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I’m a leg-lengthening surgeon. Most of my clients are men with confidence issues — here’s what the procedure’s like
© Courtesy of Shahab Mahboubian
Dr. Shahab Mahboubian at his facility. Courtesy of Shahab Mahboubian
- Shahab Mahboubian performs 30 to 40 cosmetic limb-lengthening surgeries a year.
- He said the majority of his patients are men who feel passed over in relationships and careers.
- He can add up to 6 inches to a patient’s height and said patients usually leave more confident.
This as-told-to essay is based on a conversation with Shahab Mahboubian, an orthopedic surgeon in his 40s who specializes in limb-lengthening surgeries at his private practice, Height Lengthening, in Burbank, California. It has been edited for length and clarity.
I love what I do. I see my height-lengthening patients as my kids, and I get to watch them grow. After surgery, some of them are actually taller than me — I’m 5-foot-9 — putting them above the national average.
I grew up in LA and got my medical degree from Western University of Health Sciences in Pomona, California. Then I spent six years in New York doing my residency at Long Island’s Peninsula Hospital and completing my limb-lengthening fellowship at the Hospital for Special Surgery. I’ve been practicing for 13 years, including two years at my current office in Burbank, California.
As a child, I loved working with my hands and was always taking things apart and putting them back together
I especially enjoyed working with tools like screwdrivers, hammers, and drills, but the human body especially fascinated me. The only field in medicine that uses all of these tools is orthopedic surgery, so it seemed like the right fit.
I specialized in limb-lengthening surgery specifically because I wanted to do something that was different from everybody else. I also wanted to help a portion of the population that didn’t have access to services that correct deformities and limb-length discrepancies. It’s a difficult field to get into because orthopedic-surgery programs are very competitive, and there aren’t many fellowships or training facilities for limb lengthening, but I found the challenge very gratifying.
In the beginning of my career, I mostly focused on surgeries that correct deformities from prior traumas or birth
Kids sometimes get hurt and end up with leg-length discrepancies. Others are born with leg-length discrepancies or bow-legged and knock-kneed deformities. I had a young lady who came to me with a knock-kneed deformity when she was 16 years old. Seven or eight years later, she came back with her own child who was having orthopedic problems after a car accident. It was very memorable to treat her as a child then have her come back to make sure her own child was OK — fortunately, she was.
Surgery helps patients with these deformities or injuries walk better and participate more fully in activities like sports, but my practice has since evolved. Now the people who reach out to me seem more interested in cosmetic limb-lengthening — or leg surgery to increase height — so that’s the direction that my practice has taken, though I still see a small percentage of patients to correct deformities.
The idea of being taller fascinates people
I get about 20 emails a day asking about limb-lengthening procedures and up to 40 when one of our posts goes viral on TikTok or Instagram. The general population believes that whatever height you grow to is your final height, but that’s not the case — a lengthening procedure provides an opportunity to become taller.
People mostly ask the price of the surgery, how soon they can return to work or get back to playing sports, and how long they’ll be in a wheelchair or using a walker. They want to know how the procedure will affect their lives. We also get some international patients who ask us how to get a visa if they come from elsewhere. We can’t do that for them, but we try to guide them on where to go.
The surgery is quite expensive — it can cost anywhere from $75,000 to $90,000, depending on exactly what the patient wants to do — and insurance does not cover it if it’s cosmetic. People that undergo limb-lengthening surgery are from all walks of life, and many used COVID lockdowns to recover post-surgery.
© Provided by Business Insider
Mahboubian with a patient before and after surgery. Courtesy of Shahab Mahboubian
For the most part, it’s men who want the procedure
Most men who come to me complain that they’re not taken seriously or that they’re made fun of. Plenty of patients say that they don’t get attention from women, while others say they’ve been passed over for career opportunities because of their height.
When I talk to these same patients after height-lengthening surgery, they feel like they’re on the same playing field with everyone else. They’re happier, they have a lot more confidence, and they feel like they’re able to conquer a lot more than before.
I would say 80% to 85% of my cosmetic limb-lengthening patients are men, and 15% to 20% are women. A lot of our patients are entrepreneurs, in the military, or work in tech. I’ve performed height-lengthening surgery on individuals ranging from 16 to 65 years old. I’ve had twins, siblings, and even a father and son who’ve undergone the procedure.
All of them are unique in their own ways. Some have gained as little as four centimeters, while others have gained up to 16 centimeters, or about six inches.
I’ve had a few transgender men as patients
As they transition, some patients want to have more masculine features, including being taller.
One of my patients was very hesitant to tell me about their transition — I guess because of bad experiences they’d had with other physicians for things they wanted to do, including gender-affirmation surgery. I figured it out, based on anatomy and X-rays, and told them the best thing to do is be honest. Once I gained their trust and let them know that their experience is nothing abnormal, they felt a lot more comfortable with me.
Like most other cosmetic surgeries, I don’t think an additional psychiatric evaluation is necessary before getting the procedure, unless the patient is seeing a psychiatrist or feels they need one.
I turn away some people, either because they don’t have enough muscle flexibility or because they have unrealistic goals
As we lengthen the bone, the surrounding soft tissue, such as the muscles, tendons, veins, arteries, and nerves, will also lengthen. Hence, the more flexibility a person has, the easier it will be to lengthen the bone against the surrounding soft tissues. As long as a person is healthy and active, and doesn’t have any bone disease, they should be fit for the surgery.
There are some people who want to be a foot taller and I’m like, “That’s not going to happen.” The maximum amount I can add to someone’s height for cosmetic reasons is about 6 inches in two separate surgeries at least three or four weeks apart. For most patients undergoing one surgery, the max we can add is just over three inches.
We do the surgery through a minimally invasive process
We make small incisions, and then we put in guidewires and use X-rays to make sure everything is being placed accurately on the bone. Then we surgically cut the bone and put a rod — also known as a Precice nail — that’s about 10 to 13 inches long and one-third to half-an-inch wide into the middle of the bone, where the marrow is. Then we put in screws to stabilize the nail.
After surgery, we start the lengthening process using a magnetic machine that communicates with the nail, or rod, that’s now inside the bone. The machine turns tiny gears that are inside the nail to lengthen the space between the segments of the bone, 1 millimeter at a time. When we lengthen really slowly over time, the patient’s body creates new bone and it fills in the gaps. It’s amazing, right?
© Courtesy of Shahab Mahboubian
Mahboubian standing with a patient before and after two surgeries. Courtesy of Shahab Mahboubian
All my patients leave one millimeter taller because we test the nail during surgery to make sure it’s functioning properly. A patient will typically spend two to three days in the hospital to recover, then lengthen their legs at home by about 1 millimeter a day. It’s actually fairly painless because it’s such a small amount at a time.
If a patient’s job requires them to sit for long periods of time, they can get back to work as soon as two weeks. It takes anywhere from six to eight months to a year to do activities that require being on your feet, such as labor-intensive work and competitive sports.
My caseload was on the higher end during 2020. Now, it’s about the same as it was in 2019.
In a year, I do anywhere from 30 to 40 cases. When everyone was dealing with COVID-19 at home and not doing things, it was a good time to have the surgery and recover.
An orthopedic surgeon can make $250,000 to $2 million a year. Some make more than that, but it really depends on how business-minded you are and what other things — like investing or getting involved with orthopedic products — you’re doing outside of seeing patients.
Doctors in all specialties are not making what they did 20 years ago. Insurance reimbursements keep getting lower every year as expenses get higher. It’s a challenge for everybody. You’ve got to be smart and have some business sense to make a good living.
Every day that I wake up and go to work, I feel like it’s a new opportunity for me to do good and help people.
When a patient comes in for a limb-lengthening consultation, I talk to them about why they want to get it done
We discuss whether their goals are achievable and which surgery would be best for them — either working on the femur bones in the high parts of the legs or the tibias and fibulas in the lower part of the legs. Then I make the proper measurements for the implants and make sure the patient’s fully ready for their surgery.
Before surgery, I meet the patient at the hospital, say hello, then get them pumped up and ready to go for the procedures. Before surgery, one of my favorite traditions is to play the song “Ten Feet Tall” by Afrojack on my phone as we’re walking to the OR suite. It always gets them pumped up for their surgery.
Though I’ve done limb-lengthening surgeries hundreds of times, I still get a little nervous. But when I actually start the surgery, all of that goes away.
Every job has its stresses, and mine is no different
There are times when we run into some difficulty, such as blood clots or compartment syndrome, which is when a patient bleeds a lot into the muscle. This problem can damage muscles and nearby nerves. I’ve also had a couple of patients who didn’t grow good bone during their lengthening, but after making several adjustments to the lengthening rate — and even using stem cells — we were able to help the bone grow nice and strong.
As an orthopedic surgeon, I’m constantly dealing with patients who come into the office upset and in pain, and my job is to make them feel better. I’m like their coach or cheerleader when they’re down on themselves. People talk about this surgery so much — it’s all over social media and forums. After I do these surgeries, I want my patients to be happy and encourage others to trust me and get good results.
© Courtesy of Shahab Mahboubian
Mahboubian with a patient before and after surgery. Courtesy of Shahab Mahboubian
When cosmetic surgeries started to gain popularity, people criticized it. The same is true for height-lengthening procedures.
There will always be people who have their opinions about changing what God has given us. But as more people realize that this surgery exists and as it becomes more popular, the level of criticism will decrease. There are colleagues who may bad-mouth you, but as long as they do good work, doctors, for the most part, have respect for one another.
In general, people see you for how you treat them, but you can’t make everybody happy. There will always be people who have complications or continue to have pain despite a perfect surgery. So you have to be able to relate to patients as well as peers.
It’s definitely not easy to do what I do. I have my own practice with my own staff, and sometimes it’s very difficult to balance patient care and business aspects. But as I get older and become more experienced, I think I’m able to handle those stresses better. In the end, you have to treat people with respect and always maintain open lines of communication.
Are you a surgeon or healthcare worker with a story to tell? Email mlogan@insider.com.
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Twitter clients break as API goes down
The past several weeks since Elon Musk’s takeover have seen Twitter in turmoil as rapid changes hit the platform, and tonight it appears something is going on with the Twitter API as Tweetbot and many third-party Twitter clients are down.
Around 11pm ET this evening, many Twitter users noticed that third-party clients were throwing back error messages related to the Twitter API. This widespread outage is occurring across all third-party apps including Twitterrific, Fenix, Talon, and many others on both Android and iOS, as well as macOS. Tweetbot is also affected by the API outage, but Tweetdeck, thankfully, appears unaffected.
Whether this is a temporary outage or an intentional decision by Twitter remains to be seen, as the company has issued no official explanation at this time.
it does stand to reason, though, that it is possible Twitter may be killing off third-party clients. These clients generally do not bring any ad revenue for the platform, something that Musk has made clear is a priority in his tenure so far. Just this week a report from The Information revealed desperate measures to keep ad buyers on board, and many Twitter users have noted major increases in the number of ads and frequency of ads seen on the platform. Twitter also recently forced users on iOS to view the “For You” tab by default rather than the “Following” tab that actually shows what accounts they are following.
Another piece of evidence pointing to this being an intentional decision on Twitter’s part would be that apps that use the API but are not full clients appear to still be working. It’s only replacements for official Twitter apps that are broken.
Details remain largely unclear at this point in time, but we’ll update our coverage as more information becomes available.
Twitterrific has acknowledged the problem, but offered no further insight.
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Accounting firm that issued proof of reserves report for Binance halts service to all crypto clients
Crypto and Web3 have unrealized potential, but the lack of regulation over the years has led to speculative bubbles and Ponzi schemes, Joe Lonsdale says.
Mazars, the accounting firm that issued a proof of reserves report posted by cryptocurrency giant Binance last week, has pulled the report from its website and no longer offers the service for its crypto clients.
Binance, the world’s largest crypto exchange, tweeted a link to the report on Dec. 7 as it seeks to reassure clients of its reserves following the collapse of competitor FTX last month.
Binance, the world’s largest crypto exchange, is having difficulty finding an accounting firm to conduct a proof of reserves report. (Jakub Porzycki/NurPhoto via Getty Images / Getty Images)
According to The Wall Street Journal, Mazars scrubbed the report from its site on Friday.
“Mazars has paused its activity relating to the provision of Proof of Reserves Reports for entities in the cryptocurrency sector due to concerns regarding the way these reports are understood by the public,” the accounting group said in an emailed statement to FOX Business.
FORMER FTX SPOKESMAN KEVIN O’LEARY SAYS HE BELIEVES BINANCE PUT FTX ‘OUT OF BUSINESS INTENTIONALLY’
A Binance spokesperson said Mazars “has indicated that they will temporarily pause their work with all of their crypto clients globally, which include Crypto.com, KuCoin and Binance. Unfortunately, this means that we will not be able to work with Mazars for the moment.”
“Ultimately, our users want to know that their funds are secure and that our business is financially strong,” Binance’s statement continued. “To that end, Binance’s capital structure is debt free and, over the past week, Binance passed a stress test that should give the community extraordinary comfort that their funds are secure. Despite the large number of withdrawals 12-14 December, $6B of net withdrawals over three days, we were able to fulfill them without breaking stride.”
Rekt Tech partner Robert Mowry joins ‘Cavuto: Coast to Coast’ to discuss his conversation with FTX’s Sam Bankman-Fried and the investigation into the collapse of FTX.
Binance said it has reached out to several major accounting firms, including the Big Four, seeking one willing to perform a proof of reserves report. The crypto exchange said the Big Four — which are Deloitte, Ernst & Young, KPMG and Pricewaterhouse Coopers — are all “currently unwilling to conduct a PoR for a private crypto company.”
BINANCE CEO TWEETS ‘BUSINESS AS USUAL’ AFTER PAUSING USDC COIN WITHDRAWAL TUESDAY
The crypto industry has been rocked by the downfall of FTX, leaving investors with major jitters after a run on the bank showed the exchange — worth roughly $40 billion at one point — did not have enough in reserves to honor the withdrawals. The company filed for bankruptcy last month, resulting in billions of dollars in losses for an estimated one million customers worldwide.
FTX founder Sam Bankman-Fried was arrested Monday on several charges connected to his company’s collapse, which prompted calls for greater regulations for the crypto industry by jurisdictions worldwide — including requiring proof of reserves.
Binance CEO Changpeng Zhao speaks at the Delta Summit, Malta’s official Blockchain and Digital Innovation event promoting cryptocurrency, in St Julian’s, Malta, on Oct. 4, 2018. ( REUTERS/Darrin Zammit Lupi / Reuters Photos)
Binance founder and CEO Changpeng “CZ” Zhao told CNBC’s “Squawk Box” this week that “the well-run crypto exchanges should hold users’ assets one-to-one.”
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“People can withdraw 100% of the assets they have on Binance,” Zhao said. “We will not have an issue, in any given day.”
Michael Avenatti sentenced to 14 years in prison for defrauding clients, tax fraud
SANTA ANA, Calif. (KABC) — Former celebrity lawyer Michael Avenatti, who rose to fame representing adult-film actress Stormy Daniels in her litigation against former President Donald Trump, was sentenced in Orange County to 14 years in federal prison for tax and wire fraud.
U.S. District Judge James Selna said Avenatti’s sentence will run consecutively — or on top of — the five years he is already serving for convictions in New York for an extortion scheme against Nike, and for stealing from Daniels. He has been in prison since February.
Avenatti, 51, was sentenced Monday for “defrauding his clients and for obstructing IRS efforts to collect payroll taxes from his coffee business,” the U.S. Attorney’s Office for the Central District of California said on Twitter. He was ordered to pay nearly $11 million in restitution to four clients and the Internal Revenue Service after pleading guilty in June to four counts of wire fraud and one count of tax fraud.
Federal prosecutors in Santa Ana had asked Selna to impose a 17 1/2- year term, while Avenatti was arguing for only six years. Prosecutors presented in court the lavish lifestyle Avenatti led with the stolen cash, including the purchases of a private jet and sports cars, as the clients he stole from struggled to make ends meet.
Geoffrey Johnson was one of two victims to give a statement in court.
“I’ve learned not to trust people more than they deserve,” he said.
In his khaki prison uniform, the once boasting celebrity lawyer broke down in tears in federal court and pleaded for mercy – just before he was sentenced to 14 years in prison.
In their sentencing recommendation, federal prosecutors said Avenatti’s schemes followed a “general pattern” in which he “would lie about the true terms of the settlement agreement he had negotiated for the client, conceal the settlement payments that the counterparty had made, secretly take and spend the settlement proceeds that belonged to the client, and lull the client into not complaining or investigating further by providing small advances’ on the supposedly yet-to-be-paid funds.”
Prosecutors called Avenatti was a “tax cheat,” and cited his failure to pay payroll taxes after his firm acquired Tully’s Coffee in bankruptcy and then obstructed the IRS when the agency attempted to collect the amount due.
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Credit Suisse Warns of $1.6 Billion Loss After Clients Pull Money
Credit Suisse
CS -6.85%
Group AG warned it would lose around $1.6 billion in the fourth quarter after customers pulled their investments and deposits over concerns about the bank’s financial health.
The warning of a big pretax loss pushed Credit Suisse’s shares to a new closing low, below a previous nadir hit in late September as concerns swirled about the bank’s financial health.
Switzerland’s No. 2 bank by assets said outflows were around 6% of its total $1.47 trillion assets, or around $88.3 billion, between Sept. 30 and Nov. 11. Customers in its wealth-management arm—its main business serving the world’s rich—removed $66.7 billion from the bank. Credit Suisse in late October said that a social-media frenzy around its finances was causing large outflows. The bank typically attracts at least $30 billion in net new assets in a year and hasn’t posted an annual net outflow since 2008, according to its filings.
Analysts at JPMorgan said the outflows and the anticipated loss were much worse than they expected. The bank “is not out of the woods yet in terms of stabilizing the franchise,” they said.
The fast pace of withdrawals meant the bank’s liquidity fell below some local-level requirements, the bank said. It said it maintained its required group-level liquidity and funding ratios at all times. Banks must keep enough liquid assets on hand to meet expected cash outflows in a 30-day period, under post-financial-crisis-era rules.
Credit Suisse’s stock fell 6.1% Wednesday to end at 3.62 Swiss francs, a record closing low. The shares are down 59% this year, according to FactSet.
The cost to insure the bank’s debt against default rose Wednesday.
The warning comes at a precarious time for the bank, which weeks ago launched a sweeping overhaul of its operations. Credit Suisse received shareholder approval Wednesday on a plan to raise more than $4 billion in new stock. It is in the process of selling a large group within its investment bank to free up capital, as part of its recovery effort.
The new stock is being sold to new and existing investors, with terms due to be finalized Thursday. Saudi National Bank said it would take a stake of up to 9.9% as a new shareholder. Some analysts are concerned the new capital raising may not be enough if Credit Suisse’s revamp doesn’t go to plan. The bank’s capital needs depend on selling and exiting some businesses, and on how its continuing businesses perform.
Chairman
Axel Lehmann
said shareholders showed their confidence in the bank by approving the stock increase.
The reduction of customer assets means Credit Suisse has less money to manage and earns less in fees. A broader slowdown in activity in its wealth-management division and investment bank contributed to the warning of a pretax loss of around $1.6 billion for the quarter, it said.
In all, more than $100 billion has left the bank since June, according to Credit Suisse’s filings. It said client balances have stabilized in its Swiss bank and that the outflows have slowed in wealth management, but haven’t reversed.
Wealth management, the business of managing rich people’s money, is Credit Suisse’s largest and most important business. The bank’s overhaul is meant to reduce its reliance on risky Wall Street trades and double down on the steady fee-collecting business of working with the world’s ultra wealthy.
Large outflows indicate that some of those well-heeled clients have grown wary of Credit Suisse’s troubles despite its more than 160-year history. The bank was hit hard when a client, family office Archegos Capital Management, defaulted in March 2021, triggering a loss of more than $5 billion.
Uncertain markets have meant clients aren’t transacting as much across wealth managers. However, crosstown rival UBS Group AG reported around $35 billion in net new fee generating assets from wealth- and asset-management clients in the third quarter.
Concerns about the bank reached a fever pitch in October when commentators on social-media platforms Twitter and Reddit called into question the bank’s health.
Credit Suisse warned last month it would make a net loss in the fourth quarter, in part because of costs from the overhaul. It posted consecutive quarterly losses this year after starting to restructure its operations late last year. In last year’s fourth quarter, it lost around $2.2 billion.
The bank said it is still targeting a capital ratio of at least 13% between 2023 and 2025 as it restructures.
Write to Margot Patrick at margot.patrick@wsj.com
Corrections & Amplifications
Credit Suisse reported about a $2.2 billion net loss in the fourth quarter of 2021. An earlier version of this article incorrectly said it lost around $1.7 billion in the quarter. (Corrected on Nov. 23)
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Regulator denies asking FTX to prioritize withdrawals for Bahamian clients
The Securities Commission of The Bahamas (SCB) has denied instructing or authorizing crypto exchange FTX to prioritize withdrawals of Bahamian clients.
In a statement on Nov. 12, the securities commission vehemently denied the contents of a Nov. 11 statement from FTX on Twitter that suggested it had been instructed by “Bahamian HQ’s regulation and regulators” to facilitate the withdrawal of Bahamian funds.
“The Commission wishes to advise that it has not directed, authorized or suggested to FTX Digital Markets, Ltd. the prioritization of withdrawals for Bahamian clients,” read the statement, which was shared on the SCB’s Twitter page.
Securities Commission Addresses FTX Statement on Bahamian Withdrawals pic.twitter.com/OZKWwicSuN
— Securities Commission of The Bahamas (@SCBgov_bs) November 12, 2022
Since FTX paused withdrawals on Nov. 9, the crypto exchange’s customers have been attempting to find means to withdraw their locked funds, with much of the activity going through the Bahamas.
Strategies have ranged from buying non-fungible tokens (NFTs) on Bahamas-based accounts to offering FTX employees bounties to change their country of residence to The Bahamas.
Related: Sam Bankman-Fried is ‘under supervision’ in Bahamas, looking to flee to Dubai
However, the SCB has warned that any withdrawal of funds could be clawed back as part of the firm’s potential liquidation proceedings.
“The Commission further notes that such transactions may be characterized as voidable preferences under the insolvency regime and consequently result in clawing back funds from Bahamian customers,” it noted, adding:
“In any event, the Commission does not condone the preferential treatment of any investor or client of FTX Digital Markets Ltd. or otherwise.”
The latest statement from the SCB comes only days after the securities regulator froze FTX’s assets on Nov. 10 and suspended FTX’s registration in the country.
The SCB has also stripped the powers from the directors of the FTX and said it determined the “prudent course of action” was to put FTX into a provisional liquidation “to preserve assets and stabilize the company.”
According to the statement, the Bahamian Supreme Court appointed a provisional liquidator and said, “no assets of FDM, client assets, or trust assets held by FDM can be transferred, assigned, or otherwise dealt with, without the written approval of the provisional liquidator.”
Cointelegraph has reached out to FTX for comment but has not received an immediate response.
I’m A Therapist Working With Clients Who Self-Harm. Then I Started Cutting Myself.
Moments before the session was due to start, I dug through a haphazard stack of pens and rubber bands and notecards in an unfamiliar desk drawer, searching for something sharp.
It’s OK, I’m going to fix it, I reassured myself. “It” was an overwhelming sense of frustration following a difficult interaction with a colleague.
I craved what I knew would lower the frustration’s intensity ― the sensation of mild pain on the skin of my forearm. When I couldn’t find anything in the drawer, and was forced to open Zoom and begin the session, I chewed an ulcer into the side of my cheek instead.
I was not a teenager. I was in my mid-30s and working as a clinician in an outpatient mental health center.
About six months earlier, I first experienced the power of piercing one’s skin to relieve overwhelming negative emotion. Under the stress of a project deadline and following a meeting in which everyone seemed burnt out and irritable, I instinctively gripped my left forearm, wrist and hand in my right hand. Hard. In a matter of seconds, all my rage and hurt and indignation evaporated, and I took note.
My self-harm escalated over the course of a few months. With each incident, I became less shocked at what I had done to myself, and therefore willing to use tools increasingly likely to cause injury and scarring.
Cutting is perhaps the most familiar form of non-suicidal self-injury (NSSI), a term used to describe any deliberate injury to oneself without the intention of suicide. Other forms of NSSI include burning or hitting oneself or picking at existing wounds.
Most people who engage in NSSI hurt themselves in an attempt to relieve uncomfortably strong emotions, as I did. Others may feel numb and want to feel something, are trying to gain a sense of control or resolve a past trauma, or use self-harm to prevent another and potentially more destructive behavior, among other reasons.
In the moment, I was so overwhelmed that if I didn’t do it, the emotion ― usually some combination of anger, grief, anxiety, guilt and vindictiveness ― would consume me and strip away my ability to function.
Really? I berated myself. You’re starting this now? You’ve been in the workforce for over a decade. You have two master’s degrees, in public health and clinical social work! If anyone should know better, it’s you.
Guess what the result of self-shaming is? Intense emotion. And intense emotion leads, in the absence of other methods of coping, to more cutting. I did confess my feelings and actions to both my own therapist and clinical supervisor, who responded perfectly ― without shock or condemnation.
“You were trying to cope,” my therapist stated simply, after I described becoming overwhelmed with regret ― again ― that my 15-year-old plans for an academic medical career didn’t pan out.
Eyes lowered in shame, I admitted to her that I had relieved this distress by cutting myself. She directed me to identify other coping strategies that I could use instead, but only after acknowledging that the feelings leading to the behavior were understandable.
We need to give everyone who self-harms the same validation. Of course cutting makes sense as a way to cope, because it lowers emotional intensity immediately. And there are other strategies that carry fewer risks. First we validate, then we work toward behavior change. This balance between acceptance and change is the guiding principle behind dialectical behavior therapy (DBT), the gold standard treatment for NSSI. In DBT skills training groups, clients learn to be fully present in the moment, tolerate distressing situations, communicate more effectively, and regulate their emotions.
I was familiar with DBT and occasionally suggested a DBT skills worksheet to a client, but I had not yet internalized its skills to the point that I used them in my own life. Knowledge and skill building are distinct. The skills take practice, and the person practicing will slip up. We are not born knowing how to regulate our emotions, and unfortunately many of us are not taught as children or adolescents.
Why did I start in my 30s? I’d been battling anxiety since childhood and depression for most of my adult life, and yet I’d never deliberately pierced my skin before. This wasn’t the first time I’d encountered work-related stress, and I hadn’t had any recent major life changes, such as marriage, divorce, moving or serious diagnoses.
Yet I wasn’t alone. Studies indicate that between 4% and 23% of adults engage in NSSI, and those who start the behavior as adolescents but do not successfully acquire alternative skills often continue to self-harm into adulthood.
Evidence suggests that people who self-harm, particularly those with certain psychological traits, may learn their self-harming behavior when they see the behavior modeled by someone else. In other words, NSSI may be contagious, and I may have “caught” it through exposure to other people using it to cope with strong emotion. When I was an adolescent and young adult, I did not know of anyone in my social circle who cut their skin to cope, though I had seen the behavior described in media. When I became a therapist, that changed. My clients cut themselves, and this time, it was my business to know all about it.
Why did I “catch” cutting when other therapists who work with people who self-harm don’t start doing it themselves? I have always had problems with emotion regulation, I realized, and I never recognized it. In the past, I have coped by punching steering wheels, desks and chairs, and by slamming doors. I was already primed to turn to cutting when my emotions felt overwhelming.
“Why did I ‘catch’ cutting when other therapists who work with people who self-harm don’t start doing it themselves? I have always had problems with emotion regulation, I realized, and I never recognized it.”
A few days after I searched that desk drawer at the office, I decided that I would no longer self-harm in any way, including chewing on my cheek and picking at my skin when anxious. I had learned the alternative coping skills. The only piece missing was my commitment to practicing them. I grabbed some scrap paper and jotted down a list of strategies, promising myself that I would go through the entire list before cutting myself, or punching myself or a hard object in anger, or chewing my cheeks to shreds. I wrote at the bottom of the page that any form of self-harm was unacceptable. Then I took a photo and saved it to the “favorites” photo album on my phone for easy access.
The word “unacceptable” stuck in my mind from a DBT-based book that I had read in an attempt to help a client who was cutting. The book validated the desire to self-harm to cope with strong emotions yet also labeled the behavior as “unacceptable.” Another reader may have felt shamed, but I felt motivated to commit to changing my response to strong emotion. When we label the behavior as unacceptable, we still acknowledge that it is our present reality.
In order to tell myself that self-harm was unacceptable, I had to make other actions acceptable. I had to give myself permission to cancel my clients’ sessions at the last minute if I was not mentally able to practice at my best. I had to remind myself that my therapist and supervisor are not inconvenienced or angry at me if I need to reach out to them between scheduled meetings. I had to weigh the real ― and debatable ― risks and benefits of using a fast-acting anti-anxiety medication rather than cut myself.
Next, I had to train myself to identify my emotions and name them to myself. Often the simple act of putting a word to my internal experience lessened the emotion without any further intervention. Yet this step proved surprisingly difficult. The feeling of overwhelming emotion was very familiar to me, but it didn’t always have a name. Often in the time it took me to puzzle over whether I felt indignation, sadness, worry, anger, or all four, the emotional intensity decreased.
The naming emotion strategy is backed by neuroscience. When we ask ourselves to name our emotion, we turn on the prefrontal cortex, the region in the brain where high-level thinking and reasoning occur. With the thinking brain online, the amygdala ― the part of the brain that processes strong emotion ― backs off.
The first few times I encountered overwhelming stress after making my commitment, I struggled to convince myself that trying my list of skills was worth it, when I knew that cutting would calm me down reliably and quickly.
One day, a communication breakdown with the veterinarian’s office meant that I couldn’t get my sick cat’s prescription medication before it closed for the weekend. After hanging up with the vet’s administrative assistant, I found myself with my whole body shaking and the urge to cut.
“Stop,” I told myself. “You promised you wouldn’t do this anymore.”
Name the emotion: Anger — at both the vet’s office and myself. Concern for my cat.
Count the seconds of each breath: One, two, three, four … in. One, two, three, four … out.
Mark wrist with a pen where I want to cut.
Text a friend to report what happened with the cat’s prescription and receive support.
Remind self that nothing lasts forever, including overwhelming emotion.
After going through the steps, I was still angry and concerned. Yet the intensity had lessened, and I could think clearly without hurting myself. Best of all, the success reinforced that the skills work, with practice.
Brandy E. Wyant is a clinical social worker and writer based in the Boston area. You can find her on Instagram and Twitter at @bewyant.
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Avaya’s Collapsing Debt Deal Hits Clients of Goldman, JPMorgan
The two banks sold new loans and bonds for Avaya, a cloud-communications company, in late June. Investors included Brigade Capital Management LP and Symphony Asset Management LLC, people familiar with the matter said.
A few weeks later, Avaya announced that it would miss by more than 60% its previous forecasts for adjusted earnings in the third quarter, which ended June 30. It gave no explanation. The company also said that it would miss revenue targets and announced it was removing its chief executive officer.
Prices of the newly issued debt plummeted, hitting investors who lent Avaya the money with paper losses exceeding $100 million, according to analyst commentary and data from MarketAxess and Advantage Data Inc.
Avaya said Tuesday that it “has determined that there is substantial doubt about the Company’s ability to continue as a going concern.” It also said that the audit committee of the board of directors had opened an internal investigation “to review the circumstances surrounding” the most recent quarter. The committee is also investigating a whistleblower letter, but it didn’t give details.
Avaya also tapped law firm Kirkland & Ellis LLP and turnaround adviser AlixPartners LLP as it considers its options, The Wall Street Journal reported Tuesday.
New CEO
Alan Masarek
held an abbreviated conference call Tuesday to discuss third-quarter earnings and declined to take questions from Wall Street analysts. Mr. Masarek attributed Avaya’s poor performance in part to clients signing up for smaller and shorter software subscription contracts than expected, potentially out of fear about the company’s debt load.
“I understand very clearly that there is disappointment, there’s worry, there’s concern out there across effectively all Avaya stakeholders,” Mr. Masarek said. “I’m going to thank you in advance for your patience… Give us some time to demonstrate a better future.”
Avaya’s 6.125% bond due 2028 fell as low as 48.50 cents on the dollar after the presentation, down from a close of 56.25 cents on Monday, according to data from MarketAxess.
Some analysts were already skeptical of Avaya’s financial forecasts.
“Why [are] your projections always faltering when you report quarterly results? Why can’t you have a stable outlook?” asked
Hamed Khorsand,
an analyst at BWS Financial, after the company’s last quarterly earnings report in May. Avaya undershot that quarter’s adjusted-earnings targets by about 10%.
Avaya’s former CEO Jim Chirico, applauding at the company’s stock listing in 2018, was removed last month.
Photo:
Richard Drew/Associated Press
Then-CEO
Jim Chirico
attributed the fumble to Avaya’s adoption of a new sales strategy that forced the company to recognize revenue more slowly. “We believe we’re over that hurdle,” he said at the time.
Avaya emerged as a telecommunications-equipment supplier to corporations in 2000, when it spun out of Lucent Technologies. Private-equity firms TPG and Silver Lake Partners bought the company in 2007, but it struggled to transition from selling hardware to selling software, and with servicing debt from the buyout. The company filed for bankruptcy protection a decade later before reorganizing. Mr. Chirico took the helm in 2017 and shifted to developing cloud-based software for enterprises.
“Avaya squandered a lot of money and time and has little to show for it,” independent enterprise communications analyst Dave Michels wrote in a recent report. “Many of us have wondered why the board didn’t act sooner—years sooner.”
A spokeswoman for Avaya declined to comment on analysts’ critiques.
The financial crunch hit this spring when Avaya’s cash reserves shrank to $324 million—down from almost $600 million a year earlier, according to company filings. The company tried to raise new debt to refinance a $350 million convertible bond that was coming due in 2023, according to company filings.
Goldman initially proposed a $500 million loan with a 12.6% yield but found few buyers, according to data provider LevFin Insights. The bank ultimately placed a $350 million secured loan yielding 15.5% with investors. Lenders included Symphony, which has invested in Avaya since before its bankruptcy, the people familiar with the matter said.
Avaya approached JPMorgan in late June to raise additional funds, according to one of the people. The bank placed a $250 million secured convertible bond. Investors included Brigade, the people said.
During the marketing process, Avaya executives told lenders that the company was on track to hit its earnings guidance, some of the people familiar with the matter said.
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The company had set Ebitda guidance of about $145 million for the quarter ended June 30 but cut that to between $50 million and $55 million on July 28. (Ebitda refers to earnings before interest, taxes, depreciation and amortization.) Avaya reported $54 million of Ebitda for the quarter on Tuesday, a figure that barely covers the quarterly interest expenses it disclosed in recent earnings reports.
“It is a surprising outcome for a company that priced $600 million of fresh capital…just four weeks ago,” said
Lance Vitanza,
a stock analyst at Cowen Inc. “It may be too late to accomplish much without radically restructuring Avaya’s balance sheet.”
The newly issued loans were quoted around 65 cents on the dollar Tuesday, down from 87 cents in late July, according to Advantage Data. The new convertible bond is likely to trade at similar prices in the near future, Mr. Vitanza said.
Losses have been heavier for owners of Avaya stock, which fell to as low as 82 cents last week from around $2.50 in early July and about $10 at the start of May. Avaya shares fell 46% Tuesday to 61 cents.
Alexander Gladstone and Andrew Scurria contributed to this article.
Write to Matt Wirz at matthieu.wirz@wsj.com
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