Depathologizing Self-Destructive Behaviors: Decreasing Shame As The First Step to Healthy Coping
Content notice: self-harm
People come to therapy because they’re in emotional pain. They’re generally looking for a way out of that pain, or at least to be able to manage it better. However, popular depictions of therapy and mental health tend to focus on mental illness - the idea that people go to therapy because there is something “wrong” with them mentally or emotionally.
The word pathology is used in medicine to refer to disease or things that are “abnormal.” When we view therapy as something people do when there’s something “wrong” with them, we’re looking at mental health from the point of view of pathology. We’re thinking in terms of what is “normal” and seeing anything that is not “normal” as a symptom of a disease. In this framework, to pathologize something means to see it as abnormal or a function of disease.
This has its uses. For some people, it’s helpful to think of the depression or anxiety they experience, for example, as a disease they struggle with rather than a part of who they are. Thinking in terms of pathology in this way can reduce stigma and help people to reclaim a sense of themselves even through chronic mental health struggles.
For other people, though, the pathology model of mental health isn’t a terribly helpful way to look at things. For these people, thinking in terms of pathology makes them feel worse, contributing to feelings of helplessness or worthlessness.
The most common way we pathologize in therapy is when we talk about symptoms, like anxiety, insomnia, or hyperactivity. The biggest reason for this is that when we categorize someone’s symptoms, we can start to see patterns that help us to find the best treatments. If a client describes feeling empty and worthless, lacking energy, sleeping a lot, and not feeling motivated, we can see that those symptoms line up well with what we call depression - something millions of people have experienced. This allows us to quickly zero in on treatment options that have helped others in similar situations. Pathologizing symptoms in this case allows us to provide more effective help more efficiently.
When we pathologize symptoms and behaviors, though, we then naturally tend to start seeing people through the lens of disease or mental illness. If we think this way too often, we run the risk of losing sight of how each person is a unique, complex whole. A person who experiences even chronic, deep depression is so much more than their lack of energy and motivation or feelings of worthlessness. They are a whole human being with a self and a story and dignity. In our rush to be effective therapists, we always have to be sure we’re not missing this forest when we focus on the handful of “pathological” trees
Self-harm is an example of a behavior that’s easy to pathologize and see as abnormal or a symptom of a mental illness. For those who have never experienced the urge to self-harm, it can be baffling why someone would resort to that action. For loved ones, it can be very distressing to think about a family member or friend purposefully hurting themselves. Our first reaction may be based on our lack of understanding or the discomfort we experience when thinking about self-harm, so we may start to see it as “wrong” or “bad,” a pathological behavior in need of fixing. If we do this, though, we miss out on so many ways of actually helping and supporting the person who is self-harming.
People don’t typically self-harm because they see it as a great solution to the problems they’re experiencing. They do so because, at least in the heat of the moment, it seems like the best available option for managing their current situation. Someone experiencing overwhelming emotional pain who doesn’t know how to tolerate that pain and feels like they have no one who understands what they’re going through might find that self-harm provides temporary relief from that emotional pain. In moments of profound distress, self-harm could seem like the best out of a set of inadequate options. The problem is that the effects of using self-harm as a coping mechanism make things worse over time, putting a person’s health and safety at risk and affecting their sense of self and ability to live a full, healthy life.
Lots of the things that bring people to counseling can be similarly seen as coping mechanisms that were the best someone could do in the moment, but which have far-reaching, unintended negative consequences: drinking, substance use, bingeing and purging or other disordered eating, risky sexual choices, or self-sabotaging in relationships.
People who lean heavily on these coping mechanisms often experience intense shame as a result. They often know that what they’re doing isn’t actually helping in the long run and is instead hurting them and even the people around them. At the same time, they don’t know how to stop or how to handle the pain that got them there in the first place. The shame they feel often becomes just another painful emotion that they aren’t sure how to handle and end up managing with the same imperfect coping skills, continuing the cycle.
"When we depathologize self-harm or other seemingly self-destructive behaviors, we allow room for empathy and understanding. We allow ourselves to be someone who has felt a lot of pain and who is growing and learning new ways to handle it. "
The power of this shame cycle then combines with the natural tendency of the human brain to form deep-seated habits and at times addictions as well as the immense difficulty of tolerating painful emotions. Because of this, someone who has routinely used self-harm to manage their emotional pain won’t typically be able to stop cold turkey. Rather, therapy might begin by helping them to build up other ways of tolerating emotional pain while gradually decreasing self-harming behaviors.
Other times, self-harm might have progressed to the point where more intensive treatment is needed at first to help someone stabilize. This might include attending an intensive outpatient program or joining a DBT group that teaches crucial emotional skills.
Either way, depathologizing the original behavior - understanding the self-harm as an imperfect coping mechanism rather than a character flaw or something that is “wrong” with the person - is an effective way to combat the shame surrounding it. When we depathologize self-harm or other seemingly self-destructive behaviors, we allow room for empathy and understanding. We allow ourselves to be someone who has felt a lot of pain and who is growing and learning new ways to handle it. This makes it a whole lot easier to build up some stronger, healthier coping skills to replace the initial unhealthy ones. Then it becomes possible to go even deeper to uncover the roots of the emotional pain and begin healing it in a lasting way.
Depathologizing in therapy means leaning away from seeing the things that bring people to counseling as symptoms of mental illness and leaning toward seeing them as imperfect coping skills that were the best a person could manage in a difficult situation. When therapists depathologize the way we see our clients, we invite our clients to do this in the way they see themselves, too. This is a powerful way to break through the shame holding so many people back, opening up new possibilities for building resilience and happier, healthier lives.
Brennan Mallonee is a Licensed Mental Health Counselor in Cambridge, MA. Brennan specializes in treating anxiety, depression, trauma, and questions related to spirituality. She provides a safe space in which clients can explore their spiritual side, whether that means understanding a faith tradition and how it relates to daily life, or finding meaning and purpose during difficult life transitions.