Anorexics occasionally cut or even burn themselves. Bulimics, and those who suffer from a combination of severe anxiety and depression, injure themselves as well. People with the diagnosis of borderline personality disorder do the same thing occasionally, or even frequently. But in all these cases, the self-injuring behavior remains secondary to the more prevalent symptoms that constitute the primary disorder. It remains a feature of the larger primary diagnosis. If we view all such disordered behaviors as a person’s attempt to drive away emotional pain, then we see that self-injury is a small part of that repertoire. The method such patients rely on most to stave off emotional pain—the “method of choice”—belongs to the primary diagnosis, or disorder.
It is when a self-injuring behavior begins as one of the many symptoms and becomes promoted to most often used, to the point where all other symptoms are employed less, or with less intensity, that the person has developed a full-blown diagnosis of self-mutilator. This is usually a gradual process, during which other defenses accompany the increased use of self-injury. These other personality defense mechanisms include rage, frequent dissociation, and amnesia. Often, such defenses are coupled with self-hatred, or a fear of personality disintegration (the loss of the ability to think or to use cognitive abilities).
In these cases, the disordered person responds to the strong tactile stimulus of the destruction of their own skin by means of cutting, scraping (lacerating), or burning it. The self-mutilator is also responding to the intense visual stimulus that accompanies the physical damage: seeing one’s own blood flowing out of the body through the skin surface. This combination of tactile and visual experiences may become the most frequently used behavior to ward off, and induce relief from, the dreaded feelings listed earlier.
Once this has happened, the use of self-mutilating behaviors can become even further amplified, to a point where they are used when the individual only anticipates or suspects that the feelings may arise in the near future. Eventually, the behavior is resorted to as an impulse, devoid of the thought processes just described, and employed as quickly and thoughtlessly as the nail-biter begins gnawing away at his or her fingernails.
Tracy: The Disorder Takes Shape
Tracy was a twenty-year-old who had first begun cutting herself at the age of fifteen. She had developed anorexia nervosa when she was fourteen and was hospitalized for three months. She was discharged at a normal weight of one hundred ten pounds for her height of five feet four inches. Her family history included being frequently beaten by her alcoholic father, who often used a strap with a sharp buckle that sometimes cut her, in addition to the welts that the leather made on her skin. Her mother never interfered with these beatings, which she often instigated herself by complaining to her husband about some misdeed Tracy had done.
Despite the beatings, Tracy respected her father and even worried about how his drinking might be harming him. He took her to football and hockey games, and they occasionally played one- on-one basketball using the hoop he had installed in the driveway when Tracy’s older brother was born. Her feelings toward her dad were a mixture of worry, love, rage, and hatred. She had always been distant with her mother, who felt wounded by this. “Home” for Tracy was always a combination of the mixed feelings she had for her father along with a sense of guilt for the contemptuous feelings she expressed toward her mother.
When Tracy was fourteen, a boy called her “Thunder thighs.” She didn’t mention it to her parents but never forgot the insult. A year later, she began to diet. She had a fear of being stopped by her parents so she lost weight rapidly, dropping from one hundred fifteen to ninety pounds in two months. It was the school nurse who noticed the weight loss and notified her parents with a phone call.
Almost a year later, she came into my office wearing long sleeves on a warm day. I knew they were concealing a variety of cuts and scrapes; this information was in her referral. I looked straight at her and mildly asked if she would please roll up her sleeve so I could see the damage she had done to herself. She was surprised at my slow, careful examination of each cut and laceration. “Quite a variation,” I commented.
“Each one depended on my mood at the time, I suppose,” she replied.
“Your parents didn’t notice your weight loss; how did they cope with it?”
She smiled. “My father was lost. He knew how to punish me when I did the ‘wrong’ thing. He didn’t know how to act when he was worried. My pediatrician’s warnings of the dangers of losing weight bothered my mother as well. I liked their worrying about me. After being sent home from the hospital, it seemed like it was my parents who backed away from me this time. I lost ten of the twenty pounds that the hospital put back on me. Something had changed, though. I found that I missed my old relationship with my parents, no matter how screwed up it was. I felt lonely.
“One day I found my father’s largest belt, the one he would hit me with before I got sick. It was just slung over the banister at the bottom of the stairs. I picked it up and took it to my room. I sat on the edge of my bed examining the buckle carefully. It was a cowboy-style belt. The buckle was rectangular; its corners were sharp and pointed. It struck me as odd. I had felt the pain of those corners, and had seen the cuts and lacerations they left behind, but I had never wondered what the weapon looked like. Now I had control of it.
“I turned it, fingering each corner for its sharpness. I held it in my right hand and thought about how awkward it would be to cut myself on my butt as he had often done by hitting me with the belt. Besides, I wanted to see the cutting myself. So I cut my left forearm, deeper and longer than the cuts from when my dad was the one holding the belt. The more it hurt, the deeper I cut. I finally stopped at the sight of a stream of blood running from the cut down to my elbow and onto my pants.
“I stared at it for a few moments, then ran to the bathroom sink to rinse my pants and wrap some toilet paper around my arm to stop the bleeding. I used nearly half the roll, or it felt like it, anyway. My feelings of loneliness went away.”
Tracy had fused attachment with pain. For the rest of us who do not have her experience, it is hard to imagine that the same pain that was dealt out to her as punishment could be used to relieve her loneliness by symbolically reestablishing a connection to her father. However, because this is a psychopathological resolution to her problem of loneliness, and not a real solution to her wish for attachment, which would involve a healthy relationship with another caring person, it is only a quick fix—a superficial relief—and an addictive one at that. That is to say, the symptom does not resolve the real problem, so it has to be repeated again and again to fend off the painful feelings that the unsolved problem continues to produce.
By the time Tracy came in for treatment, her awareness of the original reason for the self-injuring behavior was no longer enough to stop it. Yet there was still value in having that awareness because it gave Tracy a reason to trust someone else and generated a desire to diminish and eventually eliminate that behavior.
Oftentimes, the more chronic the behavior, the closer it becomes to being the disorder itself rather than a feature of the original disorder. This was the case with Tracy, whose disordered behavior began with anorexia before she had ever cut herself.
Tracy told me that after the first few times she cut herself, she took to doing so almost daily. Even on days when she was not upset, she would make little cuts. Sometimes she would choose her upper thighs (another invisible location) and designate that area for the anticipation of bad feelings. In effect, Tracy had become addicted to self-injury to ward off even the possibility of feeling any sort of emotional pain. It was her security, her medicine.
The Cycle of Separateness
The deeper Tracy got into her symptom, the further she drifted from important relationships, which threw her deeper into her symptom, and so the cycle went. A secondary problem here is that the more separate Tracy became, the more disordered she was likely to become. With no one to help form her inner reality, she would drift further and further away from any reality.
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I am here referring to an aspect of emotional development that occurs first in childhood and continues throughout life. The human self, made up of our innermost thoughts and feelings, is verified when reflected back to us by a trusted person. We are validated when we are understood.
A major reason I approached Tracy so directly and intensely is that I had to break through the separateness Tracy had become so used to. Breaking through this wall requires certain credentials. The therapist has to be experienced as a potentially trustworthy, helpful, and competent person. His function is to form a powerful connection between security and kindness in order to replace the original fusion of pain and attachment.
The therapist will have to monitor the patient’s self-mutilating behavior in the same way that someone treating a low-weight anorexic would consistently weigh her. A familiarity with each cut, burn, or bruise, and a recommendation as to how to treat it, including referring the patient to a physician or even a medical hospital, brings the therapist closer to the patient who has achieved disorder status (determined when self-mutilation becomes the most prevalent symptom). Here it should be noted that when the patient’s behavior has amplified beyond a feature to the level of a disorder, the pacing of the therapy and the therapist’s expectations for change must be extended to include a longer period of treatment.
In Tracy’s case, we saw extreme parental abuse lead to the extreme: self-mutilating disorder. Other less extreme, even subtle family situations can lead to the development of self-mutilating as a feature, which is more easily treatable.
Remaining at the “Feature” Level
Self-mutilating remains at the feature level, where it is easiest to stop, when it is identified early. Usually, other psychological disorders are present and have been diagnosed. These disorders commonly include:
• Borderline personality disorder
• Eating disorders: anorexia nervosa and bulimia nervosa
• Episodes of psychotic behavior
• Severe rage, especially when it has to be concealed
• Depression coupled with anxiety
• Trichotillomania (hair-pulling)
• Obsessive-compulsive disorder
When a person is being treated for any of these illnesses, her physician should be examining her regularly for signs of self-mutilation. If any evidence is discovered, it should of course be reported to her psychotherapist.
Simone: An Anorexic Beginning
Simone, a fifteen-year-old from France, had recently moved to the United States. Her family became concerned about her refusal, or inability, to socialize in school, as well as her unhappy demeanor at home. Often retiring to her bedroom with little to say to her parents, she became mysterious to them. Her mother blamed herself for taking her daughter away from her friends in France. Simone also had difficulty with English. She was a perfectionist, and her floundering in the new language contributed to her reasons for not wanting to talk.
Simone was losing weight beyond the cosmetically acceptable, and was becoming overly fastidious about her clothing and makeup, where formerly she was quite casual about these things.
I was first consulted by her parents, who were concerned that she was becoming “out of reach,” as they put it. I followed up our consultation with a call to the examining physician, who informed me that Simone was in good health generally, but if she continued to lose weight she would develop physical problems related to anorexia. I asked him if he had noticed any remarkable damage to her skin (cuts, lacerations, burns, or suspicious scarring). He responded that he had not been looking for those kinds of problems but said he would be glad to reexamine her. I requested that he do so before I saw Simone for our initial meeting.
I always weigh a patient referred for anorexia nervosa during our first meeting. However, as I am not a physician, I would not examine her for skin damage beyond what showed when she was fully dressed.
The physician reported to me that he found a number of minor scars, an inch in length, as well as a few fresh cuts, the same length, apparently made with a sharp instrument. Three of the cuts were on her upper left thigh, an example of what a cutter would consider a good hiding place for her sickness.
Simone came to my office for her first appointment in bluejeans and a long-sleeve shirt. The weather was sunny and the temperature in the mid-eighties. Simone was taking no chances. As she walked into the office, she looked as if she had come to the appointment under some sort of threat.
“Are you here because you wanted to see a therapist or were you coerced into coming?” I asked her.
“The second choice is the most true,” she said, nodding her head, pleased that she could be brief and concise in English. She smiled.
“Then it will be slightly more difficult for us to do the work we have to do,” I answered, as if she had in fact expressed interest in working with me to change her situation.
“What work is that?”
“The talk between us that will help you stop needing to cut yourself on your arms and legs.”
I stopped there and allowed for silence. Simone became a bit tense. She stuck out her lower lip a little and looked down at the floor. She was not prepared for her most secret behavior to be revealed. She seemed to be expecting a scolding for this behavior. In addition, we were going to have a language problem and I would have to allow for her misunderstanding me if I didn’t talk slowly, present one idea at a time, or attempt to work with her in French.
Since my French was rusty, I thought I had better save it for later sessions, with short phrases so she could tell that I would work in her language when I could. At this point she trusted no one. We were starting from square one, with a language handicap to boot.
“I think that you must be very unhappy. Only unhappy people hurt themselves.”
The tears fell now as she continued to look down at the rug.
“Yes . . . I am unhappy. But I don’t know why. I have a good family. I have no reason for this. Maybe I’m crazy.” She nodded to emphasize the finality of this appraisal.
“Maybe you need words instead of blades or knives.”
She looked confused, not understanding the comparison that I was making. “How do words help the way you hurt?”
“Your words can build a bridge. Your bad feelings can travel over that bridge, away from you.”
“To what place?”
“To me.”
Simone was still puzzled. “How can my bad feelings leave me and go to you? Then you will have bad feelings.”
“Your bad feelings don’t have to hurt me. Maybe I will throw them away—something you can’t do with them.”
“But I don’t know you. How can this happen?”
“It can happen as you get to know me for a longer and longer time. Talking together will build the bridge.”
“You are a very strange man. I don’t meet doctors that speak like you do.”
“Strange–good, or strange–bad?”
With a large smile she answered, “Strange–very good.”
“The next time you come here, maybe you will want to speak like that, too. Strange–very good.”
“I would want to . . . if you don’t change. I feel everyone is always changing to me. My feelings for everyone always change. Maybe if you don’t change, my feelings about you won’t change, and I will always want to come here. I hope so.”
She came across as likable, sympathetic—and misunderstood. It seemed that this lack of understanding of her emotional pain made it harder for her needs to be met by her parents, and even by herself. My next step was to evaluate whether Simone had actually alienated them so effectively that they could neither reach her nor do anything “right” in her eyes.
At that point, I didn’t know if Simone had really been disappointed by inconsistencies on the part of others or if she was suffering from a borderline personality disorder that would cause her continually to shift her feelings toward others from idealization to devaluation. Borderline personality disorder is a complex and serious illness, which produces extreme changeability of mood as well as reckless and impulsive behavior. I would, no doubt, find out, language barrier or no.
My first task would still be to develop the therapeutic relationship that I had called “a bridge” to get Simone to give up her cutting. Each symptom I could get her to give up would close off another outlet, and would eventually cause her to exchange acting out physically for talking about her feelings.
My first battle would be with her symptoms. In a sense, I had to get her to give them up for our relationship, because she did not at that point care enough about herself to give them up solely in her best interest.
This might be perceived as a controversial approach to therapy. Ideally, we all want to see patients give up their disorders for themselves. Most often, however, we are confronted with individuals who feel that they have no sense of self, or that they hate themselves. Our next task becomes winning their esteem, because we must use their esteem for us to help them value our appreciation of them. The third step in this process is to help them incorporate positive statements (which should be realistic) that we make about them into their own self-image. This is how the therapist can help patients feel better about themselves, produce pride in themselves, and raise their self-esteem.
Simone worked hard in therapy, her perfectionism spurring her to be my “best” patient. Often I would remind her that this was not a competitive process, just a place to learn about herself. She did not emerge as a borderline personality and gradually she was able to use my acceptance of her efforts and her feelings to counteract her negative self-image.
As the cutting subsided, the anorexia reemerged, which I had expected as it was her original diagnosis. Again, our work centered on dispelling Simone’s ideas about the need for perfection, which had trapped her in two isolating behaviors, though fortunately not forever.