How many years does it take to develop the disorder of self-mutilation? How many years does it take to undo what has developed? The answers vary from person to person. When we examine the factors that influence the manifestation of self-mutilation in its victims, it is easy to see that time is integral to both the formation and the dissipation of these behaviors. This chapter will identify the kinds of energy, length of time, and styles of connecting with the patient required from those who would help her to change, both behaviorally and emotionally.
What are we trying to change? Again, the question must be posed differently for each person. The goal is to free the self-mutilator from physical, self-harming behaviors. These behaviors must continue to be monitored by the helper; lack of mention by the cutter can’t be assumed to mean that the cutting is gone. Emotional distress, and areas of emotional and mental impediment to functioning in the world, must be discussed and made part of the goal of recovery.
In chapter 10, The Family System, we saw some of the circumstances that can plunge children into situations and thoughts upon which they can construct a world of ideas about themselves—what they “deserve” from others and life; how positively or negatively they should feel about themselves; and how they should treat themselves. If on balance such children develop negative ideas about themselves, through lack of spoken support by family members, they will believe that they deserve whatever negative behavior is directed toward them; not only will they accept that behavior but they will perpetuate it, and provoke it with family members and others, later on in life.
Familiar Ground
In individual psychotherapy, we want to change the expectations of the self-harming person by “depriving” them of negative and harmful verbal, or physical, responses from the therapist. Take, for example, a woman who had been a sexually abused child. In the middle of a session she suddenly proclaimed, “It’s too hot in here,” and took off her sweater, leaving her in a scanty bra. I reached for the afghan I usually keep on the side of the couch for my anorexia patients suffering from hypothermia, and draped it over her.
“There will be no abuse or sexual exploitation allowed you here,”I said. Then, in a lighter tone, I added, “You may not be here just in your underwear.” She became upset and embarrassed, put on her sweater, and left the session.
Several hours later she called me to apologize. I told her that I believed that she expected every male to want to exploit her because then she was on familiar ground. She said that was indeed the case, and that she didn’t know what to do if that element was not a part of her relationship with a man. I explained that the absence of the abuse she had become accustomed to was confusing, but she would get used to it, and that I believed that if I deprived her of the abuse, she could learn how to deprive herself of cutting.
In this case, we are trying to change the expectations a self-harmer has for relationships that she developed during her formative years, which resulted in cutting herself, and sabotaging herself in many other ways. Here, individual psychotherapy is a long and arduous process for the patient. It can be sped up or shortened somewhat if family therapy is another component of treatment. The more significant people in her life who are involved in changing the patient’s expectations, the more effective the treatment. In cases of verbal, physical, and sexual abuse by members of the family, apologies by the offender(s) are therapeutic, especially when they take some responsibility for their errors, removing as much self-blame as possible from the victim of this abuse.
Predictors of Recovery
The more people who are available as resources for treatment, the more powerful the treatment becomes. Again, what we are trying to fix are the self-destructive behaviors, the provocations sometimes initiated by the victim unconsciously, and the very nature of relationships that are being constructed in the present. We, of course, have to put the history of the individual in perspective for the self-harmer so she can better understand her own behavior. This is accomplished by an insight-oriented review of the individual’s life.
There are many barometers we use to estimate how optimistic we can be about change; how much time that change will require; and how much change we can hope for.
These barometers are a function of
—The child’s age when parental dependency, neglect, or abuse began.
—The frequency of each of the above.
—The severity of the misconduct in abusive cases or the intensity of the neediness of the parents in benign cases.
—The present support system of the individual: “Is life good enough to be worth getting better for?”
—Has the individual gone on to become seriously involved with a supportive person upon whom she can depend and trust?
These are only some of the ways we can estimate chances and degrees of a successful psychotherapeutic outcome. Other issues include hereditary-chemical factors and any additional psychiatric diagnoses and symptoms. Any other disorders present in the patient usually develop from the same core issues and can precede self-mutilation, which often develops after other diagnosed problems have emerged.
If a child first experiences neglect as an infant, she will adjust to the lack of attention, to not having her needs for holding, feeding, and being changed met, by lowering her expectations of care. Neglect results in depression at any point from infancy on. If a child is sexually hurt or stimulated by a caretaking figure, she (or he) will expect the same from all those in either caretaking or authoritative roles.
The infant or toddler is in no position to make moral judgments about these events, or her responses. It is only later on, toward puberty, that the child will sense the conflict between societal values regarding sexual behavior and her own early experiences. She will then be able to recognize that the neglect or abuse from a parent or caretaker is inappropriate. It is at this point that she will begin to devalue herself as someone who has accepted societal taboos. Her shame and lowered self-esteem will influence not only her relationships with others but how she relates to and manages her feelings about herself.
Here we need to reiterate the concept of a continuum from benign parental neglect—which consists of subtle messages of neediness, emotional exhaustion, or depletion—at one end of the scale all the way to the abusive behaviors I have described at the other extreme. It would be an error to assume that all self-mutilators come from families where cruelty and abuse are present.
We cannot change causes rooted in someone’s past, but we can make changes in the present that will correct the need a person has to act out their characteristic symptoms, and so help to heal their negative self-image.
Influencing Change
There is a lot of advising and threatening on the part of family members and the health care profession, from physician to psychotherapist, as they try to influence the cutter to recover. Such threats and advice go unheeded by the cutter. The reason for this is the unwitting assumption of the adviser, or threatener, that he is talking to a reasonable person. A healthy personality responds positively to guidance, especially guidance that is highly consequential. In the case of the self-mutilator, we are not dealing with a healthy personality. The self-mutilator is not making choices with emotional freedom. Often she is not even aware of the actions she is taking; and when she is aware, she still feels compelled, choiceless, in the matter.
If advice, guidance, and threats are useless, what kind of communication is useful and will promote change? The prerequisite for the helper is to develop influence with the self-mutilator. Influence is not easy to come by with a person who has learned from her life experience to be wary of everyone—especially if they are in a position of authority or potential authority. This is particularly true for people who were the victims of abusive, pathogenic (illness-causing) behaviors and acts during their earliest development (from birth to two). This group is likely to find it the most difficult to recover. These are the ages when pain is readily fused with attachment, often resulting in psychotic episodes and severe personality disorders.
Ages three to nine are still powerful formative years, and when repeated pathogenic behaviors are directed toward a child during these years, no matter how subtle, that child makes an unhealthy adjustment to them that will emerge as both a personality disorder and a behavior disorder—the identified problem such as self-mutilation or anorexia that results in their being sent into therapy.
Though it is unusual, when abuses described in anecdotes are sporadic or highly infrequent—say, four times a year—the child is more likely to develop phobias, and anticipatory anxiety attacks, waiting for the abuse to be repeated the next time. This situation presents the least difficulty to treat and resolve. Note that I do not say it is “easy.”
Patients Who Are More Difficult to Treat
Patients who have suffered from severe abusive or assaultive behavior will always be the most disturbed, most difficult to treat, requiring the longest treatment time (nearly a lifetime in some cases), and offering the poorest outlook for recovery. This is not to say that recovery is impossible, but it is very difficult.
In more benign situations, when parental neediness, expressed to a child, “drafts”that child into a caretaking position vis-á-vis her own parents, she is likely to feel resentful and deprived. A lack of supportive messages from her parents will lead to low self-esteem, with no way to redress her grievances. She cannot hurt the parents that she worries about and resents at the same time. So she will hurt herself. This kind of situation is characterized by the patient who feels she can’t get angry at anyone but herself.
Some individuals come to treatment living lives that are devoid of support: their parents are ill or deceased, money is lacking, and there is not much hope of improving the situation due to lack of sufficient education and/or friends. This is one of those times where unless a plan is generated for the patient’s life to improve, there isn’t much incentive for her to overcome her problems and behaviors. One factor in this formula is whether or not the person can depend on someone else in her life—a lover, spouse, parent—who has become healthier since the patient was a child, to support and assist her recovery.
Neurological Impairments
In discussing psychological disorders, we cannot overlook certain other aspects that affect the development of the disorder, and the outcome for recovery. I am referring here to organic problems, which we classify as neurological impairments stemming from the improper functioning of neurotransmitters, most prominently, serotonin. If individuals do not have sufficiently active serotonin, they seem to suffer irritability, anxiety, and depression. If one adds to the provocations already listed insufficient serotonin activity in the brain, we have a heightened sensitivity to mental pain that will exacerbate all of the dynamics previously discussed.* The implication of this organic problem is that certain individuals in treatment will require some form of antidepressant, sometimes coupled with a tranquilizer (benzodiazapine).
What we do not know at this time is whether “chemical” and “hereditary” forces are in fact the same. We do know that trauma during the formative years (and later) can affect the brain’s chemistry, but at present there are no conclusive medical tests to evaluate a patient’s need for medication. So, therapists look for the persistence of depression and anxiety. Medication is attempted by trial and error: a patient’s response to medication becomes an indicator as to the need for it. Psychiatrists who specialize in medication (psychopharmacologists) are best equipped to make this assessment.
Another issue affecting outcome in treatment is the fact that self-mutilation is often the last symptom to appear in a chain of symptoms and diagnoses. Those that preceded its appearance are significant. If a person is diagnosed as having a borderline personality disorder, the issues involved in improving or recovering from this condition are interwoven with treating the self-mutilation. The same is true for major depression, especially if it includes suicidal ideation (ideas). Other symptoms that often accompany the self-mutilating behavior may include substance abuse, eating disorders, anxiety disorders, and so on.
If we remember that self-mutilating behavior is a symptom for releasing discomfort, emotional pain, and other grievances, we need to realize that the self-harmer must learn other, healthier ways of expressing discomfort and emotional pain. Talk, trust, healthy attachment, intimacy, and secure communication are the necessary building blocks for change.
As we see that the roots of cutting, burning, and other forms of self-mutilation go deep and far back into a person’s emotional history, we can understand that the amount of emotional energy the self-harmer will have to expend in order to change their characteristic self-destructive behavior is enormous. There is no question that the helper (whether therapist, friend, or family member) must be prepared to expend a fair amount of energy, skill, and knowledge in turn to provoke and facilitate that change.
*See Peter D. Kramer, Listening to Prozac (New York: Penguin Books, 1993).