HOW AND WHY THE DISORDER DEEPENS
Most individuals do not develop psychological disorders to their fullest and most serious at the onset of their symptoms. In order to explain how the disorder deepens, it is helpful to compare self-mutilation with two other related disorders: obsessive-compulsive disorder and anorexia nervosa.
Obsessive-Compulsive Disorder: Michael
A twenty-year-old man called Michael explained to me during our initial interview that he became nearly housebound by having to repeat behaviors over and over again. These behaviors included hand-washing; drying his hands without “contaminating” them; tapping the center of surfaces (tables, countertops) five times before going on to the center of the next object; doing all of his “security-related” behaviors (checking different parts of his body) five times unless he thought that the behavior wasn’t done just right, when he would have to check each one another five times; and clearing his throat five times before he spoke to anyone.
This all began after a bicycle accident he had at the age of fifteen. As a boy riding his bike, he became distracted by the spots of tar on the pavement. He noticed that when he rode his bike faster, the spots assumed the shape of long black lines. It amused him. One day he was nearly hypnotized by the lines and collided with a parked car so violently that he was thrown over the handlebars of his bike, lacerating his genitals as he flew forward. He landed on his hands and scraped both arms.
A middle-aged couple was in the car, in the process of pulling out of their parking space. They immediately got out, saw that there was no damage to their car, and walked over to Michael. The man lifted the boy up abruptly, pulling sharply under his arms. Michael then found himself face-to-face with the woman who had been in the passenger seat. She looked at his face with a startled expression, which led Michael to believe that his face might be badly injured, possibly even mutilated.
The man asked Michael if he was all right. He responded that he was, mostly in order to free himself of this overzealous good samaritan. As the couple drove away, Michael slowly walked over to a car window to examine his face, dreading what he might see. There was nothing wrong, no damage to his face. He checked further by looking in the rearview mirror of another parked car. Still nothing.
But Michael realized that he was experiencing severe pain from his groin and his fears intensified. What could he do? He couldn’t examine his groin right there on the street. He was afraid to get back on his bike for fear that if he had damaged his genitals, the saddle seat of the bike would make things worse. He walked his bike home, wondering all the way back what damage had been done to him.
When he arrived home, he quickly went to his room to examine himself. All he could see were some small scratches, but he felt a soreness and a constant cramp or ache in the area. The next day, he noticed that his testicles were swollen and the ache had gotten worse. He was afraid that he would become sterile or physically impotent. Michael was not comfortable telling his parents about his worries since they were not the kind of family that discussed private matters, so he spent an anxious week checking himself several times a day. By the fourth day the swelling had gone down noticeably; at the end of the week it was almost completely gone, as was the discomfort he had been experiencing since the accident. Nevertheless, he continued to examine himself for months thereafter.
He began a series of superstitious behaviors before riding his bike which spread to the act of leaving the house before a ride. Soon he did these things even when he was not going to ride the bike. Michael’s sense of danger had insinuated itself into more and more activities until it was always with him.
Perhaps if he had spoken to one of his parents, and had either been reassured or taken to a doctor immediately, he would not have developed these maladaptive behaviors in order to “protect” himself. By the time I saw him, he was entrenched in them—and severely impaired. The people closest to him had no leverage with which to compete with the feeling of security that his rituals gave him.
Anorexia Nervosa: Krista
Krista was thirteen years old when she first decided to lose weight. Her parents were both working at demanding jobs and they often came home from work worn out and late, just in time to eat dinner. Despite their long hours, they didn’t or couldn’t afford to hire help. Krista did all the shopping and cooking. There was very little personal talk between Kirsta and her exhausted parents. Krista spent her spare time reading the type of service magazines for girls that they mostly read between the ages of nine and thirteen. (Readers of these magazines usually go on to women’s fashion magazines after the age of thirteen.)
Krista was not getting any feedback about herself or even her cooking from her distracted and beleaguered parents, so she turned to these magazines in order to get some sort of appraisal of her adequacy. She quickly discovered that the most important achievement associated with adequacy was thinness.
To meet this standard, she began losing weight. At thirteen, she was five foot five and weighed one hundred and eight pounds, normal for her frame. After she had lost twenty pounds, unnoticed by her parents, a school nurse called home to inform them that their daughter weighed eighty-eight pounds and that this twenty-pound loss should be investigated.
The parents were mortified and embarrassed. They did not admit to the nurse or to their daughter that they hadn’t even noticed her weight loss. They were both aware that as college-educated people, they should have identified this change in their daughter before it had gone this far. Following a medical examination which revealed no medical cause for her behavior, the pediatrician diagnosed Krista as having anorexia nervosa, and told her parents that she needed psychiatric care, which would hopefully prevent her from starving herself into medical danger.
By now Krista was so secure with her pattern of weight loss that it had become more important to her than the opinions of her parents or her doctor. It was unthinkable for her to choose to abandon her security system just because of their wishes, judgments, or even threats. She ultimately ended up in the eating disorder unit of a psychiatric hospital, where she regained the weight, only to lose and regain it repeatedly through two more hospitalizations.
It was clear to me that no one involved with Krista’s treatment had formed a relationship or a connection with her that could compete with the comfort, satisfaction, and safety that her anorexia had provided. She was so mentally involved with regulating her eating, exercising, and elimination that avoiding gaining weight was almost all she thought about, even though she had been admonished that she would be in great danger if she didn’t change her weight-losing patterns.
Krista was frequently asked rhetorically, “Don’t you want to be pretty, and healthy?” She would not give up her dangerous behavior for herself; she didn’t have enough self-esteem for that. She might give it up for someone else that she held in higher esteem. But she would be difficult to reach, since she had drifted so far away from even hoping for an important relationship that would make her feel safe and comforted.
In the case of both Michael and Krista, the length of time the patients used their maladaptive defenses for relief from psychological confusion, insecurity, or pain increased their dependence on their psychopathological behaviors. In each case, the person took a bit of truth and distorted it until their behavior was out of their own control. At the same time they were becoming entrenched in these behaviors, they were also increasing the distance between themselves and their families and peer groups. They became more and more emotionally disconnected from the people around them, which, like the chronic use of their symptoms, deepened the illness. Each became sicker, harder to reach, and more difficult to treat the longer his/her pain went unnoticed.
Self-Mutilation
What is the beginning of the loss of perspective that leads to cutting or burning oneself? Do we perceive a person who begins with nail-biting and then goes on to doing mild damage to her nailbeds by picking at them as being sick? Do we see the nervous habit of biting one’s lip go out of control and lead to self-mutilation? Rarely, if ever.
In the examples involving both obsessive-compulsive disorder and anorexia nervosa, we saw a gradual transition from mental health to mental illness, followed by a deepening of that illness. Self-mutilation, on the other hand, often starts in its pathological or “sick”form immediately, within an already existing illness. It begins as a sick feature from its onset, but may develop or deepen into such a frequent and severe form that it overshadows the illnesses from which it sprang. When I state that self-mutilation starts as “sick,” I mean that the illness does not evolve from a mild, acceptable form of behavior like nail-biting into picking up a blade, scissors, or match to harm oneself.
Reconciling Brain and Mind
Today, the chemical nature of the human brain is being understood as never before; yet it is the human mind that we inhabit and experience. We all try out new behaviors haltingly, awkwardly, full of concentration and hypervigilant. As we practice these behaviors repeatedly, we become less halting, less awkward, our need to concentrate is less necessary, and we grow more casual and more efficient at the same time. Whether it is learning to walk, swim, ride a bike, drive a car, or parent a child, the progression of the learning experience usually follows the same pattern.
When these are positive achievements, we call them learning. If they are destructive or self-destructive, we call them disorders. Though these behaviors are labeled disorders, they are born from the same mechanisms as positive learning. The major difference between the two is that positive, healthy learning is most often taught by one person to another person, instructively.
Maladaptive learning, on the contrary, is inferred and may be need-based, or copied from a role model without direct encouragement or instruction. This kind of learning is, in effect, self-taught. It is often unconscious as well. When one person is taught by another person, that child, adolescent, or adult remembers the teaching experience as well as the guidelines and limitations involved in attempting the new behavior. We usually can easily remember who taught us how to swim, or cook. But the child who is learning by inference and not by instruction is often doing so in order to survive physical or emotional unpleasantness, and does not have the guidelines that will tell her what is enough, when she can stop, or when she will be safe. Take, for example, a ten-year-old girl told to stifle a sad feeling or fear, who then carries a box of fudge to her room and eats the whole thing. She has just taught herself comfort through binging.
As different as they appear to you and me, both of these kinds of learning are treated in the same way by the mind. That is, as the thoughtfulness involved in producing the skill or behavior is abbreviated, the process becomes automatic. When the behavior, or skill, has been developed over a long period of time, we say that the person who does the positive behavior or performs the skill is “experienced.”The experienced person will often seek to increase his or her skill by trying out more difficult forms of it—whether ice-skating, skiing, mountain climbing, or playing a musical instrument.
Similarly, when a person who has developed a disorder that originated with negative, inferred learning has had this disorder for months or years, that person is more likely to push the self-destructive behavior further. For the self-mutilator, that means doing more damage to herself. This increased damage becomes incorporated as normal or usual as it occurs slowly over a period of time.
Just as there are reasons attached to increasing achievements, to pushing skills to their limits, so the mind looks for further avenues to intensify disordered behavior. In the case of anorexia, it is:
—How thin can I get?
—How much weight can I lose?
—How much willpower do I have to deal with deprivation?
—How much attention can I attract?
—How much exercise can I do on very little nutrition?
In the case of self-mutilation, a slightly different set of rationales is applied to deepen the disordered behavior:
—How much pain can I take?
—How much disfigurement of my skin can I tolerate?
—How much bleeding can I stand?
In these cases, the individual has already established the disordered behavior, and now wants more relief, more satisfaction from it. The victim starts thinking like one who is addicted to a substance: more is better. The more disordered the behavior, the greater the escape from emotional pain.
The mind in each case has adjusted to the existing level of behavior or achievement, and is now seeking to increase intensity in order to maintain the rush of reaching the current level that was once new. Let us contrast two examples—one of early detection and one that was chronic.
Katerina and Carla
Katerina had started with small cuts on the underside of her arm. They were half an inch long and just deep enough to draw blood. Over a five-year period, she upped the ante to larger, deeper, and wider cuts. Sometimes she would resort to burns with a cigarette, match, or candle. Once she pressed a hot teapot full of boiling water against her thigh; another time she bit a gash in her own arm. By this point she was emotionally and mentally disintegrating into dissociated states and experiencing amnesia during the incidents. Her behavior went undiscovered for four long years.
Carla, fourteen, came into treatment for anorexia and depression. Her diagnosis had been made within the last year. I asked her if she cut herself.
“Sure, on my arms and breasts.”
“How long have you been doing this?”
“For about three months.”
“Why these two areas?”
“The skin is very sensitive and tender in both areas. You can get a lot of pain with very little damage.”
“Why do you want the pain?”
“I’m the only one I allow myself to hurt.”
“Does anyone else know?”
“That would defeat the whole purpose. It would hurt both my parents to find out I do this.”
During the rest of Carla’s first year of treatment, there were only two more incidents of cutting and they were much milder. In fact, the second incident was scratching, and the results were barely detectable. After that, they stopped entirely.
Early detection, as with nearly all developing problems (medical or psychiatric), offers the best prognosis and outcome, with the help of skilled treatment and a supportive environment. While Carla and I were working to reverse the development of self-mutilation, we were able to reduce the addictive behaviors that precede the formation of the disorder. From there we worked to fill the deficits in her emotional development that invited these symptoms.
With Katerina, it was a long time before we could get her to stay aware of her environment throughout a session, to focus on our dialogue, and even longer before we began to reduce and eventually stop her severe self-mutilations. It was two years before we got to the point I had reached with Carla in the first four months of treatment.
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The athlete who becomes a champion in her sport, or the businesswoman who becomes the most successful in her field, often become so invested in their field of expertise that they cannot focus on any other aspects of life, even their families.
A parallel situation develops with someone who is chronically or deeply involved in his or her disorder. That person becomes more difficult to reach and to develop a therapeutic relationship with. The double jeopardy here is that when the disorder is at its most dangerous, the patient is at her most inaccessible. The therapy must be skilled, strong, and as frequent as possible: twice a week outpatient.
The learning model outlined above helps us to avoid the pitfalls of suspecting the patient of being stubborn and uncooperative; of seeing the patient as so different, so sick, that she cannot be helped; or of becoming overwhelmed by her tenacious behavior. Later, I will explain and illustrate the treatment methods I have found to be effective in reversing this process. If the family and the therapist can both keep in mind that the terms change or cure refer to rebuilding and reparenting, then the damage can be stopped and reversed. The patient can be reparented so that her unhealthy defenses become unnecessary; the newly obsolete defenses can then be extinguished, and personality deficits filled in with the help of strong interpersonal connections.