Does punishment ever work?

The most frequent question I hear when asked to consult with mental health professionals on this topic of Self-Directed Violence (SDV) is not “Why do people do this to themselves?” It is “How do we make them stop?” And the question usually has a sense of frustration and urgency. I get it. People who appear to “turn on themselves” upset the people around them, most of the time. This applies to family, friends, physicians and mental health clinicians. If you want to see intense drama see how self-injury is portrayed on crime or drama television.

Of course I do not believe that healing can occur without understanding the reasons SDV exists in a person’s life. If we comprehend that SDV serves a purpose, often survival, then we acknowledge the complexity of the task of healing and creating supportive environments. More on this next post…

The challenge is to avoid falling into the trap of “we will discover the why when the behavior is gone.” My interpretation of this is: we can intellectually discuss the reasons for self-harm when we are emotionally comfortable because it has been stopped. The priority is eliminating the behavior, regardless of the thoughts and opinions of the person who lives with the SDV.

My belief on coercion to stop someone from SDV has always been clear – I oppose all forms of coercion and see them as compounding a person’s trauma rather than promoting healing. Coercion disconnects and disempowers people who likely already have limited choices.

Yet it appears that coercion, punishment, “works” to stop self-harm, right? There are multiple ways people are punished for self-injuring. In the mental health and criminal justice worlds people are often restrained, physically and/or chemically, or locked into seclusion rooms. For decades a “therapeutic” approach to institutionalized children who self-injured was to punish them with an electric shock for their behavior. Those are the most blatant responses. It is not uncommon for those living with SDV to be subjected to other forms of punishment. People who are institutionalized are threatened with loss of “privileges” if they don’t stop self-injuring. Others are told that they will not be able to continue with their therapist if they don’t “stop it.”

What if these approaches work and the person stops SDV? Is this a victory? What is the cost of this success? Is this a permanent solution? What are the thoughts of those who have experienced these measures?

For decades I have born witness to the stories of those who have directly experienced these sorts of manipulations and coercions. What I heard validated my own experiences, as a former clinician and a person who has lived with SDV. When I was threatened to change, or when I threatened people myself (although this was considered both therapeutic and billable), I knew this was harmful, oftentimes cruel. I think most of you agree?

What is the acceptable cost of attempting to force change on a person? Consider the less direct forms of self-harm that are common. In the US, and increasingly other countries, we are in the midst of an “epidemic” of obesity. Our health care system has labeled this a disease. So should it be treated by force? To what length should I go to wrestle that donut or cheeseburger away from you if you are “one of those heavy people”? Does shaming you make you stop? How would it impact our friendship if I told you that I would not continue to be friends if you didn’t lose weight? Should you be forced to have a gastric bypass? Forcibly injected with Ozempic or any of the other new drugs that promote weight loss? Even if you said that would not be what you want?

No. None of those options are useful. Even if the behavior is harmful to you. The difference is that unhealthy eating, food addiction for some, is behavior many of us can understand, even if we ourselves don’t do it. And while we see it’s impacts on people I don’t think we as a society think the majority of us should be coerced into changing. Nor that it would work. This epidemic of obesity is a complex issue.

What is fascinating is that the consequences of obesity are more dire than the consequences of SDV. Cutting, burning, punching oneself can result in wounds, bruises and scars. Even broken bones. Rarely do people cause long term damage. The most intense forms of self-harm (people who do severe damage to themselves such as blind themselves) happen when people are trying to survive in restricted environments. And they have survived extreme attempts to coerce them to change. Think about how people live in seclusion in prison or state hospitals… beyond brutal.

What are the personal and societal costs of obesity, an issue that should concern all of us? They are profound – misery, chronic illness, disability, perhaps death. There is much to be learned about trauma, addiction, economics, nutrition and harmful social norms right? Let’s do that work, create healing environments. Let’s learn from what we scarred people teach – that we will not heal ourselves, our communities nor our society by shaming, blaming, excluding or coercing anyone. For some of us our scars are blatantly obvious. Those of you whose scars are hidden, I hope this provides you with some food for thought. When is punishment a helpful response?