Some years ago, when I was returning from Canada to where I lived in the United States, the customs officer at Logan Airport in Boston asked me what took me abroad. “Family wedding,” I cheerfully replied. Asked who was getting married, I told him it had been my mother’s cousin’s daughter.
The officer looked up, her eyes wide. “That’s family?”
I share that story with my fellow south Asian immigrants in the US, and we shake our heads. We agree that nothing shows the difference between the cultures we left behind, and the one in which we now live, more than how we connect to people – how closely and to how many.
For 25 years I worked in the mental health field and was part of a team that treated clients diagnosed with Borderline Personality Disorder (BPD).
Along with other indicators such as suicidality and self-harm, people diagnosed with BPD are particularly known for the difficulty they have in their personal relationships. The origins of BPD are many and complex and not well understood, but psychologist Marsha Linehan, who created Dialectical Behavioral Therapy (DBT) – one of the most effective treatments for the condition – believes that one of the contributing factors may be a society that does not prioritise connection.
“The problems encountered by the borderline individual,” she wrote in 1993, “may result in part from the collision of a relational self with a society that recognises and rewards only the individuated self.” And this phenomenon, she went on to say, “is more prevalent in the western world, where the individuated self… is defined by sharp boundaries between self and others.”
That phrase, “sharp boundaries between self and others” came to mind during my first session with a BPD client who held herself in a way – gaze averted, tone like someone who felt removed from other people.
As I asked my client about her living situation, family and education, I tried to keep my eyes away from the scars on her hands and face where she had burned and sliced herself repeatedly. Her left arm was crisscrossed with so many it looked like fish scales. One of the scars visibly spelled the word die. I had quite thoroughly studied the subject of self-harm during my preparation for this work, yet I had no framework to help me understand this. How would I reach her?
And to reach her was what I needed to do. As quickly as possible. The client-therapist relationship is at the heart of the DBT model. For clients like the one seated across from me, the strength of this connection might be what keeps them alive during a time of crisis. If a therapist could be a certain way, Linehan says: “compassionate, sensitive, flexible, and non-judgmentally accepting and patient… the wounds of the patient’s past experience will be healed.”
Compassion, flexibility, sensitivity and patience I could try to cultivate, but what would help me to become non-judgmental about self-injury?
In the 1990s, when American Buddhist teachers had tried to explain the pervasiveness of self-hatred in the West to the Dalai Lama, he repeatedly asked his interpreter to explain what that meant. It was not that I had not seen mental illnesses growing up. I knew people who had schizophrenia, clinical depression, and obsessive-compulsive disorder. But my client had expressed her distress in ways that I perceived as, and I hate to use the word, deviant.
One of the rules of DBT is that the therapist should be available outside formal therapy hours to help a client in distress. Individual therapists decide what limitations to put on their availability. I made a decision to put no limitations at all. So, even when she called at three or four in the morning, I responded. Sometimes these calls helped her. Sometimes they did not. But whatever the outcome, I hoped my being willing to talk to her at that time of the night would count for something. And I believe it did. On my part, I saw progress with being compassionate, sensitive and flexible. But the image of someone deliberately placing the end of a lighted cigarette on their skin or slicing their arms with a razor still triggered deep repugnance. And I feared that my repugnance would mirror and worsen my client’s self-loathing and shame. I would fake it till I could make it.
Some of the shame that a client who injures herself feels comes from people’s perception that this is just her way of getting attention – pulling people into the theatrics of a drama in which she plays the starring role. And among the people who see it this way are certainly those who work in the mental health field. Intentional self-injury is ranked high among what are called attention-seeking behaviours. Residential counsellors often roll their eyes and exchange knowing looks when a client has to be taken to the emergency room once again, complaining of chest pains with no physiological cause, or having cut and burned herself.
This judgement eventually becomes clear to the client, which can be especially devastating for people presenting with BPD, who often have overwhelming responses to perceived rejection. So I desperately wanted to overcome my repugnance. Oddly, what helped me was a journey back to the community where I grew up in South Asia – a journey back to my roots in a traditional Muslim society.
Like many women from orthodox Islamic societies, I had defied the customs and beliefs that held females back
Like many women from orthodox Islamic societies, I had defied the customs and beliefs that held females back. I stayed close to my extended family, despite breaking with some of our practices, and didn’t fully appreciate how much the traditions of Islam, to quote Linehan, “recognise and reward the relational self”. There’s no other religion that I know of where both scripture and prophetic teachings warn of heavy punishment for those who stay estranged from their relatives; and on the other side, promise great reward to those who honor kinship ties. In Muslim communities around the world, men come together five times a day to pray at the local mosque, and groups of people, both adults and children, observe the whole month of Ramadan without taking food or water from dawn to dusk. I used to do that too and remember how close I felt to my relatives when we experienced hunger and thirst together.
When one of my friends lost her father at seven, an uncle took on the role of a guardian so well that my friend didn’t really feel the absence of a parent. It can be small things, too. Once, entering an aunt’s house, I stopped to scrape some dirt off the bottom of my slippers, and she said, “Just come in – this is your aunt’s house, you know, not London.”
Tribal life has “very low rates of mental illness, especially depression-based suicide,” Sebastian Junger pointed out in his 2016 book Tribe: On Homecoming and Belonging. On the other hand, tribes aren’t necessarily good for women, and a nation built on a conglomeration of tribes – Afghanistan, for example – has notably been brutal to females. Still, my journey towards the radical acceptance of self-injury was one that paralleled a deeper understanding of the tribe-like society of my childhood. Yes, traditional cultures can oppress women, but that oppression does not blot out how the same culture can support the deeply human need for connection. Especially now, when there’s an epidemic of loneliness and an increase in what are now being referred to as “deaths of despair” – deaths related to drugs, alcohol, and suicide. As loneliness has increased, so has the incidence of self-harm.
I began to see my client’s anguish as an expression of deep loneliness. When I was able to see that her pain came from a deep and unfulfilled human need, my response to the distressing ways in which she expressed that was able to change. A radical acceptance and compassion took over. She was not attention-seeking. She was connection-seeking.
Yasmin Azad’s memoir “Stay Daughter” is published by Swift Press
