The Public
Recently, I was a guest on another talk show (this time on television) about self-mutilation. The host was highly experienced at her job, but when we got into the ways that self-mutilators harm themselves, her upper lip began to twitch and she started to characterize their behavior in strong words, including “grotesque.”I interrupted her by speaking directly to the camera:
“Most of you watch emergency-room medicine and open-heart surgery on television while eating dinner or sitting on the couch. Here we are for the most part talking about minor cuts, lacerations, and burns that many of you have experienced without getting very upset. Some of you have had to apply ordinary first aid to your own children when they hurt themselves. Perhaps what makes this concept of self-harming so difficult to cope with is the feeling that the person doing this to him- or herself is suffering from some dreadful madness that may accelerate until they damage themselves terribly.”
My point was to bring the issue back into perspective. I believe that the public’s fantasies do, in fact, run to extremes and that the mildest word most of us can use to describe self-mutilating behavior is “disgusting.” In order to help these disturbed individuals, we must first understand and overcome the origins of our own disgust.
When I was treating severe anorexics in the 1970s in urban teaching hospitals, I discovered that the staff was very angry at them. Both doctors and nurses were annoyed that they had to waste their time on patients who were starving themselves to malnutrition when they had plenty to eat. The anorexics were deliberately causing themselves harm and wasting valuable hospital beds that people with serious and involuntary medical problems could be using. These patients were uncooperative and self-sabotaging. They were also sabotaging the help their doctors were trying to administer.
Professionals in mental health, patients’ families, and the general public all harbor a very similar attitude toward the self-mutilator as their counterparts had to the emaciated anorexic about twenty years ago. The self-mutilator is looked upon with fear, anger, disgust, and revulsion.
In the case of the eating disorders, anorexia and bulimia, a younger group of mental health professionals emerged, determined to understand the illnesses, their causes, and the specifics of the behaviors involved. This population of clinicians learned how to desensitize themselves to the unusual and unattractive behaviors of their patients, and to the equally unattractive physical results of these behaviors.
Twenty years later, we are at that same sort of pivotal point in clinical history, where the same changes must happen in the mental health field for the self-mutilating patient. Desensitizing ourselves to the behaviors and the scars they inflict does not mean desensitizing ourselves to the patient’s emotional distress. It is, rather, the first step necessary to seeing the self-mutilator for what she is—a person in desperate need of help and human contact.
The Family
When family members find out that a child is cutting, burning, or in some other way harming herself, their first reaction is fright. This reaction often evolves into rage: “How can you be so stupid or crazy to do this to yourself?” No parent easily accepts that their son or daughter is showing signs of mental illness. It is easier for them to rationalize that the child will outgrow this behavior. Common parental responses include assuming that it is merely brattiness, stubbornness, just a phase. Loved ones may also be too shocked to see past their own hurt feelings. Many parents respond narcisstically: “You are trying to upset me or make me feel guilty by sabotaging all my good parenting and the love I have shown you. How ungrateful of you!”
The Professionals
Recently, a young woman of twenty-four was referred to me. At the initial interview she reported, “The first two therapists I saw told me they couldn’t help me because they were not familiar with self-mutilation.”
“How did that make you feel about yourself?” I asked her.
“Like I was a freak—beyond their comprehension to understand—or that maybe they were afraid of what was wrong with me. It also made me feel that I was hopeless.”
Was it possible that the therapists were, like the general public, repelled by her behavior, frightened by physical damage she inflicted upon herself? Might they have even been afraid of their liability should serious harm or death result from a treatment failure? Of course, we will never know for sure. What we do know is that when a patient is rejected for psychotherapy, he or she feels wounded and perhaps untreatable. On the other hand, when a therapist realizes that he or she cannot competently treat someone who is seeking help, it is highly ethical to indicate this, rather than attempt a treatment with which the therapist is unfamiliar.
In contrast to the mystery that self-mutilation currently poses to the mental health profession, we will soon be seeing a trend toward familiarization with the illness. I envisage that a few years hence there will be self-help groups and specialized treatment centers for those who harm themselves, just as there are now for the eating-disordered, drug addicts, alcoholics, compulsive gamblers, and other groups seeking professional and peer support.
The Media
Television, radio, women’s service magazines, and newspapers initially presented self-mutilators as freaks. This is simply the way a nation’s attention is attracted to a problem of this nature. As negative as it is, even this introductory period can be helpful in its capacity to demystify an unfamiliar sickness. The quicker the introduction, the better for the victims.
If the media echoes the same message that ambivalent parents, out of love for their children, are sending—“I’m afraid of your illness”—then we have done a disservice to the victim who dares to come out with her terrible secret.
In fortunate cases, the family of a patient is willing and able to provide her with as much emotional support as she needs to become healthy. Friends, however, may not be able to generate an inexhaustible amount of caring. They may recoil in fear, or go to the other extreme and try single-handedly to rescue their friend from this self-destructive behavior. If they abandon the sufferer, her illness may deepen. If they attempt to save or rescue her and fail, they may turn away because she would then be a symbol of their own failure. In both scenarios the self-mutilator ends up abandoned.
Real information about the disorder, not drama, is the surest way to stabilize the patient’s reaction. Whether we are family, friend, or therapist, we need to convey to the victims that we understand that they are resorting to an unhealthy behavior in order to relieve psychological pain. We must reinforce for the sufferer that the self-mutilating behavior is only a small part of who they are, not the whole picture.
Many self-help organizations for substance addictions, eating disorders, and other problems inadvertently assist the victim in the creation of a false identity. The members of these groups come to perceive themselves as existing solely in terms of the disorder they are trying to get rid of. They accept the message that “You will always be . . . an alcoholic, drug addict, etc.” There goes that pendulum out of control again. While we want to stress the importance of overcoming disordered and self-destructive behavior, we also want to stress that someday this will be in the past. In order to help the self-mutilator, we have to credit her with a more rounded identity. We cannot simply see her as one-dimensional—a person who harms herself. A victim’s illness is not her identity.
Mildred: A Mask of Glibness
When Mildred came into my office, she proudly introduced herself by saying: “I have an eating disorder, am obsessive-compulsive, and have been cutting and sometimes burning myself for the last three years. The first two problems go back at least five or six years. I’ve seen five psychiatrists, been in three psych hospitals, and belong to three self-help groups.”
I responded: “It sounds like your life has been taken over by these problems. Do you have any personal features other than your illnesses?”
Mildred was crestfallen. “You don’t appreciate the seriousness of my problems. Perhaps I should see someone else who will.”
“I’m concerned that you have somehow gotten lost amid the psychiatric problems you’ve got and have lost track of who you are. If you want to find out who that is, I would be delighted to work with you on that issue while we are also working on your identified diagnoses.”
Mildred entered treatment.
Mildred’s opening statement was presented far more glibly than was appropriate for the gravity of its content. This was a clear indication to me that she was very uncomfortable receiving help from someone else, especially when the project with which she needed help was herself.
“You don’t want to be here, do you?” I asked her.
She looked surprised. “What do you mean?”
“My guess is that you are more comfortable with the roles of caretaker, supporter, shoulder-to-cry-on, than being the person in need herself. In this therapy you are the recipient of care, not the giver of care. I think that you don’t know how to do that.”
“Well, I don’t know. We just met. How could I trust you to be a caregiver to me?”
“You are right, of course. But let me ask you just who do you accept emotional care from when you’re feeling needy?”
“I don’t know what you mean.”
“Who do you cry to?”
“Sometimes my friends.”
“Can you lean on your friends?”
“I’m not sure.”
“What do you imagine would happen if you were needy with your friends?”
She paused, frowned, and fixed her eyes on the rug as she spoke. “I think that they wouldn’t like me anymore. They might even get mad at me. And I would hate myself.”
“That must make you feel lonely and separate.”
“Why?”
“If no one knows who you are, bad moods included, then you must feel alone with your sadness. There are probably lots of parts of your personality that you can’t show others because you fear that reaction you just told me about.”
She shrugged tearfully.
“I am going to help you show me those parts of your personality that you can’t show your friends.”
“How can you do that?”
“I think what you’re asking is, ‘What can one person do for another?’ The answer to that question is, ‘Much more than you think.’ ”
At that, Mildred looked stunned. I asked her to explain the expression on her face.
She responded incredulously, “How can you say that to someone you just met? How can you even know that? I might turn out to be someone you can’t . . . I might even be too much for you! I’m too much for my parents, and I’ve been too much for the last three therapists who tried to help me, if you can call it that.”
“If you have so many doubts about whether or not I can help you,” I replied, “why do you look so scared? Are you afraid to hope?” At this she became a little teary. “Is there a little Mildred inside of you who wishes to hope? Do you have to tell her to shut up when she does?”
Mildred began to sob openly.
“I guess I was just talking to little Mildred, that part of you that wants to hope. I guess that’s who’s behind that mask of glibness you came in here wearing. Aren’t you glad you took that mask off?”
“It’s scary without the mask. I don’t know who’s there and I don’t know what will happen to her.”
“Then you need a guide to show you who’s there.”
“Why should I trust you?” she asked, still sobbing.
“You already trust me a little, and that’s a lot for our first meeting. I think that you will trust me more than that blade and the pain it brings you.”
She shook her head in defiance.
“We will make this a gradual exchange,” I assured her. “I’m not in a hurry. The development of trust can’t be hurried. I guess I’m asking you not to rush yourself. That may strike you as strange, but I’m thinking long term.”
“I still might turn out to be too much for you, you know. The sword cuts both ways. You just met me and you’ve already decided you think you can help me.”
I smiled. “I think you are too much for you.”
“We’ll just have to wait and see.”She broke into a friendly smile and wiped her eyes.
“So I guess you’re coming back for more of this?”
“Yeah, yeah. I guess you better get your appointment book out and see when you can fit me in.”
“When you really get moving, we’ll see about two meetings a week.”
“Oh great! You want to see how much I can take, huh?”
“No. I think you want to see how much you can take.”
_______
Mildred had indicated that she was reachable nearly from the moment she came into the room. The thin veneer of bravado was an easy barrier to break through. Self-mutilators, like anorexics, have bizarre, mystifying, and dangerous behaviors to mask their fears and keep others frightened of getting too close. The distance they learn to establish arises from their hopelessness, and keeps the value of their symptoms intact. The easiest way to break through this defense is to indicate that you are comfortable getting close to the person’s pain, rage, and despair. Kindly and comfortably devaluing the symptoms that have intimidated others is a rapid route to developing a trusting relationship with such a patient. This is one of the first but, sadly, not the last obstacles to treatment.
Mildred was not as entrenched in her self-mutilating symptoms as her glib but dazzling inventory of her pathological behaviors might have implied. There was an underlying health within her.
Breaking Down the Barriers
It is always difficult to isolate why one person develops severe psychopathology and another does not. Even when all the family relationship factors and histories of mental health or illness are tallied, one sibling does well while another does poorly. We have to keep in mind that behavioral symptoms for any illness serve as the tip of the iceberg: they could indicate profound disturbance and a poor prognosis, or simply be the proverbial “cry for help” that, when dealt with promptly and skillfully, resolves the underlying problems.
Merely knowing that someone is a self-mutilator, or an anorexic, is not enough. We need to build a developmental history that will tell us, diagnostically, of any underlying personality, mood, anxiety, or neurological disorders that could affect the outcome of treatment, as well as determining how intense that treatment should be.
If Mildred, for all her symptoms, was on the less profoundly disturbed end of the continuum, Dina was at the opposite end. Dina is an example of a self-mutilator who has created a false identity for herself.
Dina: A Mask of Friendliness
Dina came into her first session with a smile on her face. She was friendly, likable, and outgoing. She had been referred to me by a local psychiatric hospital where she had spent three weeks as a consequence of a suicide attempt. The director phoned to warn me that although Dina could be endearing, she was unpredictable and could get into severe trouble with surprising swiftness. With Dina’s approval, the file was mailed to me by the hospital. It indicated a history of hospitalizations and emergency-room visits going back five years, since Dina had turned fifteen. The emergency-room visits led to short, two- to three-day stays in the hospital for observation. They were brought on by either an overdose of a hodgepodge of medications, or a severe self-inflicted wound (usually done with a dull instrument that would make a cut broad enough to require stitches).
Nothing about her initial session suggested that Dina could be severely disturbed. There were no outward signs to suggest that she was a danger to herself and had already been in treatment with five therapists for varying lengths of time with little or no improvement in her mood changes, her lack of self-esteem, or her self-destructive symptoms.
Dina did not attempt to conceal her history, but her way of telling it suggested that most of her problems were in the past and that she was making lots of progress in getting rid of her remaining problems.
After she had reassured me of her vast improvement, I asked her if I might see some of the scars she had “from the past.”
“Oh sure, but be prepared. They are ugly. I’m thinking of having some of them removed by a plastic surgeon.”
With that she pulled up her short sleeve, uncovered her shoulder, and revealed a scar an eighth of an inch wide and three inches long.
“Did you cut a tendon or any nerves when you did that?”
She was disappointed at my lack of shock but pleased that I knew how serious her cutting was.
“No, but the doctor said that I barely missed badly damaging my shoulder joint. I don’t care about that, but I just hate how ugly it looks now. The pinkness won’t even fade like the others. It’s been a year. I took a bunch of pills, drank some vodka, and made the cut with a serrated knife.”
“I imagine that you took the pills and the vodka to kill the pain?”
“No, I took them to make sure that I would do it.”
Her facial expression changed swiftly to seething anger and determination. It was one of those “changes” the director of the psychiatric hospital had warned me about. I sat there in silence for a minute. She caught herself and donned her engaging smile again. “Well, anyway, that’s all over with.”
“But it seemed to me like you just relived those old feelings for a few minutes there.”
“Yeah, I guess they—the feelings—still come and go now and then.” She looked and sounded more resigned now.
“Are you at a point where you believe that you’ll never act on them again?”
“I keep thinking that I’m at that point, but just when I begin to believe it, I do it again.”
“Cut yourself?”
“Cut myself, starve myself, throw up, spend the day cleaning my room over and over, rearranging everything obsessively until it’s time to go to sleep. Sometimes I think that I’ll always be crazy.”
“I guess you’re pretty used to all this by now?”
“I’m used to it and I hate it.”
In Dina’s case, we see a pattern of self-mutilation that deepened until it became truly dangerous to her. By the time of our first session, Dina’s disorder had reached a level where she could, in a state of drug and alcohol intoxication, inadvertently cut an artery and not even be aware of what she did. Such behavior could lead to accidental suicide. This kind of deepening of the disorder was not motivated by the self-mutilation’s usefulness in relieving emotional pain. Rather, it was a result of other personality and mood disorders that were destabilizing her.
In later sessions, Dina would lash out at me with her anger, which could dissipate as quickly as it had appeared. She would make plans based on two successful (symptom-free) weeks and become unable to follow up on them. These plans might involve starting a college course, or a demanding job; she would then abandon the course, and get fired from the job for excessive absence. She would ascribe her failures in these areas to recurring depressions that immobilized her, or fears of failure that caused her to back away from attending class or showing up for work.
Dina had been evaluated by several psychopharmacologists for medications and many had been tried—sometimes singly, other times in combination. Still her behavioral patterns continued and her cutting disorder deepened as she simultaneously “lost the willpower” to starve herself. It seemed that cutting was the easiest of her disorders to maintain.
Dina’s prognosis was poorer than most. She embraced the identity of “mental patient” and abandoned the remainder of her high school friends, preferring the other patients she met in psychiatric hospitals. This change of peer groups made her illness feel more normal since all of her friends were grappling with similar problems. At the same time, she would become very upset when she heard that one of her friends was readmitted to a hospital due to a psychological crisis. Dina’s symptoms were a reflection of the deepening of multiple disorders and the deterioration of her general mental health.
_______
There are many ways we can react to someone with an illness. The nature of our reaction depends in large part upon how the person appears to us. As we have seen with the contrasting examples of Mildred and Dina, patients are not always what they appear to be. One who wears her pathological symptoms like badges of honor may be very reachable, while another who comes across as positive and stable may in fact be very sick. The important thing to remember is that no one is the sum of her symptoms. Behind “grotesque” behavior and “disgusting” scars there is always an individual with her own needs and her own pain.