Treating Self-Injury with CARESS: A New Way to Address the “Demons and Secrets Inside”
CARESS—Communicate Alternatively. Release Endorphins. Self-Soothe
CARESS teaches new behaviors so that self-injury clients feel less likely to follow through with destructive impulses. As a result, they can retain a sense of power and control—expanding their range of positive coping skills.
The first time Lisa Ferentz encountered a client who engaged in self-injury was on a Friday at 4:30 p.m., with five minutes left in the session. Thirty-two-year-old Robin had been in treatment with Lisa, a social worker and founder of the Ferentz Institute, for six months.
Robin was a survivor of sexual abuse, with a history of substance abuse and eating disorders. Her father had been alcoholic and violent, her mother was devoutly religious but deeply depressed, and her younger sister was the scapegoat. Robin took on the role of caretaker of the family.
By 14, Robin binged and purged, got high on drugs and alcohol, and was sexually promiscuous. In her mid-twenties, she began having flashbacks of sexual abuse by her father. She saw three therapists in four years, finding it “nearly impossible to trust anyone.” With the help of a 12-step program, she was recovering from her substance-abuse problem. Now, still living with her mother, she was in psychotherapy to address the “demons and secrets inside.”
Now, still living with her mother, she
was in psychotherapy to address
the “demons and secrets inside.”
For the past month, Robin had been working with a Lisa to resolve overwhelming flashbacks related to her sexual trauma. That Friday, as Lisa and she were wrapping up the session, Robin began to roll up her sleeve and said with a heavy sigh, “Uh, I guess I should show you this.”
This was a two-inch cut she had made on her forearm with the jagged lid of a pineapple can. It was Lisa’s first encounter with cutting.
A Therapist Scared to Death
Lisa’s heart pounded as she struggled to keep a professional facade and figure out how best to respond. Sensing her distress, Robin quickly lowered her sleeve and tried to reassure her that “it was no big deal” and “nothing to worry about.”
“I kept her in my office for two hours, attempting to assess if she was suicidal and needed hospitalization,” Lisa said. “She talked about her injury with eerie detachment, reiterating that she didn’t want to kill herself. She had cut herself—just as she had done many times before—simply to feel better.”
“She had cut herself—just as she
had done many times before—simply
to feel better.”
You cut yourself to feel better? Lisa wondered to herself. How could it possibly feel good to slice into your arm?
However unfamiliar this symptom was to Lisa, she concluded that deliberate, repetitive self-injury could only be seen as pathological. Lisa had to help Robin immediately stop this behavior. So she carefully explained why cutting was a bad idea and how it would only create more problems for Robin.
“I insisted that she agree to not hurt her body in any way during the upcoming week,” Lisa said.
“Finally, she acquiesced. I exhaled with relief. I felt calmer and more in control.”
Round One to the Client
Within the first five minutes of their session a week later, Robin rolled up her sleeve and told Lisa, “I felt really mad after I left here last week. I knew you didn’t understand, but I was also scared that you couldn’t help me or that you’d be mad at me if I didn’t stop. I didn’t feel better until after I made these new marks.” Then with a bittersweet but triumphant grin, Robin announced, “So much for the contract, huh?” Lisa had lost round one.
For the next several weeks, Lisa felt compelled to keep pushing a standard safety contract. Robin’s cutting increased.
“I feel good when I do it,” Robin said, “especially since I’m not getting high anymore.”
“I feel good when I do it,” Robin
said, “especially since I’m not
getting high anymore.”
Even when Robin could temporarily stop cutting, she reverted to bingeing and purging or having unsafe sexual encounters.
“My refusal to accept Robin’s self-cutting as anything but dysfunctional kept me from hearing what she was trying to tell me,” Lisa said. “Worse, it was actually causing more destructive behavior.”
“But Cutting Helps Me . . .”
“Cutting helps me,” Robin was saying. “You can’t just expect me to stop.” At that moment, Lisa realized that unless she rethought her clinical assumptions, therapy with Robin wasn’t going anywhere.
Lisa changed my strategy. She began with the premise that Robin, not Lisa, was the expert in self-harm. Over the next six months, Lisa let Robin teach her about the behavior, and the thoughts and feelings that accompanied it. Lisa was particularly interested in the experiences that preceded the “need” to self-injure.
In one memorable session, Robin
described an incident that put her
behavior into context.
In one memorable session, Robin described an incident that put her behavior into context.
- She was in a crowded checkout line at the supermarket, when the cart behind her accidentally bumped into her. She immediately felt enraged and anxious. She remembered thinking, Why is everyone out to hurt me? Why can’t I just be left alone?
- Her anger and sense of powerlessness grew. By the time she got home, she felt “out of it and numb.” In desperation, she cut into her left arm. Immediately, she began to feel better.
When Robin and Lisa processed this experience, they saw how benign interactions and life events often triggered strong emotions and distorted thoughts. Robin’s inability to manage these situations created overwhelming anxiety. She would then dissociate to numb her discomfort. In that “zoned out” state, she didn’t feel pain and was able to cut herself”
“Injuring the body released endorphins, the body’s natural opiates, and as a result, her despair and anxiety dramatically decreased,” Lisa said. “For her, as for many others who self-harm, the initial response to self-harm injury was a kind of pleasure: ‘I hurt myself and then I feel better.’”
Learning to Respect the Cutting . . .
Lisa learned to respect the fact that cutting felt like an effective coping strategy for Robin. In the long term, it created more problems—embarrassment; a loss of control; disempowerment; feelings of inadequacy and failure; and physical injury. These negative effects added to Robin’s vulnerability. Nevertheless, she genuinely believed that cutting was the only effective way to cope.
“Asking her to give it up was like asking her to turn over the tiny life jacket she clung to when adrift in the ocean,” Lisa said.
Lisa gave up the power struggle
with Robin. She told her she
wouldn’t stop hurting herself
until she was ready to do so.
Lisa gave up the power struggle with Robin. She told her she wouldn’t stop hurting herself until she was ready to do so.
Lisa’s job was not to browbeat Robin into change, but to introduce her to healthier behaviors to engage in before she hurt herself—that would bring her the relief that cutting gave her.
Lisa introduced Robin to a behavioral contract that Lisa has since come to call CARESS:
- Communicate Alternatively
- Release Endorphins
Communicate Alternatively: Self-harm is a form of communication. The overwhelming pain becomes visible and tangible through the wound. The injury validates and legitimizes the internal pain so that others can bear witness.
Self-harm is way traumatized clients can tell their abuse stories without words and without disobeying a perpetrator’s injunction against “telling.” So, Lisa encouraged Robin to draw, make a collage, or write about her thoughts and feelings before she hurt herself.
“I suggested she draw the body part she wanted to cut and the actual injuries she would inflict on herself, or to create a collage of words and images to articulate her feelings and thoughts,” Lisa said. “Over the next few months, she learned to use journaling, poetry, and letter writing as alternative forms of expression.”
Release Endorphins: Robin needed new ways to experience the euphoric rush that her self-cutting triggered. “Endorphins are released not only by intense pain, but also by laughter, affection, and vigorous physical activity,” said Lisa. “So, I encouraged her to listen to a funny CD or movie; to hug a pillow, stuffed animal, or pet; and to do 10 to 15 minutes of physical activity before she acted on the impulse to self-harm.”
Self-Soothe: Robin’s only strategy for managing her emotions was self-injury. So, Lisa identified new ways Robin could comfort herself, such as taking warm baths or showers; wrapping herself in a quilt and rocking; listening to comforting music; reading positive affirmations; lighting scented candles and meditating; engaging in positive self-talk; and calling a friend or hotline.
“I told Robin to do each of the three components of CARESS for 10 to 15 minutes as soon as she felt the impulse to hurt herself,” Lisa said. “That meant that she’d practice 30 to 45 minutes of beneficial, healthy, productive behaviors to accomplish exactly what the cutting had previously achieved.”
CARESS contract taught Robin
a way to retain a sense of power
and control by expanding her range
of positive coping strategies.
Robin slowly began to try these new behaviors and felt less need to follow through with her destructive impulses. When she did, her injuries were more superficial. CARESS contract taught Robin a way to retain a sense of power and control by expanding her range of positive coping strategies.
“I’ve used this intervention with many self-injuring clients since my work with Robin,” Lisa said. “Of course, not all of them comply with the CARESS contract. I’ve discovered the importance of moving in baby steps: verbally rewarding and supporting the client who even thinks about using the contract or does even some part of it before engaging in self-harm.”
Roll Up Those Sleeves . . .
When clients roll up their sleeves or pant legs, open their hands, or push their hair from their necks to show Lisa their injuries, she considers it a testament to the therapeutic relationship and trust in me. Their injuries are poignant information about their pain.
“While offering them other approaches and expressing my belief that they can embrace healthier behaviors, I respect where they are and exercise the clinical virtues of patience, persistence, and compassion,” said Lisa.
Don’t Expect Immediate Results
It took several more years for Robin to give up her self-injury altogether. The work unfolded on her terms and in her time frame, regularly punctuated by setbacks and cutting episodes.
Robin came to understand that
being bumped by a supermarket
cart from behind connected to
being sodomized as a child.
“The move toward eliminating the behavior was completely up to her,” Lisa said. “In the process, her drawings, collages, and journal entries helped connect her destructive behaviors to her childhood abuse. Robin came to understand that being bumped by a supermarket cart from behind connected to being sodomized as a child. Cutting her left forearm was a nonverbal way to indicate where her father had ‘grabbed her when he took her upstairs to molest her.’”
By her fourth year of treatment, Robin began to feel confident and strong. She chose to confront her mother about her childhood abuse and sexual trauma. When her mother discounted her pain and likened the sexual abuse to sinning, she had the courage to move out of the house.
Freed to Succeed
With her newfound freedom, she pursued a college degree. Her new dream included a master’s degree in special education. Although she continued to struggle with her weight, she no longer binged and purged.
“Several years after Robin terminated with me, she called to schedule an appointment,” Lisa said, adding that Robin—looking calm and self-assured—told her about her successes.
- She was working on her degree in special education,
- Had supportive, healthy friends, and
- Was celebrating almost seven years of sobriety.
And then, with five minutes left in the session, she leaned forward and said, “I guess I should show you this.”
“For a split second, my heart fell,” Lisa said. “With a triumphant grin, she held out her hand and revealed a beautiful engagement ring. ‘I know what you were thinking,’ she said with a laugh. ‘But you helped me figure out that I don’t ever need to go there again.’”
Ferentz, L. “Treating the Self-Harming Client.” (September/October 2002). Psychotherapy Networker. Retrieved from https://psychotherapynetworker.org/magazine/article/851/treating-the-self-harming-client