Attachment is a vital part of all human relationships, commonly defined as joining or binding by personal ties. Self-mutilators suffer from severe deficits in the ability to form personal attachments—to join others—whether it’s to have fun, to talk seriously about each other, to talk personally about themselves, or to accept comfort and reassurance from another person.
The Benefits of Attachments
In order to truly understand the void that is left by a lack of personal attachments, perhaps we ought to look at the benefits derived from having the ability to form them. When a person can form attachments to others, it means that he or she is someone who is able to trust and to develop healthy dependencies. These kinds of connections between individuals allow us to be restored or supported when we are emotionally played out. Conversely, if a person has no attachments to others, he or she risks emotional depletion, pathological levels of obsessiveness, and the disorders associated with these conditions: phobias, depression, eating disorders, obsessive-compulsive disorder, and self-mutilation.
Of course, attachments, like many of the concepts we have addressed thus far, can be qualified as either “healthy” or “unhealthy.” When someone has an unhealthy attachment, it is termed fanatic or blind.
People who are capable of forming healthy attachments have learned from their families that trustworthy, reliable attachments are possible. They know that positive experiences with others are achievable, and this kind of optimism dates back to their own childhood. Outside the psychological definitions, however, there exist a wide range of personal definitions for what constitutes a healthy attachment. Most of us find a workable medium—an attachment that incorporates both trust and distance to varying degrees.
The self-mutilator, on the other hand, is someone who has not found a workable medium, and usually does not have any healthy attachments to others. At the first therapy session with new patients, I generally ask them: “Whom do you trust? Whom can you lean on? Whom can you cry to about yourself?”
The most typical answer I get in response to this series of questions is, “Myself,” followed by, “It’s foolish and weak to depend on others because they’ll probably let you down,”or, “I’m safest trusting and depending on no one.”
This type of response indicates that some event, circumstance, personality, or even a combination of all three, has thwarted the development of the restorative mechanisms of trust and dependency. If one cannot form trusting attachments, psychological or behavioral disorders, or both, follow. These disorders fill the void left by the lack of interpersonal relationships and serve as replacements for healthy attachments. This is nearly always the case in the personality development of the self-mutilator.
Kessa: Lonely at the Top
Kessa was a sophomore at an urban college. Her circumstances allowed her to exhaust herself both at academic tasks and in her involvement in successful, even glamorous businesses in the city. The combined productivity of her school and nonschool activities produced envy on the part of her friends. This envy came out as teasing about her “Superwoman” activity. Yet it seemed that almost no one Kessa’s own age respected her, or appreciated her for her productivity and energy. Her parents continually expressed concern and disapproval that she wouldn’t have a social life if she didn’t ease up on her heavy load of schoolwork, extracurricular work, and internships. She did fall asleep in class, on the city buses, or any other time she sat still. While her parents fretted, her professors and the adults who supervised her outside school were charmed by her.
Kessa saw herself as a commodity that had to be continually honed in order to maintain success, otherwise, the rest of the world would somehow lose interest in her. At least she believed that. When she expressed the slightest signs of fatigue to her friends, rather than offer her support, they teased her and chided, “It’s amazing you haven’t dropped dead by now!” Her parents would admonish her for the fix she had gotten herself into, and wanted her to give up some of her commitments. It seemed that no one could simply be supportive. She turned to eating to compensate herself for the lack of support and nurturing from which she suffered. When her weight got too high for her to “look successful,” according to her own interpretation of society’s standards, Kessa began to purge.
She was referred to me for help with her bulimia when her roommates called her parents to tell them that they saw signs of this behavior. She began to cut herself when she felt upset, but was afraid that her roommates would catch her vomiting in the dorm bathroom. She gradually shifted her symptomatic behavior from binging and purging to cutting because it offered her more privacy.
Kessa entered the office dressed fashionably and exuding boredom from every facial muscle.
Since I had the feeling she had not come to the session on her own accord, I asked her, “Do you know why you were sent to see me?”
“For no valid reason,” she assured me.
I decided to confront her seeming disinterest with the information I’d been given. “I don’t care how hard you work, or how many activities you participate in. That sounds like good, productive, energetic stuff. I’m thinking that you don’t know how to balance your work with leisure, or restore your energy output. Your mother made it clear that you have at least one symptom of being overwhelmed and overworked.”
“What did you mean by ‘at least’ one when you were talking about me having a symptom?”
“Well, it’s clear to your friends and your parents that you are engaging in purging, a nice name for vomiting, after you eat. You are probably doing this to prevent weight gain because you are eating more than you can without gaining weight.”
Suddenly, anger flashed across her face. The boredom was gone. “Wait a minute! I just got here and you’re already saying that I eat like a pig!”
“No. I’m suggesting that the information I was given, if it’s correct, means that you’re eating beyond hunger and that means something is wrong. We call that ‘symptomatic eating’; it makes up for something that you need from other people but aren’t getting. I also noticed you took exception to my remark about you having ‘at least’ one identified symptom. That causes me to wonder what other self-harming behavior you’re engaged in.”
“I’m not engaged, as you put it, in any self-harming behavior.” Her eyes welled up though she wasn’t actually crying.
“Do you cut yourself?”
She jumped nearly out of her chair. “What do you mean, do I cut myself?”
I leaned back and spoke softly and casually, as if I were talking about something harmless, commonplace, and ordinary. “Well, let’s say you’re full of tension and fatigue. Two girls are showering in the dorm bathroom. It’s just before dinner and some of the girls are going on dates. There’s not much privacy anywhere. Everyone’s doing their nails in the lounge or the living room to your suite. Suddenly you discover that you’re alone in your bedroom. You grab a knife, a fork, or a scissors, and in the blink of an eye, you make a cut on the underside of your forearm and quickly put down whatever you used. Even if someone walked in right afterward you could always shout, ‘Damn!’, blame the cut on the corner of the dresser, and walk out of the room to dress the wound . . . Hmmm?” I nodded my head.
She stared at me, dumbstruck by what I had just said, and just as surprised by how casually I said it.
She started to stare blankly out the window behind me. Then she looked at me. “Pretty good,” she said. “And what if it’s true?”
“Do you want to show me your arms?”
Kessa paused as if she were contemplating an infinite number of retorts. Her expression turned from puzzled to mind-racing to weary—maybe weary of keeping so many things a secret.
“So what if I have done that—I’m not saying that I have—but just what if?”
“I would say that means you’re burned out but don’t know what to do about it or who to turn to.”
“Who to turn to? There’s never anyone to turn to! My fellow students think that my hard work is a joke; my parents think that I’m being stupid, showing poor judgment. If I can get my mother serious about me for more than a second, and God forbid I cry, she starts crying along with me. That’s a big help. And if my dad was ever home from work for five minutes without ‘making business calls,’ he wouldn’t listen, he’d just try to come up with a perfectly logical and totally irrelevant ‘solution’ for everything. There is no one to turn to!”
“I guess that’s why you’re here.”
“What do you mean?” She was still angry, but tearful now too.
“Well, if no one knows what you need, no one who you know yet, we’ll have to find out and address that here.”
“How the hell—excuse me—can you just sit there and say that as if I’m a customer at the dry cleaner’s and you want to know if I want some starch or not?”
“Maybe because it’s my life’s work. Maybe because helping people is my life’s work,” I said in a tone of mock casualness.
She looked puzzled again and shook her head. “Well, I don’t know how you can figure out what to do with someone like me.”
“You don’t seem foreign or unfamiliar to me.”
She giggled. “Well, you must lead some horrible life.”
“You don’t have much self-esteem, do you?”
“Through the floor. You’ll find it in the basement.”
I decided to respond playfully as a break from the intense discussion. “I guess we’ll have to find it, stand it up, and starch it, like at the dry cleaner’s.”
She smiled and nodded. “That’s pretty cool. You really think that’s possible, that you can do it?”
“I wouldn’t even suggest it if I didn’t have a large box of starch in the closet.”
“I’m not so easy to get along with, you know.”
“Thanks for the warning.”
Kessa was without secure attachments, yet by the end of our first session she betrayed her hope that it would be possible to develop at least one: with her therapist. It would be difficult to create a prognosis scale to measure hopefulness to hopelessness about establishing trust, attachment, and dependency. If we could, Kessa would fall on the hopeful side, which gave her a good prognosis. But before she left the office, I had a request to make. “Can I see those arms now?”
Her shoulders dropped. “Okay.”
She awkwardly unbuttoned the cuffs of her sleeves. Her right arm was clean, but the left forearm was cluttered with cuts and scratches (some looked as though they had been made with fingernails when there probably was no time to obtain a cutting instrument). She looked at her arm, then at me. “Pretty ugly, huh?”
“No, just sad for you, that this is the only way you know how to say, ‘Ouch, I hurt, I need.’ ”
“Well, can I make another appointment, or am I too horrible to help?”
“Of course you can come back—for years if you want to.”
Self-Esteem and Attachment
While Kessa and I did discuss the topic of being helped, we did not explicitly discuss the concepts of trust and dependency, or even attachment. We would first have to form a connection that would give these concepts real meaning before we discussed them. At our initial session, a discussion about these issues would have been purely intellectual. Intellectual discussion does not serve to create the kind of relationship that fosters the development of trust, dependency, and attachment.
The therapeutic relationship is of utmost importance here. If the therapist can prove to the patient that he is both worthy of her trust and dependable enough to form an attachment, then the patient can take what she has learned outside the office, and build positive attachments with others as well.
What transpired between Kessa and myself during our first session was implicit. My talk and tone suggested that she could risk attachment and trust. Her talk suggested her cynicism, but also a fear that these ideas could leave her vulnerable to harm. It is ironic to think that Kessa, who was harming herself the most, could be frightened about someone being capable of harming her. Of course, she preferred the harm she knew to the harm she didn’t.
I continue to find that a self-mutilator has a poor ability to form attachments to others while, paradoxically, she has an excellent ability to encourage others to form attachments to her. She can be an excellent listener, and nurturer, to others.
Kessa had many friends, but the relationships were all one-sided. She knew them on a deep, personal level, while they never even asked about her. This arrangement suited her perfectly.
Self-mutilators rarely allow others to achieve emotional closeness to them. They have a powerful sense that they could only be harmed by the closeness of others. Some of them have experienced harm at the hands of those they were supposed to trust the most—their parents.
In cases where actual physical or sexual abuse has occurred, the self-mutilator’s original adaptive behavior of emotional distancing makes sense. Though this defense will become obsolete as she outgrows the age and circumstance where there was a real threat, she will continue to keep her guard up as a result of what she learned in her formative years.
Sometimes the abuse is purely verbal. The child is insulted and criticized more often than she is complimented and supported. In this scenario, the same negative set of expectations of other people is created. With verbal abuse, the damage to one’s willingness and ability to form attachments is slightly less severe and leads to fewer and milder self-destructive symptoms. Low self-esteem, however, will be a lingering result of abuse whether it is verbal or physical.
Low Self-Esteem
Low self-esteem has a direct impact on patterns of personal attachment. The individual with low self-esteem is prone to forming attachments with persons who are abusive to her or needier than she is. She believes that she deserves this behavior and unconsciously or unwittingly invites it. Another feature of the self-mutilator’s personality, then, may be the tendency to establish abusive relationships that are reminiscent of “home,” familiar, and in keeping with her childhood experiences. One component of this phenomenon is that security and pain have become fused.
This fusion of pain with security causes her to “treat” her feelings of insecurity, loneliness, and fear of abandonment with self-inflicted pain, which temporarily produces security and even tranquility. The self-mutilator, then, is someone who trusts only her pain because she connects it with “home.” When she is older and in emotional trouble, she does not turn to another person to express her grief, but to the pain, because she can assure its presence. It is the most reliable relationship in her life, and the most familiar.
How Shame Interferes with Attachment
We have seen, in previous chapters, individuals who have committed acts against themselves which caused them pain and did physical damage to their bodies. In the cases of Jessica (chapter 2), who was sexually abused, and Tracy (chapter 5), who was beaten with her father’s belt, we saw how such individuals have explicitly used this physical pain and self-destruction to make their psychological pain go away.
Any attempts that these young women made at self-disclosure were accompanied by shame. Both had difficulty describing their behavior, and in both cases they had never shared this information with anyone else. Each of them took approximately a year in therapy (following years with other therapists) to finally let out these secret behaviors they had been so ashamed of.
In Jessica’s case, her behavior involved irritating her genitals with soap. This is not something that most people could readily discuss with a friend. Tracy’s behavior of cutting herself with the buckle of the same belt her father had used to beat her with was equally difficult for her to reveal. Imagine the shame at having to discuss this information, and the fear of the listener’s possible reaction to it. This gives us some idea of how a self-mutilator’s isolation and lack of personal attachments become a self-perpetuating cycle.
Another factor that comes into play is the effect that the years of secrecy—the years of hiding self-mutilating behavior—has on the developing personality. The sense of shame spreads from the specific act of cutting to a general sense of shame about oneself. For Jessica, this constant state of being ashamed, coupled with the shame surrounding the original acts of childhood rape that she endured, combined to create a general sense of self-loathing. The conflict caused her continually to sabotage any chance of success she might have at any job, or in any personal relationship. This ambivalence came out in her therapy when she became sulky and answered questions by equivocating, thus stalling the progress of the therapy. Unconsciously, she may have felt that she did not deserve success, even in overcoming her psychological problems.
This kind of patient poses special difficulties since she is both a danger to herself and a saboteur to those who wish to help her. She is constantly fighting the attachment she wishes for with her therapist. She knows, intellectually, that he is not a danger, but psychologically and emotionally he does represent a danger because trusting him would cause her to reorganize and possibly give up her defenses. This last danger can be the most threatening of all.
In some cases, the fear is not that an attachment to the therapist would lead to an undeserved cure, or the dismantling of her coveted symptoms, but that the therapist would be rejecting. As we saw with both Tracy and Jessica, one reason the self-mutilator lacks personal attachments is that she avoids even attempting them for fear that if someone got to know her, they might be shocked, repulsed, and rejecting of her.
This fear extends to the psychotherapist as well as friends. Recently, I have received several calls from parents of girls who have been cutting themselves. In each case, they have consulted non-medical psychotherapists (only psychiatrists have a medical degree). When the therapist was told that the patient was a cutter, they declined the case, expressing that they didn’t “have any experience with this kind of problem,” or that the child should be seen by a psychiatrist. This made both parent and child feel rejected, lost, and hopeless about obtaining successful treatment.
Like the glib Mildred (chapter 4), who insisted that she was “too much” for me because she felt she had been too much for everyone else (or so they allowed her to believe), including three previous therapists, the rejected patient feels that she cannot be helped, that she is a psychiatric “freak.” This sort of discouragement can worsen her symptoms. It also throws into turmoil the secret wish for a helpful attachment. Ultimately, what I call the attachment-dependency-trust axis is crucial to recovery from cutting or burning behaviors and all the personality deficits and disorders behind them. The task of the therapist—and ideally of the parents, too—is to form a relationship based on trust that encourages dependency and leads to a healthy attachment.
This is the only way the patient will finally find the courage to abandon her self-harming behaviors and learn to form such a healthy attachment.