The Relationship Between Eating Disorders and Self-Injury

Getting help for self-harm and the relationship between eating disorders and self-injury

Dr. Sharon Farber, the author of When The Body Is The Target: Self-Harm, Pain and Traumatic Attachments and therapist, believes self-injury is addictive and counsels people on self-injurious behavior ranging from cutting, burning, and general self-mutilation to eating disorders, including bulimia (binging and purging). She discussed the trauma that can lead to self-harm and how to recover from a lifetime of self-injury

David: HealthyPlace.com moderator.

The people in blue are audience members.

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Self-Injury Conference Transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Getting Help For Self-Harm." Our guest is author and therapist, Dr. Sharon Farber.

Our topic tonight is "Getting Help For Self-Harm." Our guest is author and therapist, Dr. Sharon Farber. Dr. Farber is a board-certified clinical social worker and author of the book: When The Body Is The Target: Self-Harm, Pain and Traumatic Attachments.

Dr. Farber maintains that there's an addictive-like nature to self-injury. We're going to be talking about that along with the role that childhood neglect, abuse, and other trauma play in self-harm, along with why it's still difficult to find qualified therapists to treat this problem and where you can get help.

Good Evening, Dr. Farber, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Could you please tell us a little more about yourself and your experience in the area of self-harm?

Dr. Farber: I have been in practice for around thirty years. My interest in self-harm came about when I developed a specialty in treating people with eating problems. (Detailed information on different types of eating disorders.)

I came to understand that a lot of people with eating problems, especially those who binge and purge, have problems with self-injury (especially picking their skin or scratching themselves, sometimes even more obtrusively through burning). Then I went on to do some original research. I wanted to understand why people who injure themselves may also have some kind of disordered eating, or why people who have disordered eating may injure themselves.

I did research where I compared bulimic behavior with self-mutilating behavior for similarities and differences. The similarities were extraordinary. Very powerful. I became fascinated and began treating more patients who self-injured. (Symptoms of Bulimia Nervosa)

I should also tell you, when I use the word self-injury or self-mutilation, I am also talking about a passive form of self-mutilation, and that includes people who compulsively get their bodies pierced or tattooed or branded.

David: What were the similarities between those with bulimia and those who self-mutilated?

Dr. Farber: Well there were quite a lot of similarities. Both of them seemed to be an individual's attempt to solve emotional problems, to make himself or herself feel better. They really served as a form of self-medication. Just as drug addicts and alcoholics use drugs or alcohol in order to medicate themselves, in order to calm themselves down or to rev themselves up, they use self-mutilation to make themselves feel better.

I came to regard both the binging and purging and the self-injury as functioning as someone's drug of choice. I found that the self-injurious behavior and the bulimic behavior, especially the purging (which is the most painful part of that experience), were being used as an attempt to release tension or to interrupt or end a feeling of depression or extreme anxiety.

David: In the introduction, I mentioned that you believe there's an addictive nature to self-harm. Can you elaborate on that, please?

Dr. Farber: Sure, what happens is that a person may start out scratching at their skin or pulling off scabs. It starts out, usually, in a milder form, possibly in childhood, and tends to, for the time being, make the person feel better. The problem is that it doesn't last - the feeling better. So what happens is then they have to do it again and again; just as an alcoholic becomes an alcoholic (what is an alcoholic?). He develops a tolerance for alcohol, so he has to drink a greater quantity and much more frequently. The same thing happens with self-injurious behavior. So someone who starts as picking at the skin then turns to mild cutting, which then becomes more wild and severe. In other words, they develop a tolerance for the self-injury, so they have to up the ante and do it more severely.

One of the things that I have found that was very interesting has to do with symptom substitution. That is if somebody tries to give up their self-injury but they are not psychologically ready, but they are doing it to please somebody (a boyfriend, parent, therapist), what will happen is another self-destructive symptom will crop up in its place.

One of the things that I have found in my study that was very, very interesting is that both the cutting and the purging (very, very painful and violent) seem to have the same kind of strength as a form of self-medication. Both are extremely powerful, and so often people will react as if they took instant or immediate-acting Prozac. It's that powerful as a form of self-medication and that is why it tends to be so addictive. Of course, it means that if they need something so powerful to make themselves feel better, getting into treatment with a therapist that is knowledgeable and understands how the self-harm behavior works is very, very important. The right kind of treatment can help enormously.

David: We have several audience questions on what we've discussed so far. Let's get to those and then we'll continue with our conversation.

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Detached9: Why do you think self-injury is so common in people with anorexia or bulimia? possibly punishment?

Dr. Farber: Well the fascinating thing is that punishment is one of the functions it can serve, but for many people, it's a form of their body's speaking for them. In other words, the body says for the person what they cannot allow themselves to say or know in words. It's about speaking about the emotional pain that they cannot put into words, so their body speaks for them. If you want to think of the bleeding as a form of tears that they couldn't cry, I think that's a good metaphor.

It can be about punishment. Punishing one's self or punishing another. It can be about ridding themselves of something bad or evil inside. A form of cleansing or purifying themselves, except, of course, it doesn't work. If it did work, they would only do it once and they would be sufficiently cleansed or purified.

It starts as someone's solution to an emotional problem, but the solution can become more problematic than the original problem. The solution can take on a life of its own, and become like a runaway train. One of the psychological problems with self-harm is that it creates, for the person, a sense of being in control but then it becomes very out of control.

Cissie_4233: But anorexics and bulimics deal with a certain amount of vanity, therefore why are they now concerned with the scarring?

Dr. Farber: Well because anorexia and bulimia are not always about vanity. It's not always about wanting to look thin. For many people, it is more about emotional pain. And for many people who have a problem with eating they have difficulty with using words to express their emotional pain. So when someone says "I feel fat," they really mean "I feel anxious" or "I feel depressed" or "I feel lonely." For many people with eating problems, the obsession with their physical appearance is just a cover for much deeper emotional pain.

David: I just want to clarify one thing. You are saying that there's a link between eating disorders and self-injury. But, of course, there are people who self-injure who don't have an eating disorder. What about them? Why have they turned to self-injury to cope with their emotions?

Dr. Farber: What I have found in my study is that the people who have suffered the most trauma in their lives, especially childhood trauma (and that trauma can be the trauma of physical or sexual abuse, or children who suffer through various medical or surgical procedures), may need to use more than one form of self-harm.

Sometimes trauma is not the dramatic kind of trauma that I have just mentioned. It can be a loss, like a child suffering the loss of a parent or grandparent in childhood. Children can be traumatized by being constantly or chronically neglected (either emotionally or physically or both).

Abi: How/why, as you say, is body piercing, tattooing or branding described as a 'passive' form of self-mutilation when there are obviously so many people that have such things done and yet do not self-harm as in cutting or burning, etc?

Dr. Farber: Because they are having someone else mutilate their skin, their body tissue, you know? With people who get themselves tattooed constantly, many of them do it not only for the way it looks but for the experience of the pain. Some people will get a buzz from the tattooing. Some people even experience this erotically and get turned on by it. And the same thing goes for the people who purge.

About the piercing and tattooing, I am not talking about someone who just gets a tattoo in order to look cool or because their friends are doing it. I am not talking about that. I am talking about people who feel a "need" to do this to their bodies and have this kind of physical experience. What it does for them is what cutting or burning does for others. It distracts them from the pain that is inside; the internal pain. In other words, they'll have pain inflicted on themselves in order to divert the emotional pain that is inside.

TheEndIsNow: Many people talk about cutting, or other forms of self-injury prevalent among the abused. Are there other common reasons as to why a person might turn to self-injury?

Dr. Farber: Yeah. As I have said before, it usually comes from experience in childhood of trauma, but the trauma doesn't have to be the trauma of physical or sexual abuse; it certainly can be. It can be the trauma of losing a parent or grandparent. They may have no one in their lives that can help them express their pain so they may turn to doing something to their body.

lra20: What about the people who don't know why they do it? I have never been physically or sexually abused.

Dr. Farber: You don't have to be physically or sexually abused. People experience events very very differently. Trauma can be parents splitting up and all of a sudden the child no longer sees his or her father or mother, and that is a terrible trauma for a child, and that is terribly painful, and that child may start to express that pain through scratching himself or throwing up.

The trauma of physical or sexual abuse is certainly one of the major factors in self-harm, but there are many people that have been traumatized but not through physical or sexual abuse. Trauma comes in many different forms.

David: Here's the link to the HealthyPlace.com Self-Injury Community.

David: I want to address the treatment of self-injury, Dr. Farber. What does it take to recover from self-harm?

Dr. Farber: Well, first of all I think it takes a lot of courage. I think it also takes a relationship with a therapist in which you feel really safe -- And this feeling of safety doesn't have to start right from the beginning of therapy.

Most people who harm themselves come into therapy feeling very suspicious or wary of the therapist, but over time a sense of trust develops and the patient feels the therapist is not trying to control her (but when I say her, I am speaking of my own experiences, where most people who do this are female. Please understand when I say her, I mean her or him). I think when you are in therapy, you need to feel in control of yourself and that your therapist isn't trying to control you or insisting you stop hurting yourself. That is a good start. What can be very helpful is if a therapist can try to help you make it less dangerous (through medical help).

Also, it helps if a therapist can let someone know, right from the beginning, that even if you can't articulate in words why you are doing what you are doing, you must have good reasons for doing it. I think in good therapy, the patient and therapist work together to try to understand how and why self-injury became necessary in your life. When you do that, you can try to find other ways to make yourself feel better that are not so harmful - ways that can make you feel better about yourself, ways that you don't have to hide. And I think while all of this is going on, you start to have more control over yourself than you thought, and you find you are more able to speak about the pain that you are feeling inside than you thought, and you don't need to cut yourself or burn yourself so much in order to express that.

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David: Are you saying that one method of treating self-injurious behavior is to taper off; sort of like quitting smoking cigarettes, where you smoke lower nicotine cigarettes or use nicotine substitutes until you finally quit?

Dr. Farber: I am not suggesting anything about how they do it. I think when people feel understood, they start to understand the how and why of why they felt the need to hurt themselves and they'll find other ways to make themselves feel better and the self-injury quite naturally diminishes.

You see, when I talk about treatment, I am not talking about treatment of just the symptom (the self-injury), I am talking about treatment of the person who has that symptom.

I think, very often, that people who hurt themselves tend to have relationships with others that are very painful, where they really cannot trust other people and I think that when someone can start to feel really safe in a therapeutic relationship, really safe with the therapist, that this attachment with the therapist, this relationship, can even become stronger than the relationship to self-harm, than the relationship to pain and to suffering.

David: Then what you are saying is: that until the person can work through their psychological issues, it is very difficult to control the self-injury.

Dr. Farber: I am saying that people need to do both at the same time. They kind of work together, both understanding how and why the need for self-injury arose. Therapists can help their patients find ways to control the self-harm behavior. One way I find extremely effective is when they are feeling the impulse to hurt themselves if they can try just to delay it for five or ten minutes. During those five or ten minutes, pick up a pencil and start to write. Try to put into words what you are feeling. In the process of doing that, in the process of using words to put shape or form into the pain you are feeling inside, the pain inside starts to diminish and by the time you finish writing, the urge to hurt yourself may well be much, much less. It's a way of starting to use your mind to deal with the pain rather than to use your body to deal with the internal pain, and that's the key to recovering from a life of self-injury.

David: We have many audience questions and I want to get to those. I have one last question for the moment. I know that you teach therapists how to treat self-injurers. In your estimation, are there many qualified therapists out there right now to provide proper self-injury treatment?

Dr. Farber: Not many at all, unfortunately. There are a number of reasons for this. One is that therapists become very anxious around people who hurt themselves, and really, there is nothing much in our training that teaches us how to handle people who do this to themselves.

One of the things I have become very interested in doing, and have begun doing, is teaching other mental health professionals how to understand and how to treat people who harm themselves. I want to make therapists less frightened. One of the ways that I am doing this is this summer I will be teaching a seminar at the Cape Cod Institute in July on the treatment of people who harm themselves, and anyone who is interested can go to the Cape Cod Institute website. I also have a toll-free phone number (888-394-9293) for information about the program this summer. You will receive a catalog with the registration information.

David: I ask that because I know that self-injury is still not understood, or is misunderstood, by many. So where does one go for qualified treatment? How do you find the proper treatment for self-injury?

Dr. Farber: I wish I could answer that, really. It can be difficult. First, find a therapist who is willing to learn about self-injury, if they don't already know about it. Then, you really need to search for qualified professionals. I know there are a number of websites about self-injury that have names and addresses of different clinics or therapists that are interested in working with patients who self injure, so that may be a good way to do it. Also, there are some therapists that are learning to do DBT (Dialectical Behavioral Therapy) and this is often a group treatment for people who harm themselves in different ways, who have various kinds of self-destructive behavior.

David: So, for those in the audience, that means if you are looking for treatment, you need to interview the therapists before starting treatment with them. Make sure they have an understanding of self-injury, or at the very least, they are willing to find out more about it. Here are some audience questions:

shattered_innocents: Hi Dr. Farber. Do you recommend any kind of art therapy for dealing with self-injury?

Dr. Farber: I think that anything that can help you express your emotional pain can be helpful - art therapy, poetry, music. Anything to help you express what you are feeling inside, so you don't have to use your body to express it, is wonderful.

Crissy279: Are there any alternatives to cutting or burning that you find have a high success ratio?

Dr. Farber: As I have already said, I think if people can get themselves to sit down and write what they are feeling inside, that can be enormously successful. Often people are afraid to write. You are not writing for publication, so forget about grammar and spelling. Just write what is in your heart. Just as you could use art or poetry or music or dance to express what is feeling inside - these are all much healthier, much more constructive ways of dealing with your emotional pain than using your body to express your pain. You deserve better than to hurt yourself in that way.

angels0ul: Am I just crazy, because my parents are together, my family is supportive and functional, I'm a straight-A student, busy in my community, and have never been through what you could really call "trauma" - not even the death of relatives or friends, and I still SI and struggle with anorexia?

Dr. Farber: As I have said before, trauma comes in all different forms and sometimes it is not nearly so obvious. If you can sit down with a therapist who wants to understand, you may be able to piece together why self-injury came about in your life and why it is something you need to use. You may not be able to know this now or articulate this now, but in time you may be able to.

jjjamms: I really would like to know why I cannot have feelings - good or bad ones. I have anorexia, MPD and self-injurious behavior. I try so hard to get through the feelings, but they are intolerable. How do I HAVE feelings?

Dr. Farber: Well, to be able to feel your feelings, I think first you need to be able to try to express them to somebody. Often that can be a therapist, and often at the beginning, it doesn't come out as something understandable or intelligible. For most people, to go from the experience of inflicting pain on your body to the experience of articulating your pain into words is a long process that doesn't happen overnight. It is also one of the reasons that short-term therapies are not that effective.

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peanuts: How often is self-injury found in those with high abilities to dissociate?

Dr. Farber: Most people who self-injure dissociate either when they are self-injuring or right before. What the self-injury does is, if you are in a dissociated state that starts to feel intolerable, the SI can help bring you out of that state.

For some people, they can be in a state of extreme anxiety (hyper-arousal). Sometimes, when they self injure, the self-injury ends that state of hyper-arousal and brings about a dissociative state which may be more desirable. So self-injury can be used to interrupt a dissociated state or a state of hyper-arousal or a state of depression or a state of anxiety.

aurora23: I self injure and sometimes I feel suicidal and wonder: if I just went a little bit further or I cut a little bit deeper this time, what would happen. But my self-injury is not a suicide attempt. Are these feelings normal or should I have some concerns about these thoughts?
(note: Extensive information here on suicide,suicidal thoughts)

Dr. Farber: You should have some concerns about these feelings because there are some people who do not have the intention to end their lives but they like to flirt with the idea of going a little further and die in the process, although that was not the intention.

David: Earlier, you mentioned substituting one self-injurious behavior for another. Here's a question about that:

asilencedangel: If a person should turn their razors over to a therapist as the beginning of giving up self-injury and then starts abusing their body sexually and physically, could this be symptom substitution and how do I stop before it too gets out of hand?

Dr. Farber: I think if the person gives up the cutting before they are ready to do it, psychologically, they will find some other ways to hurt themselves or find other people to do it. So before someone gives up their cutting implements they need to think about whether they are ready to do this or not. You really need to be honest with yourself about it.

Asilencedangel, why did you turn your razors over to your therapist?

asilencedangel: I thought that I wanted to stop cutting, but now I am starting to question that.

Dr. Farber: I would say that if you turned over your razors to your therapist because the therapist requested it, and you did it for your therapist and not for yourself, then it is not going to work.

mucky: I think that turning razors over just makes it worse, makes me crave it more. At least if I have the razors, I can talk myself down or write a lot of times. Is this ok?

Dr. Farber: Of course it is okay. I think a lot of people who give up their self-injury do it knowing that if they really need to do it (self injure), they can (it's like having an ace up the sleeve). Making the decision to give it up makes someone feel more desperate - forbidden fruit always tastes sweeter. When you give something up, it makes you yearn for it more. I think getting beyond self-injury is more than giving up a certain behavior. It's about giving up a way of life that is attached to pain and suffering, emotional pain and emotional suffering, and when this happens, the self-injury falls by the wayside because it is not needed.

David: Here are a few more audience comments on this subject, then we'll go to the next question.

Jus: That was kind of my question too because someone told me that you should be SI free for 7 months before getting rid of your blades, etc.

2nice: My therapist said she couldn't see me anymore if I didn't stop and it scared me. I couldn't imagine starting all over again with a new person. So I gave everything to my shrink.

cassiana1975: My question is, how do you let everyone know about the self-injury? No one knows I do it. I know that I need help. I want help from friends and family, but I am afraid they will call me crazy.

Dr. Farber: I think you need to be able to talk about it with someone that is not your family or friends. Someone that will help you find a way to tell your family or friends. SI thrives in an atmosphere of secrecy and that promotes the shame. When you can come out to family or friends about it you are taking the behavior that seemed shameful and you're turning it into something else. You are starting to connect more with the other people in your life and that can only be good. Sometimes a therapist can help you to tell your friends or your family about what it is that you are doing, if you feel that you can't do this all by yourself.

David: Here are a few audience suggestions on where you might consider finding someone to talk to:

Trina: Teachers, GP (General Practitioner), guidance counselors, a walk-in clinic are all places teens can go to talk.

peanuts: My GP was supportive - admitting not knowing much about it, not being able to do therapy, but he was willing to listen anytime I needed to talk. It was a start and got me to therapy and other help.

Silent Night: How can I help my mom better understand self-injury?

Dr. Farber: Your mom may want to look at some of the websites about self-injury. There are a number of books out there. And try talking with your mom in an honest way; that would be a good place to start.

David: I know it's getting very late. Thank you, Dr. Farber, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful.

Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others: http://www.healthyplace.com.

Dr. Farber: It was a pleasure being here and I thank you for inviting me, and I hope this has been helpful to the people that have tuned in. And to everyone, I wish you all health and hope and healing.

David: Thank you, again, Dr. Farber. I hope everyone has a pleasant weekend. Good night.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.