Pain as the Goal
It takes quite a stretch of the imagination to understand why a person might seek out pain and her own wounding as a solution to her mental and emotional suffering. Though we all put up with the pain inherent in dentistry, say, or childbirth, or surgery, pain is the unwanted by-product of these experiences. The pain is endured for a positive outcome—the repairing of a tooth, the birth of a baby. The role of dentistry and obstetrics is to minimize the pain; in self-mutilation, pain is the goal, not the by-product.
A certain amount of pain in life is inevitable. If we try to insulate ourselves from all pain, we become numb. Repression, which is the process of pushing unacceptable feelings out of one’s awareness, doesn’t really make negative feelings go away, but rather will channel them into disguises. Sometimes these disguises show up as psychosomatic symptoms like headaches, backaches, stomachaches, high blood pressure, and so on. Other times the disguises are psychological symptoms that may take the form of moodiness, depression, or anxiety. These may, in turn, develop into serious behavior disorders like anorexia, trichotillomania (hair-pulling), or self-mutilation.
Cutting: An Act of Anger
A cutter who has been abused often employs the psychological defense of self-mutilation. She is in fact using physical pain, with which she is familiar, to ward off emotional pain. One of my patients—Lynn—as a child experienced frequent and extreme sexual abuse. She was in a constant state of emotional pain. This kind of pain is overwhelmingly complex and vague, and because it is undefined, it cannot be reasoned with, it has no name. Lynn’s emotional pain seems to have an infinite life. In order to control it, she creates physical pain, which is finite and results in a state of calm.
The infliction of pain on oneself is often a substitute for anger toward another, and possibly the unconscious desire to inflict pain on that other person. Consciously inflicting pain on another person is forbidden for a variety of reasons: the fear of the destruction of a needed person, or the fear of loss of love or care by that person. So, cutting may indeed be an angry act, which temporarily (and fictitiously) redresses the cutter’s grievance with the other person.
Cutting: An Act of Self-Medication
When the body is injured, hormones called endorphins are released to fight anxiety, agitation, and depression.* The self-mutilator may be combining depression, anxiety, and past history (during which she was the recipient of harm at the hands of others) in order to become the architect of her own pain. By determining which punishments to dole out, she can take charge of her worst experiences. The chemical interplay can produce an addiction to the “drugs”manufactured by one’s own body. This suggests an attempt at self-medication of one’s mood disorders.
When we see a patient who cuts, burns, or in some other way does physical damage to herself—exempting direct suicide attempts, with which self-mutilation has sometimes been confused—she is acting in a state of severe mental illness.
What Is the Cutter Thinking?
We have already seen some of the different ways that individuals injure themselves. As great as the variety of tools and methods used by these self-injurers, equally varied are their states of mind when they either set out to hurt themselves, or do so impulsively without premeditation.
There are those, like Lynn, who are a living example of someone whose earliest interpersonal experiences are interlaced with pain. They slip into the trancelike states I have mentioned, and some don’t even remember the event, although most do. Here is Lynn’s description of one such episode:
“I don’t remember what happened. I just know that I ‘woke up’ parked on the side of the road and it was four o’clock. I was sure it was one o’clock, but I had lost three hours. My left arm was high on the steering wheel and it was covered with nearly dried blood, running from near my wrist all the way down to my underarm. Some had overrun my short-sleeve shirt and gone down the side of it. It seemed like a lot of blood, but after years of doing this, I looked to see if it had formed a pool anywhere. It hadn’t, so I knew that I hadn’t lost a dangerous amount, but it looked so gross!
“I found my little penknife on the seat beside me: the blade and handle were covered with blood. It was all so sloppy. That may sound crazy to you, but it matters to me how I do it. It’s kind of like being double out of control. Cutting myself may sound crazy or out of control to you, but how I do it should be in control. If I ‘space out’ on my bed and wake up three hours later, it’s like I took a nap—not so bad. But if I ‘wake up’ behind the wheel on the side of the road, maybe I picked up a hitchhiker who raped me and left. Then I have to wonder, did I space out in the middle of the rape, if one happened, and if I did, did he quit and leave or not?
“So then I have to check my clothes and underwear for signs of ‘him’, whether I’m disheveled or not, whether there’s semen there or not. I have to treat this like a police investigation—but I never would go to the police. I have found evidence of rape before; not this time. If I went to the police, I would have nothing to tell them except, ‘Pardon me, but I’m given to amnesia and I was raped during my last episode. Can you help me?’ How stupid and crazy would that sound?”
Trading Pains
Lynn’s self-mutilation would continue to benefit her by acting as a constant shield to separate her emotionally from the assaults she remembered experiencing during childhood, as well as the feeling that there was “nobody out there” who would ever protect her. Since talking about this in therapy might produce those old feelings, I was concerned that the therapy itself not provoke additional cutting. We kept “memory discussions” down to ten minutes of any session and monitored her behavior between sessions.
Lynn had been raped by her baby-sitter’s boyfriend from the time she was six until she was eight. Like so many other child victims, she was told by the seventeen-year-old boy that he would kill her if she informed her mother. Lynn’s mother had to work full time to support them since her father left them penniless when Lynn was five and a half. She was not only afraid of the boy’s threat but understood that if her mother had no baby-sitter, she could not go to work, and then they would be out on the street, as her mother had often said when Lynn asked, even pleaded with her mother not to leave for work on a given day.
Since there was no one to protect her, Lynn had to retreat inside herself and find ways to cope with the nightmare her life had become since her father left. She did what many incest victims do who feel hopelessly trapped: They “go away” during the assault. If she is lucky, she invokes amnesia so well that she doesn’t remember the event. Then, if the assaults continue repeatedly, she begins to utilize amnesia for other and lesser conflicts. Eventually, it becomes involuntary a good part of the time.
In these situations, Lynn’s cutting herself without feeling it became the first step in her “going away” by proving to herself that the “mental Novocaine,” the numbness, had taken effect. The cutting would take place after an assault. The rape of a child by an adult is not only terrifying but extremely painful. It is this pain caused by the rape that is used as the trigger to invoke “going away,” “spacing out,” or creating a dissociative state—amnesia—to spare the victim her terror, pain, humiliation, and feelings of helplessness. These feelings would create deeper flights from reality, perhaps even permanent flights, or psychosis.
Other cutters are not necessarily fleeing the grotesque experiences suffered by Lynn or Jessica (chapter 2). Theirs may be milder physical abuse by parents.
I am aware that the word “milder” when discussing parental- or sibling-generated abuse appears to degrade the intensity and horror of this kind of experience, but I am trying to create a continuum necessary to distinguish between levels of symptoms, of mental illness, and the environmental provocations involved.
As problems continue for the cutter, she retreats further into herself. In this way, she can block out past memories and experiences without turning to another person for help. Her childhood experiences have taught her that others are never much help or protection. As she turns more deeply and more frequently inward, she simultaneously cuts more often and more severely. At the severer end of this process, Lynn would be prone to go into dissociative states to protect herself from her feelings more often. At this point we would diagnose hers as a dissociative disorder as well. This places her at the most pathological end of the continuum.
The American Psychiatric Association defines dissociative disorder as follows:
The essential feature is sudden temporary alteration in the normally integrative functions of consciousness, identity, or motor behavior. If the alteration occurs in consciousness, important personal events cannot be recalled. If it occurs in identity, either the individual’s customary identity is temporarily forgotten and a new identity is assumed, or the customary feeling of one’s own reality is lost and replaced by a feeling of unreality.*
In the case of nondissociative cutting, where numbness is not the goal but feeling the pain is, I often find the provocations to be related to feelings about others in the person’s life. Perhaps the nondissociative cutter is marginally healthier than the dissociative cutter.
Love Hurts
Sonia (chapter 3), the cellist whose mother dug her fingernails into Sonia’s bow arm when she made mistakes, still loved and was attached to her mother. She also feared and distrusted her mother. When her mother said that the punishment was “for your own good,”Sonia tried to believe her. She incorporated this idea so that when she made mistakes but was not in her mother’s presence, she would either dig her own nails into her bow arm, bite herself there (she did this once in my office waiting room after a session where she felt she did a poor job answering my questions), or scratch or cut herself with a penknife small enough to fit on her key chain but effective enough to draw lots of blood.
Sonia was psychiatrically on the cusp, exhibiting signs relating to both the dissociating and the nondissociating self-mutilator. She spaced out, but at the same time needed the pain as part of her “conscience,” or connection to her mother. Her behavior was intended both to maintain this connection and to express her self-loathing, using her mother’s criteria. She was not conscious of or able to feel anger toward her mother’s Draconian rules for failure. This would come later in her therapy.
Sonia was also bulimic. When she purged, she was unconsciously expressing anger not at herself but at her parents. When she became conscious of her anger toward them, she gave up her bulimia. (This is not to state that anger toward parents is the only reason for the development of bulimia.)
The Payoff of Pain
Carla (chapter 6), who suffered from anorexia and depression, cut her arms and breasts when she was angry at herself, or felt anger toward her parents but believed them both to be too emotionally frail to deal with her hostility. Their marital discord made each of them unhappy: her father developed a stutter and her mother became withdrawn. Carla’s cutting was designed to create the most pain with the least damage to herself.
This satisfied Carla’s need for an outlet for her disappointment and anger without directly hurting her parents. She stated earlier that the areas that she was cutting were selected because the skin was most sensitive to pain. Carla’s cutting falls into the nondissociative, non-amnesia-inducing, consciously pain-seeking category. This part of the spectrum suggests a sad, angry, but more mentally integrated personality than the earlier examples.
The Exhibitionist—and Secondary Gain
At the opposite end from the dissociative cutter is the cutter who is not at all secretive about her activities, and sometimes even exhibitionistic. She is damaging herself in full view of the world. When others around her find out what she is doing to herself, they become frightened for her, sometimes angry at her, while expressing their worry and helplessness to her. This intense focus and attention is gratifying in its own way, despite the fact that anger, worry, and fear are what we call negative attention. She also feels more powerful when she commands this type of attention. This emotional dynamic is known as secondary gain, a familiar concept in child psychology.
Think, for example, of the child who misbehaves in school because he’s not getting enough attention; singling him out for frequent scoldings makes him feel important. The ability to stop the teacher and the class from normal functioning and focus on him rewards him with feelings of power. The gain is called “secondary” because the primary reason for misbehaving is usually another problem, such as a learning disability or a troubled home. Secondary gain occurs when the child starts to notice the benefits that occur as a result of misbehavior. Thus the scoldings reinforce, rather than discourage the bad behavior, by making him feel important and powerful.
When the cutter experiences secondary gain, she is getting benefits because of her sick behavior. Secondary gain is unconscious, which means that she has no awareness of her motives. The cutter who exhibits rather than hides her symptoms is not a phony. She has simply discovered that negative attention is better than none. Also she has attained a sense of powerfulness which may be in sharp contrast to the helpless feelings of her childhood.
If we have to decide who is the more pathological, or sicker, the dissociative self-mutilator or the secondary gain self-mutilator, the former is in even more trouble in terms of recovery. But we must understand that all self-mutilators are in serious psychological trouble.
Becoming Comfortable with Pain
If, as a reader, you have been able to stay with this text until now, without skipping pages that are too painful for you, then your capacity to deal with the graphic details of self-mutilating behavior has been expanded. In fact, you have probably been desensitized to cutting, burning, and bleeding far beyond where you were when you started this book.
It is much the same for the cutter. She gradually becomes desensitized to her existing repertoire of self-harming behavior. Unfortunately, she has increased her capacity to become dependent on greater self-harm, while you as a reader have become capable of coping more easily with this subject. It is vital for the therapist who treats such a patient to understand this phenomenon, because reactions of shock or dismay about the cutting make her feel incomprehensible to the very person she has turned to for understanding and help.
As the connection between patient and therapist becomes stronger, the benefits of self-wounding become weaker. Later, we will see how the therapist can finally help the patient to exchange her pain for personal attachment.
*See Hans Heubner, Endorphins and Anorexia (New York: W. W. Norton, 1994).
*I have used the older description found in the Diagnostic and Statistical Manual’s 3rd edition (1980), since I believe it to be more concise for our purposes.