The anonymous author of this article is a person in the recovery of Major Depressive Disorder and Borderline Personality Disorder. The views of the author are not those of Promises.
I have struggled with Self-Harm since I was a kid. Most of us are aware of the tantrum’s kids put up when they are upset. They hit others, drop to the floor, scream, and cry. When I felt overwhelmed by certain emotions, in particular anger or sadness, I would use my hands to hit my head. I had trouble identifying and regulating my emotions. My primary school counsellor told me that I have anger management challenges when I shared with her how I find myself unable to control my anger and would hit myself or the well. Little did I know that these behaviours were early signs and symptoms to what would become a diagnosis of Major Depressive Disorder and Borderline Personality Disorder given to me in my 20s.
When the word ‘Self-Harm’ is mentioned, most people think about ‘cutting’. A very common and increasingly concerning the mode of coping for persons in distress, more so for young people, even children. Fortunately, I never turned to ‘cutting’ until I was 23. I was actively suicidal from the stress of battling my illness while also trying to excel in my degree. I began with a penknife and one cut. Soon, that one cut led to many and I found myself with a new problem.
I struggle with Self-Harm till this very day; however, I have come a long way with the help of medications and therapy to reduce the frequency of Self-Harm. I have been trying to replace Self-Harm with healthier coping methods such as exercise.
When I do not wear long sleeves, I end up exposing the scars on my wrists to the world. Generally, I tend to feel ashamed of my scars and it took me some time to embrace them. However, responses from others who have noticed my scars have caused discouragement to me and led me to feel ashamed once again. Ironically, this does not deter me from ‘cutting’; instead, it increases the urge because I develop self-hatred and feel like I deserve to be punished and scarred for my behaviour.
Through this sharing of my experience, I hope to send a message of love to peers who are challenged with Self-Harm, whatever form it might take on. I also want to raise awareness among members of the public on what were some unhelpful words and behaviours people have made towards me, more so out of a lack of awareness rather than a lack of concern. I have learnt to forgive them, and at times have also made the effort to voice my discomfort over their words and actions. Here are five things people have said or done to me that were completely unhelpful, and very likely also to be unhelpful to anyone else challenged with Self-Harm.
1. Touching me without permission I get it, you notice the scars and you get worried. Without thinking, you grab my arm and go “what is this? Did you cut yourself?”. Leaving the question for later, the very act of grabbing my arm to look at my scars without permission is a big ‘NO’. I am hypersensitive to my scars and it takes much courage for me, even till today, to deliberately lift my arm to show my scars. What may surprise you is that, often, this act comes largely from my own parents and also the professionals I see for help. It is good practice to always ask someone for permission if you wish to touch them, even if it means to give a hug. Because some of us who have challenges with trauma and dissociation are hypersensitive to touch. Hence, do be mindful of those around you and remember: If you do not like people grabbing you to see something (on you), it’s the same and perhaps even more, for those of us learning to accept our scars.
2. “Doesn’t it hurt?” No, it doesn’t. This answer may come as a surprise to many, but when I am under extreme stress and emotional distress, the act of physically inflicting hurt on myself gives me relief. The greater the physical “pain” the greater the relief. For me, this goes for any act of self-harm be it ‘cutting’, punching the wall, or knocking my head against the wall until it starts bleeding. I can only compare this to someone who meets with an accident. The body goes into shock to the point the person may have a broken leg; however, he or she is not feeling any pain. I do not have a formal education in psychology or biology, but I believe my brain “shuts down” the part that feels pain which aids me to self-harm without feeling the actual pain.
3. “The scars are so ugly! Why do you enjoy this? Can’t you stop?” This is a three-part question, but it often comes to me in one line of questioning. First, I want to say that I do not enjoy this. Not at all. I would love to have clear and beautiful skin too. Every time I look down at my arm to see the scars, I feel hatred towards myself. “How could I do this to myself? I am a horrible person”. And yet, I find that I cannot stop. A coping method I have turned to, since childhood, to cope with the traumatic experiences and intense emotions is self-harm. It has become the default and almost automatic ‘subconscious’ act whenever I am in distress.
4. “It doesn’t look too bad” I know that this statement is in direct contrast to the one above. But I have had this said to me by peers and sadly, professionals. There is not much need for me to elaborate on this statement as it is obvious that it is unhelpful. This statement makes me feel like a failure and makes me want to hurt myself even more. The ‘Depression voice’ is always on standby, ready to jump in with a “See, you are useless at even trying to hurt yourself? You call that a cut?! You are a coward. Go and do it again”.
5. Taking away or hide the sharp items that I could use to hurt myself This is probably most relatable to parents and caregivers supporting someone who is challenged with self-harm. It is very natural to become protective and do what it takes to stop your loved one from hurting themselves. “If I take away their means to hurt themselves, then they have no choice but to stop, right?” Unless you tag along with your loved one 24/7, it is very easy to drop by the nearest bookstore to buy a new penknife. More importantly, in doing so, you are taking away the one thing that I have which keeps me from jumping out of my window or overdosing on my pills. Until I learn to safely stop self-harming in therapy, to take it away from me by force, will throw me into an emotional turmoil that will only make me feel worse.
So please, next time you notice someone with scars that look like they might be from the act of cutting one-self, please be gentle and kind to the person. Be extremely mindful of what you say. Perhaps, a guiding thought could be: If you cannot entertain the idea of causing pain to yourself, imagine how much pain the person must be in to be able to cause harm to themselves. When I self-harm, it is a desperate means for me to stay alive. It is a cry for help: for attention, for love, care and non-judgemental support.
If you know a loved one who self harms please do gently prod him/her towards seeking help from a trained professional.
For individuals that are taking the first step to seek help from mental health professionals, it is natural that they may be concerned with the possibility of a misdiagnosis, or perhaps an overdiagnosis. With the pre-existing stigmatisation of mental health disorders, clients would have needed to pluck up their courage to seek treatment in the first place. A misdiagnosis could not only hinder them from receiving the appropriate treatment for their affliction, but also allows for their distress to grow unchecked as their hope for recovery diminishes. In other words, accuracy in evidence-based mental health diagnosis is crucial, and this article aims to help you better understand how the diagnostic process works.
As the term “Evidence-Based Diagnosis” implies, psychiatrists or clinical psychologists take extra care to ensure that any diagnosis made is accurate, objective, and not subject to any form of personal bias. In some sense, this also means allowing for a safe, non-judgemental and compassionate environment. Primarily, clinicians would have to understand the client’s suffering and situation, before thinking about how that might relate to a possible mental disorder. Perhaps you may be unaware of this – clinicians do not simply jump straight into tying the client down with a specific diagnosis of a mental disorder. Before all else, clinicians have to consider if the client’s symptoms meet the definitions of a mental disorder in the first place. As per the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the definition of a mental disorder considers these five factors:
A behavioral or psychological syndrome or pattern that occurs in an individual
Reflects an underlying psychobiological dysfunction
The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)
Must not be merely an expected response to common stressors and losses (i.e.. the loss of a loved one) or a culturally sanctioned response to a particular event (i.e. trance states in religious rituals)
Primarily a result of social deviance or conflicts with society
With reference to the definition of a mental disorder, it is particularly important to note that the consequences of a mental disorder is clinically significant, and causes a weighty amount of disruption to one’s lifestyle and day-to-day activities. For example, it is completely natural for one to feel upset over certain situations, and this does not necessarily mean that you have a case of depression. However, you might need to get it checked out if you find yourself unable to cope with prolonged feelings of sadness which start to interfere with your daily activities, or are causing you to have suicidal thoughts.
Of course, clinicians then assess the syndrome one displays. By “syndrome”, we mean a collection of signs or observable aspects of the client’s suffering (i.e outward expression or behaviour). The main point of this is to identify if the syndrome is clustered in an identifiable pattern that is noted to be severe or pervasive. During the assessment phase, clinicians also try to understand the internal experiences of the client. Besides their outward display of distress, their thoughts and feelings are also important information which counts towards the diagnosis of certain disorders. Upon identifying that the client is indeed suffering from a mental condition, clinicians then try “assigning” the client to a particular category. You can think of it as, “can the syndrome be broadly identified?” There are certain broad categories of disorders, such as anxiety disorders, or psychotic disorders. Needless to say, clinicians have to consider which category the client best fits in.
The last step of the diagnosis process concerns the further narrowing and identification of the specific disorder – branching out from the broader, generalised category and into the specific details. For example, a client could be diagnosed with Obsessive-Compulsive Disorder (OCD), a form of an anxiety disorder. Ideally, a specific disorder is identified during the diagnosis process for various reasons – for the sake of the clients themselves, but also for clearer communication with other mental health professionals (in the case of continuity of care), and even for legal or court matters. Under rare circumstances, some clinicians are able to identify the broad category of the mental disorder, yet are unable to specify the exact condition that the client is suffering from. In cases like these, their disorders will be labelled as “unspecified”, as per the 10th version of the International Classification of Diseases.
As mentioned, evidence-based mental disorder diagnosis is all about diagnosing clients accurately and objectively. To enhance objectivity, some clinicians go the extra mile, stopping to consider if the diagnosis given was biased, or influenced by his or her own culture and history. “Is the syndrome maladaptive?”, “Did I take cultural variables into account?” An objective diagnosis will certainly go a long way in ensuring that the client receives the most appropriate treatment, which will in turn enhance his or her recovery journey.
Overall, it is safe to say that it takes two hands to clap in every treatment process. Clients and clinicians should try as much as possible to work together, be it in the assessment or treatment phase. For an effective treatment, clinicians will do their best to assess the severity and pervasiveness of any syndrome using understandable language such that clients are well aware of their condition. However, clients also need to understand that transparency on their side is pivotal and that it will drastically impact the treatment process, for better or for worse, depending on their cooperativity and how much they choose to reveal.
Dr Robert Shwartz, Ph.D., PCC-S, Evidence-Based Mental Disorder Diagnosis: How to Increase Accountability, Efficiency and Objectivity, video recording, Mental Health Academy
For many individuals, therapy is a rather intense and personal topic, and it could have taken them a lot of courage to finally seek the help that they need. Keeping this in mind, it is exceptionally crucial that one finds the right therapist, for there’s a pre-existing implicit clinical belief that the level of treatment effectiveness is greatly dependent on the therapist-client fit. Of course, every client would love to be able to – ideally – find that one therapist whom they can fully open up to from the very beginning, but in reality, that may not be the case. At times, it is necessary to assess your relationship with your therapist and evaluate if there’s the good rapport you need for your sessions to be a success. Ultimately, it boils down to whether you feel a steady, reliable and safe connection with the therapist, and whether you are making the progress you hope for.
To give you some background, studies over the years have shown that the more similar the therapist and the client, the higher the rate of recovery. As an example, an assessment instrument entitled the “Structural Profile Inventory(SPI)”, which measures seven “independent yet interactive” variables (behaviours, affects, sensory imagery, cognition, interpersonal, drugs/biological factors or BASIC-ID), showed that client-therapist similarity on the SPI predicted a better psychotherapy outcome for the client as measured by differences pre- and post-treatment on the Brief Symptom Inventory. Moreover, the demographic similarity between therapist and client facilitates positive perceptions of the relationship in the beginning stages of treatment, enhances commitment to remaining in treatment, and at times can accelerate the amount of improvement experienced by clients. More precisely, it can be said that age, ethnicity, and gender similarity have been associated with positive client perceptions of the treatment relationship. With gender and cultural similarities appearing the most strongly preferred among clients, these domains generally enhance clients’ perceptions of their therapists’ level of understanding and empathy, and as a result, sessions are judged to be more advantageous and worthwhile. However, besides these, there are also other means to assess your “fit” with your therapist, and we’re here to discuss just that.
First and foremost, consider if you are seeking help in the right place. Does the therapist you are looking at specialise in the area you are seeking help for? Before we can even touch on the topic of interpersonal therapist-client fit, it is important for you to take the time to do some research on various therapists’ profiles – in other words, to sift through and read up on their respective areas of expertise. Typically, therapists would have their area(s) of specialisation up on their online profile directories. It would be clearly indicated if they specialise in areas such as substance abuse, family therapy, or even anger management. It goes without saying that, for example, it would be inappropriate to consult a psychologist who specialises in child psychology when you’re clearly looking for someone who can help you with your substance-use addiction. With that said, it is to no one’s benefit for you to rush into therapy blindly.
Once you have chosen the potential therapist that you are most likely to want to have see you through your road to recovery, another essential question you should ask yourself is whether you are comfortable with their suggested mode of therapy. During consultations, you will have the opportunity to enquire about their recommended techniques or treatment methods that will be explored during your subsequent sessions. If you are uncomfortable with any particular process, giving honest feedback and exploring other methods is always an option. However, at any point, you also have the right to seek other therapists who may be able to help you in other ways that don’t put you in a tight spot. After all, therapy is all about having a safe and comfortable space for you to sort out your difficulties.
When assessing your interpersonal connection with your therapist, make sure to trust your gut. This way, you’ll also be able to track your progress better and to seek alternative help if required. Some questions you can ask yourself are:
Am I satisfied with the current balance of talking and listening with my therapist?
Is my overall therapy experience safe, warm, and validating?
Am I fully assured that I’m in a non-judgemental space where I can be fully honest?
How much has the therapist helped me to gain greater insight into my own behaviour and thoughts so far?
Am I becoming more capable of coping (independently) with stressful or triggering situations over time?
Am I noticing more positive changes in myself, as compared to when I first started therapy?
As mentioned, a major deciding factor should also be on whether you find yourself noticing positive changes in your thought cycles and behaviour after a couple of sessions. At the end of the day, therapy should be about working towards achieving your desired outcome, and should definitely not be limited to weekly venting sessions. Although venting and letting out hard feelings can provide temporary relief, it fosters a client’s dependence on the therapist over time and further reinforces the client’s problems. Therapy should instead help you to feel more confident that you’ve developed the relevant skill sets in order to cope with whatever emotional challenges that brought you to seek therapy in the first place.
Naturally, there’s no guarantee that we will find chemistry with the first therapist we meet. The chemistry between people varies, and sometimes it’s just not possible for us to force it. Thus, it is important to remember that a lack of fit between therapist and client is no one’s fault. However, remember that the ball is in our court, and it is within our control to start looking in the right place for the sake of our own well-being.
1 Herman, S.M. (1998). The relationship between therapist-client modality similarity and psychotherapy outcome. Journal of Psychotherapy Practice and Research, 1998 Winter; 7(1): 56-64.
2 Luborksky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983). Two Helping alliance methods for predicting outcomes of psychotherapy: A counting signs vs. a global rating method. Journal of Nervous and Mental Disease, 171, 480-491.
3 Jones, E. E., (1978). Effects of race on psychotherapy process and outcome: An exploratory investigation. Psychotherapy: Theory, Research and Practice, 15, 226-236.
4 Blase, J. J. (1979). A study of the effects of sec of the client and sex of the therapist on clients’ satisfaction with psychotherapy. Dissertation Abstracts International, 39, 6107B-6108B.
Beutler, L.E., Clarkin, J., Crago, M. and Bergan, J., 1991. Client-therapist matching. Pergamon general psychology series, 162, pp.699-716. (Accessed 30/08/2020)
What comes to mind when someone mentions alcohol? For many, alcohol is often associated with the temporary avoidance of daily struggles. Whether or not we have the habit to drink, it is a known fact that people may tend to have “blackouts” whenever they’re really drunk – and are unable to recall anything during these periods of time. As for young adults, perhaps it could also be attributed to their keen desire to look “cool” and to show off their high alcohol tolerance to their friends. However, alcohol can be addictive, and frequent heavy drinkers run the risk of becoming alcohol-dependent and hence developing alcohol use disorders. But what actions can we take if we find ourselves constantly wanting to submit to such an altered state of being, and seeing the appeal in losing control of ourselves as a form of escapism?
What is an Alcohol Use Disorder?
According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.;
DSM–5; American Psychiatric Association, 2013), an alcohol use disorder is essentially characterised by “a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring within a 12-month period”:
Alcohol is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations where it is physically dangerous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
In regards to the disorder’s severity, it is safe to say that an individual categorised under the ‘mild severity’ category would display two to three of the above symptoms, while those under ‘Moderate’ would display four to five. For persons who develop six or more of such symptoms, they would, unfortunately, be diagnosed to be severely alcohol-dependent.
In the development of alcohol abuse, we need to recognise that the physiological and psychological reward system in our brains are what contributes to the clouding of negative consequences and effects associated with alcohol dependence and addiction. In other words, the possibility for change is tough, and the learnt habit can be hard to kick. Positive and negative reinforcements play a major role, especially in the beginning stages of alcohol abuse. Positive reinforcement occurs when the chances of an individual performing an activity (in this case, drinking) is heightened due to his previous experience of feeling rewarded by the “high” he or she obtains when getting drunk. On the contrary, negative reinforcement occurs when the probability of alcohol-seeking behaviour increases upon allowing the drinker to avoid certain situations or negative stimuli. Therefore, it can be said that alcohol abuse is fuelled by the physiological and psychological reward system, thus increasing one’s motivation to consume more alcohol, though sometimes a little too much.
Alcohol addiction can be greatly detrimental to our lifestyles, as well as to our physical and mental health. Known to be a depressant, alcohol can have a significant impact on our brain’s activity. If you’re drinking unhealthy levels of alcohol in an attempt to manage other mental health conditions such as anxiety or depression, stop it immediately! Alcohol affects neurotransmitters in your brain, potentially worsening your pre-existing condition. As such, it is crucial that we help people with alcohol use disorders to move past their addiction to a more fulfilling lifestyle.
What forms of treatment can I consider?
Alcohol abuse can be treated with psychiatric or psychological intervention, sometimes a combination of both.
When it comes to psychiatric medications, psychiatrists may prescribe medications used primarily to treat alcohol withdrawal by targeting the GABA neurotransmitters in the brain, allowing the brain to restore its natural balance when the person abstains from alcohol. Another common medication prescribed mainly affects the individual’s alcohol metabolism. The drug increases the concentration of acetaldehyde, a product formed when alcohol is broken down. The buildup of this acetaldehyde induces undesirable effects such as vomiting, hence holding the person back from consuming large amounts of alcohol. However, despite these drugs being the commonly prescribed medications, it is extremely dangerous for one to source and consume them without first consulting a professional psychiatrist. Everyone’s case is different, and people may have differing medication needs.
Another form of treatment one can consider is Cognitive Behavioural Therapy (CBT). CBT is an effective method which focuses on helping one identify and uproot negative or irrational thoughts and/or behaviours. Being highly solution-focused, such forms of therapy can include trying to help these individuals to recognise situations in which they are inclined to drink, and how they can better repress themselves. As such, the main goal would be for these people to recognise their problematic behaviour, and subsequently cut down on and adhere to healthy alcohol consumption levels. Since the impact of alcohol abuse is usually not limited to the individual, family therapy may also be recommended at times, especially if the individual’s alcoholic behaviour causes others distress.
Predictive algorithms, the creation of alternate realities in which we are unlimited by the constraints of the real world we live in – such methods are extensively practiced by the gaming industry to draw players in. Gaming is undeniably a popular and widely-adopted mode of de-stressing, but how much is too much?
In May 2019, the World Health Organisation officially recognised “gaming addiction” as a mental health condition. It is diagnosed when a person displays a gaming behaviour pattern that causes significant disruption to their daily life for a period of 12 months. Meanwhile, a study showed that Singaporeans aged 18 and above spend a weekly average of 7 hours and 26 minutes playing video games, and that approximately 10 percent of Singaporeans game for more than 20 hours per week. This ranks us as the highest in Asia, and third highest in the world, falling only behind Germany and the United States.
What leads these addicted individuals to their compulsive gaming behaviour? Besides the prevalence and ease of access to games on various gaming platforms, video games often act as a form of escapism for many players. As a shining proponent of the alluring, edge-cutting virtuality, games allow for players to throw themselves into a virtual landscape that is contrasted from their – comparatively – mundane everyday lives, and can serve as a distractor from real-life problems that they are unconfident or reluctant to face. Moreover, it can be easy to fall into the trap set by game creators. Game designers construct games in a way that applies principles of behavioural economics as well as psychological mechanisms to explore stages and levelling up processes that trigger the brain’s reward system. In-game statuses matter a lot to gamers – the higher the rank you possess, the more pride and self-esteem you hold, knowing that you can show it off to your friends or gaming counterparts. As a result, individuals are often inclined to continue striving to climb the virtual hierarchy.
Naturally, excessive gaming has its consequences. When an individual develops a gaming disorder, his lifestyles can be disrupted in more ways than one. What is also important to take note of, is that the harmful effects of gaming addiction is not only limited to the individual alone, but could also affect the people in his or her social circle. Some of these adverse effects can include:
Obsessive Behaviour Individuals who are addicted to video games are always anxious to get back to games and will often display irritable, bad-temper aggressive behaviour whenever they are separated from their games unwillingly.
Increased Social Isolation With extended periods of intense gaming, these individuals become more withdrawn and disconnected from family, friends and colleagues, causing them to drift away from their loved ones.
Other Mental Health Conditions Gaming addiction can eventually lead to other issues that include depression or anxiety disorders. Sometimes, depression may follow due to the prolonged social isolation.
Other Physical Health Conditions A gaming addiction can also have a number of physical effects. When one devotes an excessive amount of time to the gaming activity, this can lead to physical conditions such as the carpal tunnel syndrome, migraine, back-aches or eye-strain. Extreme addiction may cause gamers to skip meals and rest, or neglect their personal hygiene as they lose control of themselves and can’t resist the desire to play more and more.
Gaming addiction is a serious matter, and can be degenerative if not addressed in the early stages with the initial symptoms and signs. Habits, including unhealthy gaming habits, can be formed anytime between 1 to 3 months, and it will be significantly easier to curb such self-destructive behaviour the earlier we try to tackle it.
While we are concerned with the various health risks and conditions commonly associated with gaming addiction, we cannot deny that video games are also undoubtedly entertaining and can be a good way to de-stress. However, as the risk of gaming addiction increases with increasing time spent gaming, what we want to advocate is moderation, rather than complete avoidance. With that said, if you are someone who is battling gaming compulsion, try to keep the amount of time spent gaming under control by setting time limits for play and stick to them. If possible, try reducing your playtime gradually by setting a timer on your phone, or use softwares such as ‘Cold Turkey Blocker’ to help you do this by blocking access to websites or applications so that you can get offline when you need to.
Like other forms of addictions, don’t try to go cold turkey at one go. Stopping altogether may cause you to feel as though there is a huge void in your life, hence increasing the likelihood of a relapse instead.