How do we get a frightened, ashamed, guarded person to reveal herself to us? To make the task more difficult, she has not developed a language with which she can talk about herself. She has not grown up around others who permitted or role-modeled talk about their own feelings, their complexities, their conflicts in a manner that the child could hear, understand, and depend upon for support.
Typically, a self-harmer appearing in a therapist’s office has nothing to say. She prohibits herself from complaining about others, or accusing them; to her, that’s immoral. She can’t complain about herself; that’s being weak. She can’t analyze or interpret what goes on inside her head, or between people she lives with, or peers she is friends with, because she has no vocabulary for this. She experiences her feelings of anger (when she can feel them) as dangerous.
More than likely the self-harmer sits down on a chair or couch in a therapist’s office and often presents a blank stare, waiting for the therapist to speak to her. She typically has been referred to the therapist. She often doesn’t even know why she is there.
Breaking the Ice
It can indeed feel as if there is no way to start the session that won’t sound chatty, patronizing, or worse, threatening. The way around meeting someone who offers no invitation or opening to converse is to keep in mind the description of her mental state and outlook offered above. This will enable the therapist or counselor to provide the generosity that the patient needs. It is important that the therapist not have expectations for the patient to talk much, if at all. This will be a long-term therapy because its goal is to build up facets, communication skills, reflection skills, into a personality riddled with deficits in these and other areas.
The therapist, then, is the builder, the more active and sometimes the only active member of the pair.
Not all cutters present with such extreme communication deficits as the blank slate patient, but perhaps it is best to start with the most difficult. Other versions of the cutter are the false self, who lacks genuineness, and says a lot, but nothing meaningful; and the deflector, who dodges every personal question by telling an irrelevant story about someone else.
But let’s return to our blank slate patient, who doesn’t try to fool or distract us, just offers us nothing to respond to. Well, not exactly nothing. She presents an appearance in terms of body language, and facial expressions, that is open for comment. Such comment should focus upon unstated conflicts that her nonverbal communication suggests. Remember my earlier exchange with Emmy (chapter 11) who wore the cufflinks.
The Silent Beginning
Fon arrived in the United States from Hong Kong when she was nine years old. Her father never sent for her mother. Shortly after his arrival, he married another woman. Fon was lost on Mott Street, bereft without her mother, and furious because of the new woman in her mother’s place. She spoke only Cantonese up to that point and was enrolled in an elementary school in New York’s Chinatown where she was teased by the first-generation native-born Chinese child, who called her “Foreigner” or Ju kok.
At home Fon was passively uncooperative; she did the dishes slowly, cleaned up after herself poorly. By the time she had reached seventh grade, she began to faint in the hallways during changes of class. She had to be carried to the school emergency room, where she would open her eyes but make no complaints about the way she felt. Her family was notified that she needed to go for a physical examination to determine the cause of these fainting episodes. They were afraid of government agencies, and the public school was considered allied with these agencies, so they complied.
On examination, Fon was given a clean bill of health, though bruises made with blunt instruments were found on the backs of both hands, her arms, and her legs. They were not serious, and the prevailing attitude at that time, twenty-five years ago, was that it was difficult for municipal services to enforce extensive cooperation from the Chinese community, which “took care of its own.”
Fon was referred to me for school-based counseling. She came in to the office suffering from all the deficits mentioned above, as well as being limited in her ability to speak English. She had been in the United States for nearly three years but lived in a community where one was encouraged to speak Chinese outside of school.
Fon sat before me with a severely forlorn look on her face. She made strong eye contact with me but her eyes were set in a complex expression that I would have to call “angry defeat.” Her lower lip protruded upward, raising her upper lip a bit. In her lap, clenched tightly with both hands, was a Chinese-English dictionary. She wanted to communicate. I kept my sentences simple.
“You look unhappy.”
She stared away from me and tightened her face muscles.
“Now you look away. You don’t want me to see your unhappiness.”
She looked down at her dictionary.
“You want the book to talk to me about you.”
She lifted the book several inches above her lap and subtly slammed it back down again.
“You are mad at the book.”
She looked at me again. “I . . . am . . . mad . . . at . . . me! Myself is no good.”
I argued, “You are alone.”
Her eyes welled up. Several tears fell. “You see . . . no good! Good person not alone!” She nodded repeatedly.
I understood that her “no good” was her linguistic and culturally impaired way of saying volumes. I had to help her develop her ability to speak them, one page at a time.
I noticed black and blue marks on the back of her left hand. The doctor’s notes had listed the bruises on both hands, suggesting abuse by another person. “What caused that?” I asked her, pointing to the back of her hand.
“Always there,” she responded.
“No, that is not possible. That is caused by a blow.”I hit the back of my left hand with my right. “Then it will go away, unless there is another blow.”
“There is always another blow,” she replied sourly.
“Why?”
“I told you, myself is no good. Hitting hand show that.”
“Who hits your hand?”
She shrugged her shoulders, looking down. “Many people.”
“Which people?”
“My father, my, um, stepmother. I hate her. I am mad at him. He not have to marry her.”
“Who else hits you?”
“I hit me—harder than they can. Then I can be right.”
“You are ‘right’ because you do to yourself what they do to you?”
She smiled and nodded defiantly.
“Why do you close your eyes and fall down?”
She looked surprised that I knew about the “fainting.”
“I don’t know why. Is good for me.”
“It makes you feel good?”
“Everything goes away. I don’t like when it’s over. Everybody talk to me and ask me questions I don’t know answer. Then everything bad is back in my head.”
“What is in your head?”
“I don’t know . . . but it bad, very bad, bad about me.”
“You are sure that what is in your head is correct?”
She looked at me as if I had said something foolish.
“Of course—it is in my head. How not correct?”
“How do thoughts get into your head?”
She shrugged her shoulders, turning her palms out and up.
“I will tell you how thoughts get into your head.” I raised my voice authoritatively, making intense eye contact and nodding my head for emphasis. She looked surprised but attentive as I continued.
“How did you learn words, to speak?”
“I don’t know.”
“When you were a baby, did people around you tell you the words? Did you hear the words from them? Did you learn the words from them?”
“Yes.”
“If you grew up among silent people, people without talk, would you have words in your head?”
“I don’t know.”
“When you were a little girl in Hong Kong, were there English words in your head?”
“No.”
“How did the English words get there?”
“English people put them there.”
“Who put the Chinese words in your head?”
“Chinese people,” she conceded.
“Which Chinese people?”
“My mother, my real mother, and my father.”
“You copied the way they talked to you?”
“Yes.”
“Did you copy what they said about you, and put that in your head?”
“Maybe”—she paused pensively—“but they are always right. They are my mother and father.”
“The words in your head that tell you bad things about yourself, did you ever hear these words, these sentences from anyone else?”
“Yes, but they are correct. My parents could not say what is not correct even if I hate what they say. New mother is not true, but my father and real mother are true.”
“What do these ‘true’ people say to you about yourself?”
“They say I’m bad girl.”
“Tell me the sentences they use.”
“They say, ‘spoiled girl, ungrateful girl, girl should be sold to another family. Other family would own her, make her work harder.’ I know nobody can like me, no good. See. I tell you before! If my parents cannot like me, only a fool can like me. Not true like. I am smart. I don’t like me, too.”
“You hit yourself, too. You fall down in the hallway. Where did you get the idea to fall down and close your eyes?”
“Sometimes I don’t want to feel ‘bad girl’ ideas. I have to go away from myself.”
At this point I was treading on dangerous ground. I was treating someone who grew up in a culture where parents are venerated, and I wanted to challenge what she had been taught by them. If I faced this task head-on, she would distrust me. I was, after all, a Caucasian therapist who spoke a foreign language to an Asian girl who spoke and thought in Cantonese. I could hardly be considered a valid competitor for those who gave her negative identity messages, probably in reaction to her acting out on her father and his new wife.
Yet if I could not reach into Fon’s sense of trust and belief system, she would probably become a more serious self-injurer and develop other symptoms. I had to stress growth and not change; change would imply betrayal of what her parents had taught her. Growth would merely be adding to what she had been taught.
“So, English people put new words in your head. Did they erase the old Chinese words?”
She shrugged her shoulders.
“No, maybe not.”
“Maybe I’m going to put more English words in your head.”
“What English words? Maybe not good English words.”
I leaned forward. Our faces were two feet apart. I smiled sympathetically at her and answered her unasked question. “No, they will be good words. You need good words.”
Her eyes became watery again. She blinked hard to keep back the tears.
“Bad girls must have bad words.”
“I will decide if you are a bad girl or not.”
“I know. You cannot decide.”
Her voice rose. Her tentativeness was clear. The ice was cracking. It was presumptuous of me to suggest that I could usurp her preexisting thoughts and ideas.
Two days later, I walked to my desk and found an envelope on which was neatly printed: MR. LEVENKRON. I opened the letter.
Dear Mr. Levenkron,
I am like a bird with a broken wing. Mother bird throws broken bird out of next [sic]. No other birds want it. It is let to die. I don’t like broken wing. Can you fix wing?
Sincerely,
Fon
I was surprised and relieved by the letter. Fon had apparently used her Chinese dictionary to talk to me. Instead of seeking supervision from a colleague for this unusual case, I signed up for a course in “Spoken Cantonese” at the China Institute in America, on Manhattan’s East Side. I knew that I would need more credentials to gain her trust, to attempt to treat her.
I talked to Fon for the three years she was in the middle school. Her English improved at a far greater rate than my Cantonese. She always wrote to me in between talks. Her written English improved but her endearing Chinese idiomatic way of writing never changed. I always cherished her style.
She stopped hitting herself. She stopped referring to herself as a “bad girl,”and went on to a high school for gifted girls. She never did make contact with her mother, who presumably remained in Hong Kong. In her last letter, she wrote about a boy she was seriously involved with and hoped that they would go to the same college.
Reaching In
What was the aspect of Fon’s treatment that helped her transform her self-image as a bad person to one deserving of success and happiness? It was her ability to communicate her inner thoughts and feelings and have them validated by an interested person. By talking to me and finding that she could trust me with her worst thoughts, Fon was able to use her healthy attachment to me as a bridge away from her isolation.
Thirty years ago, beginning therapists were warned about the Rescue Syndrome. This was a caution that we not aggrandize our roles beyond helping patients clarify their problems. The modus operandi was that the patients must work, on their own, to change their behavior. To do more than this was to become directly involved in their lives, to become “real” people to them. An active role for the therapist was (and still is in some psychoanalytic circles) frowned upon because it might cause patient confusion and blend the therapist into the mix of their problems, “excusing” them from their own responsibility to create change within themselves.
Today’s patients come to us with fewer support systems than ever: no extended family; broken, subdivided, blended, and reorganized nuclear families; sometimes repeatedly exhausted and depleted single parents. In addition, there is little or no sense of community, and less faith in religious institutions. It still remains the responsibility of the nuclear family to be the primary resource. If this is not available, today’s psychotherapist is often drafted into the role of surrogate, therapeutic parent. This implies, if not outright rescuing, assisting, advising, then sometimes intervening on behalf of the patient, if she is a minor, with individuals and institutions. All of which is a far cry from the analytic couch of the last generation.
Self-mutilation also demands a team approach, including physicians and often psychopharmacologists who will evaluate, and prescribe medication where necessary. This means confidentiality is more defused among those who will be involved in helping the self-mutilator. It does not mean that the contents of the therapy session go beyond those clinically participating in treatment.
“Reaching in” implies such nontraditional concepts as intruding into the patient’s ideas about herself, where they involve areas of erroneous negativity about appearance or intelligence, likability, and so on, and contradicting them. Such a move will be met with resistance, but behind the patient’s resistance lies a wish that the intruding therapist is correct.
Treating the self-mutilator, in the beginning, often requires that the therapist adopt a highly authoritative, though warm, supportive posture. This will be regarded as trustworthy by the patient only if the therapist is truly comfortable with the features of such a posture. The therapist is appointing himself or herself as a guide for the patient who is lost.
The assumption here is that the therapist is familiar with the patient’s character structure and has determined what developmental deficits must be developed (self-esteem, ability to communicate, etc.) in the therapy. A blind authoritarian approach is not recommended.
Reaching the Deflector
Meg, a fourteen-year-old girl, was discharged from a medical hospital after making a severe cut at her elbow joint, which severed the tendon and caused the loss of nearly a pint of blood despite her own efforts to stop the bleeding. Apparently she did not intend to wreak as much damage as she did. She called for her mother after her own efforts to stop the bleeding failed. She did not remember actually making the cut, but did remember the immediate aftermath.
As a result of the mother’s and Meg’s retelling of the episode to the hospital staff, Meg was not designated an attempted suicide but a self-mutilator. She was released from the hospital after three weeks in the psychiatric unit, on condition that she engage in intensive outpatient therapy.
Meg entered my consultation room and promptly sat down mechanically in the center of my three-seater couch. I greeted her with “Are you glad to be out of the hospital, or were you more comfortable there than at home?”
She shrugged very slightly. “The hospital was okay. It’s okay at home,” she responded in a monotone, her face expressionless. She sat straight, her hands clasped in her lap. She continued to stare straight ahead. I thought about all the questions I could ask her, envisioning all the equivocal, meaningless answers I would get. I decided to stop asking questions.
“If you hadn’t cut your arm and were never allowed to hurt yourself again, you would experience bad feelings.”
She restrained her emerging, startled look and remained silent for a minute.
“I don’t know what you want me to say.” Her tone was mildly plaintive.
“I want you to tell me about the bad feelings you have.”
“I feel all right now.”
“You don’t always feel all right. When you don’t, what do you think about?”
“I don’t know.”
“Your arm knows. It found out when you cut it.” (I anthropomorphized her arm to create a metaphor for a dialogue between herself and her arm.) She was affecting a self-contained or isolated posture in order to remain hidden. I demonstrated that I knew she had strong negative feelings that were not only betrayed by her most recent cutting episode (she had thirty other cuts on her arms, thighs, and stomach, according to the medical examination). By characterizing it as an “attack”on her arm, I could characterize her as concealing aggressive feelings.
“Why did you say I attacked my arm?”
“If you cut my arm with a kitchen knife, I could say you attacked me, or you attacked my arm.”
“But it was my arm. I can’t attack myself.”
“Cut me or cut yourself—it’s an attack on one person’s body or another.”
“I don’t get angry at anybody. I don’t attack anybody.”
“You attack yourself, so I know that you get angry at yourself.”
“That’s not the same. That’s not real anger. Real anger has to include someone else.”
“Who told you that?”
“Everybody knows that [reverting to a monotone].”
“Nobody believes that . . . but you.”
She shifted in her seat, crossed her arms and legs.
“Anger is bad. I don’t have anger.”
“You aren’t aware that you have anger. You don’t want to be aware of that. Cutting yourself is like screaming out that you have painful feelings and angry feelings . . . everybody knows that.”
Her face became more expressive. She looked confused, frightened. My complacency with such a powerful “accusation” unnerved her.
“Does that mean I’m a bad person?”
“It means that you are a confused person, who feels guilty toward other people and about your own feelings.”
“Then I must be a bad person.”
“No. You are not a bad person. You just can’t understand complicated feelings, your complicated feelings. You need instructions so you can understand these complicated feelings. Then you won’t have to attack your arm.”
She looked at me meekly, almost pleadingly.
“I wish you wouldn’t say that I ‘attacked’ my arm.”
“I will help you understand your complicated feelings. Then you won’t have to damage or hurt any part of yourself.”
“You think that my complicated feelings, as you put it, are connected to the cuts I made?”
“Yes, of course. It’s clear that these cuts you make are powerful, dangerous, crippling, and bloody. These are hardly casual acts.”
I could see the tension in her face as she reacted to the evenly stated but severe words about her actions.
Meg attended her sessions regularly, twice a week. She began to quote things that were said in sessions to her parents. They occasionally called me to tell me that she was becoming more enthusiastic about the things she was learning in therapy. She never cut herself again, and by the end of the first year of therapy, I went from doing ninety percent of the talking-teaching to barely being able to get a word in edgewise. Meg became a talkative, self-analyzing patient!
_______
When working with many of my teenage patients, especially the self-mutilators, I find that initially I have to reach out to them and verbally draw them to me with statements about their unspoken pain, which is sometimes unconscious as well, and with explanations to their unasked questions. This, of course, involves some risks. When I begin with such a patient, in my own mind I’m digging in for the long haul . . . of talking, explaining, and teaching before expecting to be rewarded by responsiveness, trust, and attachment, the necessary requirements to fill the deficits that overcome self-mutilation, self-loathing, and low self-esteem. In order to do this, one has to keep in mind the following:
—Establish trust by letting the self-mutilator know she is understood.
—Allow time for trust to build a healthy attachment.
—Expect the self-mutilator to depend on that attachment during the course of therapy.
—Encourage the self-harmer to accept and incorporate the therapist’s positive ideas to replace her negative self-image.
—Help the self-mutilator to build her own strength on the new positive ideas, thereby developing a healthy independence.