Webinar: Self-Injury and the Attempt to Cope, Connect, and Communicate

Webinar Description: There is growing awareness of the link between trauma and the development of coping strategies such as self-injury. However, the concept of coping does not always answer why some people continue to use self-injury even after other, healthier tools are available. This webinar will take a look at the impact of trauma on language and relationships to understand how self-injury may also function as the individual’s best attempt at connecting and communicating. When self-injury is viewed in this light, new ideas and opportunities for healing engagement can emerge.

Objectives: Brief overview of self-injury Function of self-injury in coping Trauma’s impact on language and relationships Function of self-injury as a means of connecting and communicating New ideas for engagement

Webinar Duration: Approximately 71 minutes

Brandy Brooks: Good morning, and welcome to the Self-injury and the Attempt to Cope, Connect, and Communicate Webinar. My name is Brandy Brooks, and aside from being the moderator this morning, I am a contract manager for the Massachusetts Department of Public Health Suicide Prevention Program, the sponsors of this morning's Webinar. Before I introduce our presenter, Beth Filson, I would like to go over a few housekeeping issues. First, to join the video portion of the Webinar, go to www.readytalk.com. Again, that's www.readytalk.com. And under "Participant, Join a Conference," enter 6245494. On the next screen you will be prompted to enter your name and email address, and then click the green "Register for this Meeting" button.

Second, to join the audio portion of the webinar, please dial 1-866-740-1260 and enter the passcode 6245494. Again, to join the audio portion of the webinar, please dial 1-866-740-1260 and enter the passcode 6245494.

Third, should anyone experience any technical difficulties with either the audio or video for this Webinar, please dial 1-800-843-9166. Again, that's 1-800-843-9166, and a ReadyTalk representative will be more than happy to help.

Lastly, all telephone lines are muted except mine and Beth's, so please use the Chat function located in the left corner to type in any questions you may have. Given the number of participants, Beth will do her very best to answer as many questions as

possible as she goes along, and at the end of the Webinar during the question-and-answer period.

Now that I've gotten that out of the way, let me introduce our presenter, Beth Filson. Beth Filson is a certified Prevention Specialist and has a master's in public administration. She is a nationally recognized trainer and curriculum developer in trauma-informed care, trauma-informed peer support, and peer workforce training and development. Most recently, Beth co-authored the manual, Engaging Women in Trauma-Informed Peer Support, a guide for the National Center for Trauma-Informed Care.

In addition to her work with the National Center for Trauma-Informed Care, Beth co-facilitates international peer support with Shery Mead and Chris Hansen. She is also a Consultant with the Massachusetts Department of Mental Health, developing guidelines for supporting people whose distress results in the use of self-injury and other behaviors that rise the level of risk management. Beth utilizes her personal experience in offering alternative ways of understanding critical behaviors such as self-injury and the opportunities that can be created for healing relationships. Beth is also a self-taught artist and she currently resides in western Massachusetts.

So, now that I've introduced our presenter this morning, I would like to go ahead and turn it over to Beth. Beth, are you there?

Beth Filson: I am. Thank you, Brandy. Just to clarify, I am actually a certified peer specialist. And so, my credentials are really my lived experience. So, it's important for everybody to know that this is an opportunity to think about another way of understanding and engaging with people who use self-injury.

Now, the first thing I want to say upfront is, if you are working with someone who uses self-injury, and the two of you have found a way that is really, really working for you--it's helpful, it's hopeful, you're both in agreement about it--then keep on doing what you're doing. But if you're stuck, curious, unsettled, confused, dismayed, et cetera, I hope you will consider the topic from a different point of view.

And the point of view that I'm proposing today is one that believes that at its core, self-injury has meaning, and that we can talk and do need to talk about that meaning, when we pay attention to our relationships with each other. And that at its very least, self-injury is absolute evidence that you are working with a person who is determined to find a way to live.

Also, keep in mind that the best way to understand self-injury and what it means, is to ask the person who's using it, including what helps, what doesn't, and what the focus should

be. If, however, someone had asked me about why I was using self-injury at a certain time in my life, and what meaning it had had for me, I probably would not have been able to really answer that question. And it would not be because I didn't have or didn't know my answer, but because I needed an essential relationship where that kind of difficult discussion could take place, and that was really what the focus needed to be on, before we could even approach the issue of self-injury.

Two, for me and for others, trauma really enforces a code of silence. For others, the events that have taken place are private and for whatever reason they will not be shared with you, and that has no reflection on you. It is simply the preference or the need of the individual. But asking someone about the personal meaning of self-injury, showing an interest, demonstrating that you want to understand, that this--that you do want to understand, is the starting point for building a relationship where meaningful dialog can take place, and that's based on learning about the person and their world rather than trying to problem-solve the person or fix what you might consider to be the problem, but for the person is the solution.

So, we're going to do a poll next. I'd just like to get a sense of who is attending. So, if you would, take a look at this list and just indicate which of these most represents you.

Are you there yet? All right. Let me see what our results are. Okay.

So, our big group is the consumer, survivor, ex-patient, and peer community--I'm sorry, the peer specialist and recovery support folks. We've got some direct care workers. Lots of licensed clinical social workers. MDs, PhDs--no. Occupational therapists--no. We've got some family members. I'm really glad to see that. And we have public health and mental health. And then there's a group of "other," and maybe we'll find out a little bit more about who you are in our question-and-answer session. Probably the question-and-answer session will occur at the end.

So, language and terminology. I don't want to spend a whole lot of time on this slide, but we'll refer you to some of the resources that I've included at the end of this presentation. They're easily accessible and they can provide you with a solid foundation for understanding self-injury. However, I do want to clarify a couple of things that I think are important as we talk about self-injury.

First of all, self-injury does not always result in self-mutilation. So, that is a term that really doesn't apply to all of us. The term is actually really not useful in a large majority of cases. Referring to people as cutters further stigmatizes what is already a burden for people struggling with self-injury. Self-injury is neither a suicide attempt nor a gesture.

Most people have heard the acronym SIBs as well as non-suicidal self-injury. What I'd like to say about that is that it's really important that, like all clinical language, we need to be careful that these categorizations do not obscure the individuals that we're talking about and the idiosyncratic meaning self-injury has for people.

We will talk about people who use self-injury rather than people who self-injure. And the reason why, is to really underscore the fact that self-injury is one of many, many, many activities people use to reduce their distress and to feel better. So, in general, self-injury refers to direct harm to the body, but has no socially sanctioned purpose and is not about the intention to commit or attempt to commit suicide.

However, if you think about it, this definition really breaks down when we take a look at the person choosing to eat a gallon of ice cream while watching CSI rather than making use of the gym membership that they have; or, coming home from a bad day at work with two bottles of wine, determined to get drunk. Surely these are self-injurious acts as well.

Researchers and theorists suggest that, you know, whether or not a behavior is viewed as self-harming, really depends on the context in which it's occurring, including social, cultural, personal, and psychological context. I think it's important to realize that we all self-harm and it is most often used to deal with stress. Think about smoking, drinking a little bit too much, overworking, overeating, undereating, et cetera, et cetera, et cetera.

Now, one of my teachers has been Ruta Mazelis, and her blog I've listed also in our resource section, and I think it's very, very helpful. But she suggests that the really--the only difference really between self-injury such as cutting, burning, or deliberate bruising of the body, and extremes of plastic surgery or the anorexia that is so valued by our society in the fashion industry, is the response we have to it. That's the only difference.

So, our negative response to certain kinds of self-injurious events is curious, I think at least. And it gives us cause for a reappraisal of what we're valuing in our society, like standards of beauty and (inaudible) performance. And just a quick note, I don't think it's helpful to think about self-injury as an addiction either, since this does not take into account the sociopolitical relational context out of which it first emerges.

So, we're going to do another poll here. And I just want to get a sense of what you guys are most interested in. So, if you would select one of these.

All right. Let's take a look at the results. Stopping self-injurious behavior. Look at that. Wow. I am so thrilled to see, understand meaning of self-injury. That's the huge one. That's great to see. Risk minimization strategies--excellent. There's a resource at the end of this presentation that you'll want to take a look at, that talks about risk minimization

strategies. So glad to see this one--helping providers. I really think that we're not paying attention to the providers that are working so hard with so many of us, and their own needs and their own struggles, and their own grief and pain as they try to figure out how to best partner.

All right. So, let's move on. So, in rethinking self-injury--in order to rethink self-injury, we need to first and foremost understand it as a meaningful behavior and not as evidence of either pathology or worthlessness.

My approach to self-injury is to think of it as having three basic functions: as a way to connect to self, others, or to the world. And when I say to the world, I include the divine, a higher power, or a sense of spirituality or nature. Two, as a form of language or communication. Three, and I think as most of us are familiar with already, as a way to cope with overwhelming distress, as a means of survival.

Now, self-injury may serve all three functions at once. The reason why someone is using self-injury in one instance is not going to be the same reason why they used it--use it in another. Its meaning will likely change over time. We need to ensure that our interventions are not one-size-fits-all, or that our interventions remain static. So, we need to support--our interventions, our relationships, our conversations, need to support this mutability of function that is so inherent in self-injury.

And now here are some examples of what I mean about mutability of meaning and function. Let's take the example of a child that may start using self-injury as a way to master the pain he feels in an abusive home. For the child, self-injury is about managing the physical distress of his scary and hurtful environment and relationships.

Over time, as the child interacts with the world that does not understand what he is doing or why--does not understand that he is trying to navigate a chaotic and abusive home life--he's going to likely experience profound disgust from his schoolmates; from other family members, even; from his community. He's going to experience, or--and definitely internalize that as shame. Ultimately, he may experience a sense of being other--as not being a part of. So, now, his self-injury becomes about dealing with the loss of meaningful connection to others, and becomes how he is going to connect to himself.

What's the core problem in this scenario? If we don't take into account his home life--if we are trauma-unaware--it's going to be very likely that we're going to assume that the central problem is his behavior, when it's actually the abuse the child is living with, or at one time lived with.

So, focusing on stopping the behavior effectively deprives the child of the one way he has figured out how to operate in the world, and to experience himself in the world. So, those of you that are most interested in stopping self-injury, I am so sorry I couldn't give you an answer to that.

Or, let's push this a little bit more. In the case of self-injury as language, it may be the only way that child has to communicate his agony. You know, if the first utterance that he makes is hitting himself in the face, and that's met with behavior modification or some other means of containment, he's effectively silenced.

Do we let the child continue to hurt himself--beat himself in the face? Well, of course not. But we can't isolate the issue within the child. We cannot take the child out of this world and think that we're going to be able to successfully support his healing.

Here᾽s another poll for you. So, I'm just curious where you think self-injury comes from. If you would take a minute there, on this poll.

Okay. I'm going to skip to our results. Now, good for you. Good for you. And there's some honest answers. I just don't know. Wonderful to see that. All right.

Now, before I go on I just want to talk to you a little bit about the art that I'm using. I want to share with you a story about, you know, my own experience. During a lengthy hospitalization due in part because of my own use of self-injury, I turned to the materials that were available to me, which turned out to be chalk pastels, oil pastels--ones like that. And it became a way for me to communicate my truth and to connect to who I knew myself to be. And that was so critical because of the onslaught of the diagnosis and it’s--my perception of it as wiping out who I was--who I knew myself to be.

But later, my artwork began to be shown in galleries. And so, it became a means to a larger identity than just simply that of a mental patient, as well as how I finally was able to participate in a very different and in a very meaningful way in my community. So, I'm always talking about the importance of art in healing.

So, when we understand that trauma is the context out of which self-injury and other coping strategies emerge, what happens is that we think of trauma as sort of how it's been defined in the DSM; or we get these very clinical terms; or we think that the only trauma impact is PTSD, when actually PTSD is just one of many trauma impact issues.

So, I was doing the training in Vermont and I asked this question to my participants: what is trauma. And the most helpful, most useful definition that came up was this, that I use

all the time now: trauma is something that happened to you that still haunts you today. And if it doesn't still haunt you, it sure did for a long, long time.

And I find that incredibly useful. Because we so often don't recognize the issues, the events that happened, that impacted and haunt people today. What happened for many of us in the mental health system is that trauma is not recognized, and therefore providers may not make the connection between self-injury and past or present trauma experience.

Now, trauma-informed systems of care assume trauma. This universal expectation of trauma places the person at the center of a world, grounding care providers and, well, all of us, in an appreciation that the person comes from a world we know nothing about--a world that has shaped how he reflects on, organizes, and makes sense out of the events that have taken place. And I really have to question, how can we treat someone whose world we know so little about, whose language we're not sure we understand, and whose customs seem so strange and alien to us? We must know the world from which people emerge.

So, we've got one more, I think, poll for you. The best way to stop self-injury. There you go. Give me some answers there.

All right. And I'm going to skip to the results. Wow. Absolutely. It occurs in the process of healing. And we've got that little green group there that's saying, it's--let's not give it any attention. That's okay. Let's keep going and see what new meaning might emerge here.

So, here᾽s the question: why won't he stop? And the answer is, for a lot of us, that the sources of trauma have been normalized within systems of care, or simply go unrecognized. In the resource section, again, you're going to find information about risk minimization which I think will be helpful for you. It is not helpful to try to stop someone--to simply focus on stopping the behavior. For that to be the extent of the treatment.

So, let me talk to you a little bit about why. Let's say you've acknowledged past trauma in the person᾽s life--and we will, over the course of the next few slides here, talk about that. But coming back to this, let's say you've acknowledged past trauma in the person᾽s life and you're certain there are no chronic triggers or ongoing violence for which this person is attempting to cope, and you've been working with this person on using healthy coping strategies; but they are still, time and time again, falling back on self-injury. What's going on?

Let's take a look. Let me start this with a little bit of a story. In my wanderings around the country I talked with some providers, wonderful people that were working with a young woman who was using self-injury. So, we were talking about the trauma link. And one of the providers was really baffled. She said, you know, our agency has really established a very positive relationship with this young lady. We've worked very hard with her for most of her life. Her foster care placement had been stable. You know, while there were some hospitalizations, she herself never reported any abuse or adverse events from these experiences.

And are your ears starting--picking up what my ears are? Foster care. Early separation from family life. Life lived in the care setting. Well, we've got a whole bunch of reasons for a person to still need to figure out how to cope and make sense out of the world.

So, if you look at the blue circle here, many of us that are receiving mental health services, or have received mental health services--we have a current context that we're constantly living in. And that may be due to a number of reasons, but the result is racism, oppression, marginalization, and discrimination. Those continue to require some strategy for coping. And these are the contexts that are so often not recognized in--when we're treating folks--when we're thinking about supporting someone's healing.

The red circle, these current conditions, which also affect this ongoing need for coping--so many of our services with supports create some compromised access to basic human needs for food, shelter, safety, personal freedom, and personal agency. If you think about guardianship; if you think about having a payee; if you think about court-ordered treatment; if you think about having to jump through hoops before you're given shelter, housing. If we're not paying attention to the immediate needs for safety, we've got a person that's going to have to cope.

So, the idea here is that we make meaning out of our context of racism, oppression, marginalization, and discrimination. We begin to shape an understanding of the world. And that this in tandem with the current conditions in which we're struggling to get help or to receive--or to be a part of healing relationships, sort of merges into an ongoing trauma world--traumatic world--a traumatic experience.

So, we want to recognize context--current context and conditions in people's lives that replicate trauma impact. And so that is going to include living in communities where violence is the norm. It is going to include combat experience; historical intergenerational trauma, including genocide and slavery. It's going to include the marginalization and disenfranchisement that occurs for people who've been incarcerated or live with a psychiatric diagnosis, and the oppression and the poverty and the discrimination that is still part and parcel of that--being labeled with a disability.

All right. I think we can all agree that human suffering is incredibly complex, and how we attempt to talk about it, how we attempt to make sense out of it, is complex as well. You know, suffering is really such an isolating event, and it's a singular event. You know, it's unlike happiness or joy, which seems to increase the more we're able to share it with other people. You know, diagnosis and symptom-speak obscure the fact of that suffering. We see depression, which we want to treat, rather than grief that needs support, empathy, compassion, and comfort. And so, what we see shapes the relationships we have with others.

So, if we can see self-injury as a complex form of suffering and an attempt to communicate that suffering, we understand that the relationships we want to create have to do with empathy, compassion, and care.

Oh. One more poll for you. Curious about how prevalent self-injury is among this group. So, if you would answer this--these couple of questions here.

All right. And I'm going to skip to our results. Most--we've got lots of people providing services to someone who uses self-injury. I am not at all surprised to see, "I use self-injury and provide services to people who use self-injury." And then, "I know someone who self-injures." So, I don't know--you know, math is not something I do. But it--could I--am I safe to say that, like, 100% of us have had contact with this issue?

So, let's talk a little bit about some--these three functions of self-injuring. And I'm going to start here with its function as language. Now, if you think about trauma; if you think about abuse; if you think about violence; if you think about being a victim of crime, there's oftentimes a failure of language to stop the abuse. Saying, "No, no, I don't want this to happen," is useless. So, the word no--language itself--does not do anything; does not change the outcome. It fails us.

You know, if--I'm sure most of us--all of us--can relate to that place of being in such profound pain that the only thing that emanated from our souls was the groan or the sob, that this thing that hurt so deeply and so profoundly had no language whatsoever.

And then, you know, also, the failure of language to get help. I know so many of us have tried to tell a school counselor; have tried to tell a mother or a father; have tried to tell an adult at some point in our childhoods, about what was going on, and were met with, you know, "That's not happening"; "That's not possible"; "How dare you?"

And so, again, language fails us in the most critical way that we need, which is to secure help to stop the injury from occurring. And so, if you have somebody that is constantly

using self-injury--I'm going to skip back--I want you to think in terms of, is this a failure of language, of words, for this person to tell what is going on, or what they feel, or what it means? I love this quote by Judith Herman: "Repetition is the mute language of the abused child."

And before I talk to you about this slide, let me just say, too, that if you've got someone--if you're working with somebody who continues to use self-injury, the answer is not to give that person another diagnosis and more medication. The answer is to look at your services and your supports and your interventions, and to figure out with that person, do these really meet your needs? Does this answer your pain? Is this allowing you to feel that we are hearing you?

Now, we hear a lot about the issue of contagion which, you know, is the transmission of, you know, a disease among a group of people. And so, in self-injury it is the transmission of a behavior among a group of people that are closely connected.

So, let's talk about that. Language, you know, really--in fact, I think we all know, develops and takes root because it binds together a community. It's effective. That's why we use the language that we use. So, in terms of our use and the epidemic of self-injury in our schools, I'm wondering, could it be that self-injury has simply become the most successful way to communicate distress--especially, you know, for a culture that in so many ways is connected through social media, but also profoundly disconnected by virtue of the ever-growing complexity and fragmentation of our society?

In the resource section you're going to find a website that my friend in--out in Kansas, Christine Young, turned me onto. It's called, "To Write Love on Her Arms," and it's geared toward children and youth--young adults. I think it can be very helpful.

So, the simplest beginning to the issue of contagion is the simple question, what are you trying so desperately to tell me? And again, this is not going to be an easy answer. But it has to--it doesn't have to be answered in the moment. It's the question itself that lays the foundation for your relationship, where people's truths, their stories, can finally be told. And in addition, where alternative stories can be tested out and tried out.

Let's look at another function of self-injury, and that is its function as a way to connect. We want to be really careful to not underplay relationship and overplay skills teaching. I met a woman once who used self-injury an awful lot. I asked her how people responded to her need to hurt herself, and she told me that, you know, whenever she approached staff about feeling like she was going to hurt her staff, she was told to go use her skills--to go use her safety plan. And in essence, the skills and the safety plan became the tools for disconnection. So, it was not effective at all.

There's an article that I found really fascinating, by Heather Trepal. And I'm probably pronouncing her name wrong. But there was research from Trepal and Lester in the Journal of Counseling and Development in 2010. She did some research around what interventions were the most helpful in supporting people who used self-injury, to stop. And she came to the conclusion that a strong therapeutic relationship being more--may be more important than any particular treatment method in reducing self-injury. Huh. Figure that.

Not just connection to others. Let's talk about connection to self. I don't know if this resonates for any of you. But in some ways, who we know ourselves to be, becomes inseparable from our traumatic experiences; and therefore, by extension, inseparable from our self-injury.

Trauma makes experiencing new events in a person᾽s life pretty terrifying and actually unbearable. You know, if you think about the body's ability to tolerate additional arousal, it--you know, it just makes it very hard to go out and try new things. And so, basically, what we do is, we seek what we know. Self-injury may be how we're connecting--how we're actually disconnecting from others in order to reconnect with sense of self, to return to the harbor of self and identity.

When people hurt themselves after a period of not, or return to the hospital after a period of success, we often label this as sabotage; not recognizing that the real issue of identity, or the--you know, not recognizing that the real issue isn't fear or isn't being afraid, you know, of the outside world, or comfortable in the mental health arena, but is actually an issue of identity, and how we know ourselves to be who we are.

So, if we make the mistake of focusing on beefing up socialization skills to reduce isolation, or working on self-esteem, we overlook the possibility that self-injury is there to disconnect from others in order to connect to oneself. And I also like to point out, too, that when trauma--a trauma story has not been told--and I'm--when I say "told" I mean either symbolically, literally, through art, dance--however. But when it's not been told and it's still--it's almost like, to move on with your life is to betray the self that is still wounded. And so, too, I want you to think about that, rather than thinking about sabotage, or sabotaging one's success.

And I love this graphic. Autonomy--and actually, this statement is paraphrased from Judith Herman as well, that in the context of institutionalization, self-injury may be the only autonomous act that an individual has. And I think you can think about court-ordered treatment, having a payee, a guardian--if the individual is distressed about those things, those too function in the way that institutionalization functions here.

So, it's helpful to understand that this need for connection to self is actually a drive toward autonomy and self-direction. I have a flipchart on my wall in my office of all the things that so many of us who have been hospitalized no longer have, or no longer have any control over. And I keep adding to it.

And some of those things that we have no control over in the context of a hospital, is noise; lighting; privacy; number of roommates; who the roommates are; access to outdoors, to doctors, to friends; entertainment; education; art; other resources; as well as access to healthcare providers; access to a smoke, to food, to a candy bar; who's on shift; who can spend the most time; who we get to spend the most time with; what time lights go out; what the day's activities would be; what we will eat. And we have no ability to control our own safety. There are no locks on our bedroom doors; on bathroom doors; on doors that lead to somewhere else.

So, self-injury, though it may look so destructive, may be a statement of, "I am a human being in the world, and this is how--the only way I know to self-actualize." For people who have been impacted by adverse events, the issue of safety--this is another aspect of self-injury in institutions.

So, for people who have been, you know, really impacted by trauma, safety is a paramount issue. And we define safety as kind of, you know, being able to predict what's going to happen next. So, in a place where there is so little that we can control, self-injury may also be an event with the most predictable consequences.

You think about it. If you've in a hospital, if you know what's going to happen, it becomes a means of safety even though what you get is more pain. It tells us that safety, predictability, is more important than the consequence. I think this is true in juvenile justice systems, the forensic system, penal system, substance abuse and mental health systems, and nursing care and medical facilities.

So, the antidote, if you will, is something that we talk a lot about. And it's called being person-centered, supporting self-directed recovery, collaboration, shared power, and decision-making. But do we really know what those terms mean and what they look like and feel like, and are in action. And if you're not sure, that's, I think, a place for real enquiry.

Relationships that hurt; relationships that heal. We need to be sensitive to the fact that relationships themselves have often been the route for interpersonal violence. I think in general--not always, but in general--men most often experience violence at the hands of

strangers, and women in general most often experience violence in their relationships with significant others: mother, father, uncle, boyfriend, husband, partner.

So, this is what I mean by trauma shaping how people participate in their world, and how they're responding to care providers. So, our past relationships sort of lay the groundwork for all subsequent relationships. And so, service interventions, if we're not aware of this--service interventions, service relationships, can inadvertently reinforce past trauma dynamics, especially if your focus is on trying to stop a behavior, trying to control that behavior, or trying to contain that behavior, even when you think it's for the individual's own good.

Does that mean we don't stop somebody who is in the throes of hurting themselves? For me, no. But it does mean I'm going to have to have a huge conversation with that person about what my own fear brought into our relationship, before we can heal that relationship and keep on going.

So, let's look at kind of, a little bit more of the antidote here. So, we know that the impact of trauma is a loss of power, choice, and control. It's a violation of physical and emotional boundaries. Safety and trust are shattered. How do we fix that? What's the antidote?

What is it our relationships need to really be about? They've got to provide meaningful choice. They've got to be trustworthy. We both need to define what safety means. It can't simply be defined by the provider, and it can't simply be defined by the person receiving services and support. It's a--I truly believe, a place of negotiation and collaboration, which you see in the next bullet. All of this, I believe, is what we mean by empowerment. If we can achieve, you know, these top bullets, we have created the conditions in which people can experience empowerment.

This is something that a wonderful, wonderful peer taught me, Mary Blake, that--she said there was three characteristics or dimensions to trauma. And we usually get very hung up and think that the only characteristic to trauma is the event.

So, the first characteristic of trauma is the event. It's the "what happened." But the second is its impact. You know, how does this affect you today? And the third characteristic is the meaning that the individual has made out of what has taken place in his or her life. We so often get lost in a focus on just the event, that we become overwhelmed by the weight of tragedy. So, it's really important for us to recognize and appreciate these other two dimensions of the trauma narrative, this impact and meaning.

I want to point out that in your resource section I've listed the manual that I had the honor of co-writing, called Engaging Women in Trauma-Informed Peer Support. Chapter 11 is called "Trauma-Informed Story-Telling," and this chapter like many others applies to men as well. So, I think it'll give you some really good ideas about the kinds of conversations that you might want to have around meaning and impact.

Also, chapter 12 in the same manual is "Self-Inflicted Violence and Peer Support." I think this is a helpful chapter, whether you're a care provider, family member, or, you know, non-peer provider as well. This too will give you some ideas and, you know, good thinking about working with or carrying on a dialog with people about self-injury.

I want you to think about the relationship itself--the relationship that we're creating with each other itself, as the coping strategy. You know, if you think about it, it's where we feel the most safe to try out new things. It's, you know, when we're mutually involved or actually mutually building resilience.

This is really interesting to me, and forgive me if I'm wrong, but I believe it was from Jean Baker Miller, the idea here is that for women--you know, I felt actualization is not an event of becoming independent, but is actually a process of creating relationships. Isn't that amazing?

So, I think we really, really want to pay attention there, especially to our relationships. It's always the vehicle for collaboration. And please don't forget--you know, when we're thinking about community integration; when we're, you know, so wanting our peers, each other, you know, the people we serve, our family members, to get out of the mental health system, to become part of the community--that community is based on relationships. It's not based on isolated individuals. And so, just really, really keep that in mind. I wish I could have been more articulate with that one. But, anyway.

So, trauma and loss. Need for meaningful connection. Here᾽s a picture of a bridge. I think of self-injury as a bridge. It's nothing more. It's an opportunity to connect you to another human being--to approach another human being to begin a conversation, a dialog.

Now, we have been pathologizing this need for connection. Who among us does not need connection? Who among us did not this morning look in a mirror to comb or hair, or at least figure out if the clothes we were wearing, you know, were passable? Is that attention-seeking? I think it might be. But we're not pathologizing that. We understand that in the context of social interaction.

So, really, really important to stop thinking of this as manipulating, attention-seeking, or acting out, being dramatic. That is a tragic outcome, is that people get the message, I am

to be alone. I am meant, and I need to function, as an isolated individual. When we use those ideas, when we use those terms, we are supporting people to internalize the hatred that they are already expecting as a result of other people's responses to their coping, to their attempt to connect, to their attempt to communicate.

And so, I, among people who self-injure--among, you know, the community of providers that are supporting people to deal with that self-injury--I think, you know, if there's anger, if there's frustration, if we're beginning to hate, it's because we've been taught to. And if we've been taught to hate, we can be taught to love. We can be taught to stop hating. We can be taught to go to a deeper place where we can connect around our shared human condition of suffering and trying to figure out how to live as well as sharing our joys.

So, at the heart of self-injury I believe there's a story. And like every story, it has its own author, it has its own vocabulary, and it has its own meaning. And it requires someone to tell it to. Stories are what bind us to each other. They create the teller and the listener. And as we go back and forth, writing and rewriting our stories, we really are shaping who we are in our relationships to each other. These two-way relationships are so critical in healing.

Our stories are what we have experienced, what we have learned about the human condition, and what it takes to prevail. These are the stories that have become what our society needs in order to figure out how to survive the natural and manmade disasters of this century and beyond. What I am saying to you is that the person who is using self-injury has profound wisdom and insight--knows something about resilience and survival.

And I love the book Healing Invisible Wounds by Richard Mollica. He says that the real role of the helper is to make of the person who has suffered so much trauma, a good storyteller, so that they may go out into their community and teach their community.

All right. Let's do a quick one here. So, if we're really going to be able to--if we're going to change the way we think about this work, you know, we're really going to have to start thinking about relationship as being everyone's focus. That means direct care worker. That means cafeteria staff. That means direct--I already said direct care worker. That means care specialist. That means nurse. That means doctors. That means attendant. That means any person that comes in contact with an individual can take part in some aspect or some form of meaningful relationship.

If we're going to do this work in a different way, we've got to pay attention to our self-care and we've got to pay attention to what our relationships need in order for us to stay connected. So, that's what I mean by relational care. I think that staff have got to begin to really be supported, and I believe that we can create a different way of supervision that

allows for this co-support of each other, that allows staff to break free of the delusion that they're supposed to have all the answers and to not be affected by human suffering.

I think we've got to utilize multiple ways for people to experience their--you know, the language that they have and the multiple ways they can be in relationship. And I do profoundly believe in art, and writing, and dance, and music, and nature, and all of those things.

We've got to utilize the peer workforce. It's our peers who are our teachers. These are the folks that have taken their experience and said of it, hmm, I think I know something about what we can do a little bit differently.

And ever crucial is to really understand that in a closed system like a mental health system, we can't achieve success, we can't get out of that system, unless there's true linkage to alternative views. And those come from our peer support communities. For example, peer support and wellness centers. Peer-run respite is a critical place for relationships between the system and the community to be created.

I need to just look at time, because I want to make sure we've got time for questions. Ha ha. I think I skipped something, but that's okay.

So, I'd like to leave you with this summary. Self-injury, I do believe, is a story of pain, but it's also a story of hope. Because it's evidence of the person᾽s struggle to figure out some way to go on living.

I always tell the story--I met a wonderful woman named Clare Shaw in the UK, and she was living with self-injury and had--it had so overtaken her life that she made the--after years and years and years of it, and living in hospitalization and, you know, the terrible pain of her family, she decided to end it. She decided to kill herself. And lo and behold, after she made the decision to kill herself, she suddenly realized that she no longer wanted to hurt herself. And in that moment she realized that self-injury is a statement of hope. So long as she was self-injuring, she was still trying to find a way to live.

And it is a story of redemption, because healing does occur. And that redemption is a community event. It is not the redemption of one person. We do not fail or succeed as isolated individuals. We fail and succeed because we are connected to a community, to other people. And in that regard the success of one of us becomes a redemption for all of us.

So, there you have it. Here are some resources. Not all of the resources that should be here, are here. Please feel free to email me if you have questions that don't get answered

in this presentation, or if you need more resources, or even have some resources that you have found helpful. There's been a lot of work done lately around really identifying helpful resources out there, so let's keep sharing them.

So, Brandy, I think what we'll do is open it up for questions at this point.

Brandy Brooks: Yes. If anyone has any questions, again, please use the Chat function located in the lower left-hand corner and type in any questions you may have.

Beth Filson: Oh, come on, you guys. How about, it doesn't have to be a question. Maybe it's an impression, thought, statement--something that stood out for you? Something you're not so sure about?

Okay. It looks like we've got some questions coming in. Great. All right. So, let me take a look at this.

"What are some of the ways you use to communicate your fears with the person you care about who self-injures?" This is from Karen Rosenthal. What a great question.

Intentional care support, which is work done by Shery Mead and now Chris Hansen, is--has been a critical place for understanding this idea of a focus on the relationship--what our relationship needs from both of us, in order for us to stay connected. And so, instead of placing the focus on changing one or the other of us, we're going to talk about what the relationship needs. And that also can become a place of negotiation about what's going to work, what limits our--you know, that you have, that the other person has.

The last thing I want to say about this, too--if you've--you're in a position where you feel like you cannot--you are too afraid, then please call upon others, whether that's the peer community, other providers, non-peer providers--call upon others to take part in that relationship with you.

All right. And go back up, because we've got a lot more. Just a minute, folks. Kate (ph): "There is a common assumption that if a person self-injures they are more likely to be diagnosed with a personality disorder. Is there evidence to support this?"

Actually, there's evidence to support that it's not associated necessarily with a personality disorder. I think if you would email me at bethfilson@gmail.com, I'll share an article with you that I was just recently reading. And I believe it was a Bessel van der Kolk article, but I can't be sure.

And then Kath (ph), it looks like your question didn't come through. Right? So, here᾽s one from Jennifer. "I would be interested in seeing slide 17 again." Okay. So, let's go back to that. Whoops. Right here. All right. Now I bet there's going to be a question that comes up for that.

"What is the prevalence of male non-suicidal self-injury?" I don't know. All right. This is just off the top of my head, but if you think about it, in our society we have a lot of ways for men to hurt each other that is socially sanctioned--football, wrestling, et cetera, et cetera. So, I don't know if there is another avenue that men use. I don't know if men just hide it. But I know men use it. But I'm sorry, I don't know the prevalence. And Laurie (ph), I'm not going to spell--say your name correctly, but--oh, thank you. Laurie says, "Very powerful. I realize that self-injury can have many faces and levels. Thanks."

Here's a question. "Will this Webinar be available at another time to review?" Brandy, I believe that it will be. Is that correct?

Brandy Brooks: Yes. The Webinar is being recorded and I will be sending all the participants in today's Webinar a follow-up email with the link to the podcast. So, they will be able to download it, send it on to their colleagues that may be interested in viewing it as well.

Beth Filson: Great. Here's one. "I'm wondering if your artwork is available for others to use? Images are powerful and speak so much louder than words." Thank you so much for that. If you would email me, we can talk about that. You know, if you're interested in using any of the artwork, bethfilson@gmail.com.

And from Christine Young, "Thank you for sharing your story and helping those who don't have a voice, find some understanding." Hey, Christine. We all have voices. But I get you, girl.

Karen Lillen (ph). "I've long viewed self-injurious behavior as a way of coping; but hearing that it has a function of communicating and especially of affirming the desire to live, is new for me. Eye-opening." So glad to hear that.

Janice. "I'm wondering what you would say about Thomas Joiner᾽s thoughts related to self-injury and suicide, that self-injury increases capacity to tolerate pain, making one closer to being able to take suicidal action."

Yes, I have heard that. I don't--I actually do not think that that's real, and I'll tell you why. These--there are two different functions here. I think if anything, what people who use self-injury and more than more lethal ways run the risk of, is accidentally dying. So--

but, you know, I'm not an expert. So, please do some investigating and talking to colleagues and coworkers about that.

Oh. Jennifer--"That's not the right slide." Oh, okay. You're looking for impact and antidotes. Let me see where that is. All right. I'm going the wrong way. There it is. There we go.

"I'm wondering if you're--" okay, we've got that one. Laurie, thank you.

Karen: "Can I get a copy of the PowerPoint?" Yes. We're going to make that available.

And, "Thank you for acknowledging the power of bearing witness to the struggle of survivorship as well as the actual traumatic event." You are welcome.

So, I've got to tell you, thank you so much for letting me have this time with you, and I hope that this is just the beginning of a deeper conversation. I think we're all learning so much. And I just really look forward to the work ahead.

Oh, wait, we've got one more. Let me see if I can get that. So, we've got somebody that said--was saying that they're diagnosed with a personality disorder because of this--I mean, self-injury. "However, I always thought it was an extension or parts of my PTSD. What do you think of this?"

What do you think of that? I bet you already know. Happy to keep the conversation going with you, if you'd like to make contact with me.

All right. Anybody else?

"Do you consider risky sexual behaviors to be a form of self-injury?" Well, like eating too much ice cream, that you know it's harming yourself, especially, you know, let's say you are on diabetic medicine--yes. It is a form of self-injury. But we also know that risky sexual behavior is, you know, correlated to adverse childhood events. If you're interested in looking more at that, that would be--take a look at the ACE study, acestudy.org. But, yes, it is a form of self-injury.

Okay. I think we're going to wrap up, then. Again, my thanks to you and to Brandy, and to the Department of Public Health, for making this possible.

Brandy Brooks: And before we conclude today, I'd just like to again parrot Beth. I'd first like to thank her for presenting this morning, into the afternoon. And I'd like to thank all of you for participating in the Webinar.

Again, everyone who participated in today's Webinar--you will receive a follow-up email containing a link to the podcast as well as the slides, which Beth has agreed to share with you all. In addition, be on the lookout for emails about upcoming Webinars and training being sponsored by the Department of Public Health.

After you log off this afternoon, please take a few moments to complete the evaluation, as we do use that information to put on future Webinars. I hope that today you've gained a little bit more knowledge about the links between trauma and the development of coping strategies, such as self-injury, as Beth has elucidated today.

Again, thank you all for participating. Thank you again, Beth, for presenting. And have a wonderful day, everyone.

Beth Filson: Bye, all.