what we know is that the more you rely on self-injury to regulate, you often fall into this, this sort of track of you need to self-injure more and more to gain effectiveness and deeper and deeper.

Gabe Howard: It really seems to mirror alcohol and drug addiction or self-medicating. We hear about people who are self-medicating to resolve mental health issues or trauma issues, or to emotionally regulate. And it’s often done with drugs and alcohol, and they’re like, well, it works. You know, I have a couple of beers and I calm down or it works, I smoke a little, or I do an edible and I calm down. But eventually you follow up with them and they’ve lost their job because of drug addiction. They’re stealing money. They’re no longer able to sustain life because they’re always drunk. They’ve lost their families. I mean, we I don’t think there’s anybody listening to this that would think to themselves, oh, well, drugs and alcohol are a good way to emotionally regulate. But you know, over on the self-harm side, you know, somebody might think, well what’s so bad about it. I mean, you know, it’s a feeling. It’s a feeling. Having a feeling is good. But I, I really appreciate how you explained that. It just keeps getting worse and worse and worse and worse and worse. Now, if you are somebody who loves somebody and you notice that they’re self-harming because like you said, eventually you need stitches, you need medical care, you’ve got scarring, etc. So now you’re looking at someone you love and you’re like, okay, you’re clearly self-harming. I imagine that the intervention is not to tell them to stop it. It’s probably much more complicated than that. How can a loved one intervene on behalf of their loved one who is self-harming?

Gillian C. Galen, PsyD: Yeah. I mean, this is it’s a great it’s a great question because it can be really, really scary. And it’s, you know, I think unless you actually have self-harmed or you spend like me, a lot of time with people who who use self-harm as a way to, you know, regulate. It really is hard to wrap your mind around.

Break

Gabe Howard: Hi, listeners. Your host, Gabe Howard here. And I want to let you know about a fantastic free resource I recently learned about. If you or someone you know is struggling, or even just wants to learn more about mental health, check out the Anxiety and Depression Association of America’s website at ADAA.org. The ADAA has tons of free resources and even a Find Your Therapist tool to help you find support close to home. Their website again is ADAA.org. That’s ADAA.org.

Gabe Howard: Funding for this episode was provided by McLean Hospital, and we’re back with Dr. Gillian C. Galen discussing self-harm.

Gillian C. Galen, PsyD: It’s very hard to think, you know, why? Why would you do this? And I think, self-harm can go underground for a long time, right? People can be self-harming for long periods of time before anybody knows they can hide it in different parts of their body. I think the way to talk with people around this is with curiosity and validation. Right before you move into, okay, you’ve got to stop this. It’s scaring me or it’s, you know, getting in the way of your goals or your life. You got to get curious with them about what’s going on. Because if somebody is self-harming, there’s a level of emotional distress that we may not be aware of. So you’ve got to be curious. Telling someone to just stop it is the same as telling somebody who’s addicted to anything. Oh, just stop it. It’s like they this is a lifeline, right? So many people that are self-injuring. Like that’s how they manage getting through the day. They self-injure because maybe they have so much anxiety at work, but if they self-injure at work, they can stay at work, they can stay at work, they can keep their job.

Gillian C. Galen, PsyD: Right. So, you know, the key is to validate and be really curious about, like, wanting to understand if they’ll be willing to share it with you. Like, what’s going on and how does the self-injury help you? And is it getting in your way? Really the most robust way to get anybody to change a behavior is to link it to their own long term goals. If self-injury isn’t getting in the way for somebody and it’s working really, really well, it’s very hard to get them to change. And of course, with our loved ones, we don’t want to wait until it gets in the way. Right? But before you ask somebody to change. I think it’s very easy to make a lot of assumptions about why people do it, or how easy or hard it is to give it up. We got to get curious, because what will happen is if people feel like we’re not curious about it and we don’t really understand why they’re doing this, and we don’t want to understand why, we just want them to stop, then the behavior will go underground. It’ll just get hidden. They’ll find ways to hide it, and they’ll continue to do it right, and you’ll sort of move further and further away from them in terms of connection. So you got to be curious. You got to get to ask them about it and you’ve got to and it which is really hard because you have to tolerate all of your feelings.

Gabe Howard: Now, many people believe that if somebody is self-harming, it’s just a prelude to suicide. So as we talk about suicidality one, let’s talk about that. If somebody is self-harming, are those dry runs for suicide attempts or is it something that is separate in and of itself?

Gillian C. Galen, PsyD: So for the majority of people these are two different things. For the majority of people that are self-injuring almost everybody, they will say, absolutely, this is not a suicide attempt. This has nothing to do with practicing a suicide attempt. These are not dry runs. However, if you have to use self-injury to regulate emotions, that means the emotions are making it very hard for you to live your life.

Gabe Howard: If you are concerned that your loved one might be at risk for suicide, how should you handle that?

Gillian C. Galen, PsyD: Yeah. You know, I think the first thing is you got to talk about it. Okay. There’s a lot of myths around around talking to people about suicide. Right? So some people, there’s a myth that says, like, well, if I talk about it, then they’re going to do it. If I talk about it and they’re not suicidal, then now I’ve just put the idea into their head. And what we know is that’s not true at all. That actually the thing that is the most effective is to talk to somebody. If you’re worried about it, ask them, right. Believe what they say, right? If they say that they’re struggling and talk about talk about thoughts, talk about feelings, ask them, share your worries. And you have to listen without judgment and without arguing. Right. So one of those pitfalls is like, but you have such a great life, but this, but this. And in the beginning you just want to listen and you want to recognize their suffering, right? You want to ask questions which can be really hard if you’re worried about, like, are they feeling suicidal right now? Like, do they feel like they’re going to do anything right now? Do they have access? Access to anything to hurt themselves? Right.

Gillian C. Galen, PsyD: Validate how painful this is. Express your empathy. And then then comes the encouragement. Like I think we maybe should go to the hospital, right? Or I think we should talk to your therapist about this. You know, could I join? And this could be whether you’re a loved one of an adult, a partner, a friend, a sibling, a parent, or of a child now with a child, right? You can maybe go in and sometimes you can be a little bit more aggressive around them. Accessing help. Calling a therapist. Talking to the therapist. Right. Because you don’t have to worry with the child about some of the releases of information and being able to talk. Usually there’s, like, a more free flowing conversation. Though I would I would encourage parents of adolescents to include the adolescents at a minimum in this. And avoid going behind people’s back. The same with adults. It becomes really hard. But if you are worried that somebody is in imminent risk, they should go to the hospital or you should call 911.

Gabe Howard: Dr. Galen, I know that we’re almost out of time, but I would be remiss if I didn’t cover one of the controversies. And that’s that self-harm is simply attention seeking behavior. And the best way that you can handle this is to ignore it. A lot of people really feel that anyone who self-harms or talks about suicide is simply trying to manipulate the people around them.

Gillian C. Galen, PsyD: We always take suicide and self-injury 100%, like, at face value for what it is. We always take it seriously. I take it seriously as a provider. If by chance that that tiny little, you know, possibility that it was more of a we usually say a communication, right? Which is the idea that they didn’t have the skills to communicate something, their distress or their suffering. And so the way it was communicated was through self-injury or saying that they’re suicidal, right. If in fact, that is what’s happening, even if that’s what it is, that is such a profound skills deficit. And such suffering that we have to take it seriously. That’s still a huge problem. It’s a huge problem, right? And what we know is those are not the kinds of behaviors that we want to let go, because people can hurt themselves. I think there’s a lot of judgment and a lot of stigma. And I think that self-injury and to some extent, suicide, has been linked up with the word manipulation in a very pejorative type of way that, like, they’re just that person is manipulative people that self-injure a lot are manipulative people. And that’s just often because people are very afraid of the behavior. Right? And so they respond differently. And then we blame the person that is suffering. So, it’s just our job to help people understand it’s a myth. Because I think it’s one thing to say, well, you got to take it seriously. But people will say I’m terrified to take it seriously. How do you take this seriously? How do I talk to them? What if I say the wrong thing? What if they get mad at me? What if they self-injure because I’m confronting them about it right now? I’ve caused more distress. So? So I think you’re right. It’s easy to just sort of say, like they’re just, you know, they’re just it’s just a cry for help and we can ignore it.

Gabe Howard: And we absolutely cannot ignore it. Dr. Galen, thank you so much for your time today. Can you share more about McLean Hospital and where folks can find it?

Gillian C. Galen, PsyD: Absolutely. So McLean Hospital has an array of services, actually, they specialize in in lots of different disorders, but they have many, many, many options, all the way from children and adolescents to adults who struggle with emotion regulation, self-injury and suicide. Where I work at, 3East, we’re an array of programs for kids that are about 13 all the way up to their mid 20s. We have an outpatient clinic that does a partial hospital and a residential program, all doing adherent DBT with fidelity to the model, which is great. There’s adult programs, there’s the Gunderson outpatient program, the Gunderson Residence and DBT, and the outpatient clinic. We also offer some MBT. Mentalization Based Therapy, which is a great treatment also that helps people with emotion dysregulation. So you can find all of this on the website at McLean Hospital, which is McLeanHospital.org. And we are outside of Boston and just have wonderful resources and actually some great webinars if people are interested that they can find on the website as well.

Gabe Howard: Yeah. So just head over to McLeanHospital.org and check that out now. And again, a great big thank you to McLean Hospitall for sponsoring this episode and for allowing us to do this and for giving us time with Dr. Galen. Thank you again for being here.

Gillian C. Galen, PsyD: Thank you so much for having me.

Gabe Howard: And a great big thank you to all of you, our listeners. My name is Gabe Howard, and I’m an award winning public speaker, and I could be available for your next event. I also wrote the book “Mental Illness Is an Asshole and Other Observations,” which you can get on Amazon, but you can get a signed copy with free show swag. Or learn more about me by heading over to gabehoward.com. Wherever you downloaded this episode, please follow or subscribe to the show. It is absolutely free and you don’t want to miss a thing. And hey, can you do me a favor? Recommend this podcast to everybody you know. Sharing the show with the people you know is how we’re going to grow. I will see everybody next time on Inside Mental Health.

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