Since the chief characteristic of self-mutilating is physical wounding, a person who undertakes to help the self-wounder must have some knowledge of what constitutes physical danger and what does not. Talk about cuts and burns must not be overwhelming to that helper. If the self-mutilator senses fear on the helper’s part, she will dismiss him or her as having no emotional value to her. The helper will have to be comfortable talking casually with the patient about the physical harm she does to herself.
Sometimes the context will be in asking about new injuries; other times the context will be looking at the wound, confronting (without drama) the infliction, interpreting the wound by its severity, and requesting the person to reflect on what her thoughts and feelings were preceding, during, and after the act. This process is important because it desensitizes the act of self-harming by removing the drama and replacing isolation with sharing.
Profile of the Effective Helper
If the self-mutilator sees signs of anxiety or nervousness on the part of a helper, that will make her disinterested and unreceptive to the offer of help from this person. Clearly, a helper needs certain personality traits in order to function properly:
• Confidence, which ranks very high on the list.
• The ability to stay empathetic and close to the patient when that patient hears her own talk as strange, even to herself; when her thoughts don’t make sense; or acts she has committed against herself are mysterious to her.
• The ability to appear knowledgeable about her illness, her cutting, her depression, her low self-esteem, her feeling that she doesn’t belong with others, anywhere.
• An understanding of her despair, and the ability to convey that understanding to her.
• A nurturing posture, continuously directed toward her, regardless of whether or not she requests it.
• Optimism about her future and ability to overcome the feelings that wear her down, such as wanting to give up, or to hurt herself.
The helper who combines all of these traits offers the self-mutilator a way out of her painful loneliness: their relationship. The patient will be suspicious and will test the helper repeatedly. While some of her testing will be verbal, for example, “I knew coming here, just sitting around and talking, wouldn’t really help anything,” some of it will be acts of cutting or other forms of self-injury. These must be attended by a physician, if they warrant it. So the helper has to be aligned with a physician who will accept the task of working with a patient who actively undermines her own safety, physical functioning, and health.
A parent should tell the physician about the self-mutilation and be sure that he or she is understanding, calm, and projects confidence. The physician, in this case, is continually cleaning up after her, knowing that she may “mess up” again, much as a mother changes a diaper knowing that the new one she has replaced the soiled one with will in its turn be soiled. Perhaps metaphorically, the treatment team is dealing with a person who suffers from unresolved infantile issues, such as a lack of basic trust.*
You may have noticed that this profile could describe a calm and confident parent. Working with a patient to repair childhood deficits includes a component of reparenting, which describes a psychological process of changing the parental stance to a warmly authoritative, more directive approach, making the self-harmer feel younger and more protected. In this state, she can accept support to build in the missing trust. But reparenting is not exclusively the province of the therapist. In fact, reparenting within these guidelines can be highly effective for parents; the child’s first preference is to get what she needs emotionally from her own parents.
The Reparenting Relationship
At the beginning, the helper must do much of the talking. If he (or she) asks too many questions, the self-mutilator will infer that the helper is needy (of answers from her), and not knowledgeable. The helper is taking a gamble in making highly personal generalizations about someone he doesn’t even know. But the patient won’t really be looking to find an error; rather, she is hoping that the helper is right . . . most of the time. She does, deep down, beneath her despair, wish for a helper who can be depended upon. She knows that she can’t help herself, no matter how much charm and bravado she exudes to others.
Occasionally, the helper will find himself bordering on the overconfident. It is better to make this error than to be so prudent and careful that he/she looks hesitant, and shaky. To illustrate this confident style, here is a typical exchange from a therapy session. As usual, I’m very active in providing answers rather than asking questions:
“You seem to have made quite a cut on your foot.”
She shrugs, looking embarrassed.
“I’m going to tell you why you cut yourself.”
She looks surprised and relieved.
“When no one can reach you, even though you can reach and affect others, you feel empty and unreal. Life feels unreal, hopeless, devoid of fun. You get unhappy, and after a while, depressed, flat, blah, no ups, no downs, everything starts to matter less and less. You begin to say to yourself, ‘Why bother?’ ”
“How could you know that about me? I never told anyone about my feelings.”
“That’s not all I know about you,” I continue. “I know that when you feel despairing and the ‘why bother’ takes over, that’s when you are ready to cut or otherwise hurt yourself. At different times you may ‘choose’ to feel the pain or go into a trance, become numb and ‘watch the cutting happen’—even though you’re doing it, you feel like a spectator. It is at that moment that the ‘why bother’ goes away.”
She shakes her head. “Everybody who comes in here asks me questions that I don’t know the answers to. So I make them up. I make up some pretty good ones, too. But you come in here and you don’t ask me questions, you give me answers to questions that I have about myself. I still don’t know how you can do that.”
She is gesturing wildly with her hands to emphasize her point. I smile at this emotionally lost thirteen-year-old.
“I guess there’s a lot about yourself that you don’t know. I think that you are going to need someone to help you learn those things, and help you grow up.”
“Nobody can do that for someone else!” “Oh yes they can. I can.”
She looks worried. “But I’m the one who does that for other people. It would be too much for you to try to do that for me!”
“Apparently, you are too much for yourself to fix or help. But that doesn’t make you too much for me. I don’t even think that helping you will get me the least bit tired.”
“I get everyone tired. And you’ll get tired of me, too.”
“I know you’re not used to leaning on anyone. But I think that a small part of you is beginning to believe me—that maybe I have an answer to your secret wish.”
Making a mock frown at me, “What secret wish?”
“The secret wish that someone could take care of you. That they would take such complete care of you that it would be as if you were a baby to them, and they would always be there to protect you and calm you down when you needed it.”
Her eyes become watery but she flexes her face muscles to prevent the tears from falling. I lean toward her and gently tell her to let her face muscles relax. The tears begin to fall.
“I think that those tears mean you’re beginning to trust me.” I take a tissue and wipe her face. “I’m going to keep these tears in this tissue. They are precious tears; they mean that you can like yourself, and even hope for your future.”
“Well, I don’t know about that,” she protests mildly.
“Well, I do.”
Certainly, there are risks involved in getting so far ahead of the patient about herself. But these risks are less than they would seem, since the “knowledge” stated by the therapist is really quite general. Barring a unique trauma that began her illness, she would have had to experience such feelings. She desperately needs to know that she can be understood by someone who takes a parental posture toward her. She has already given up on the authority figures in her life.
These character traits and behaviors I have suggested for the therapist—warm and bossy, unflappably confident—must be real and comfortable to be effective. Parents can support the therapeutic process by adopting a similar style at home. If they have difficulty as they attempt a new style of interaction, they should consult a family counselor. The most successful treatment includes help and guidance for parents and other family members.
A Chain of Helpers
Often the therapist is called upon to loan some of the confidence described above to others who wish to help. The professional helpers include the psychotherapist, family counselor, physicians, and nurses involved with the patient. Nonprofessional helpers include a larger group: parents, grandparents, other primary caretakers, foster parents, siblings, close friends, and institutional helpers, guidance counselors, teachers, boarding school staff ranging from house parents to headmasters/headmistresses. At the college level, helpers include student services counselors, deans, and student self-help groups.
Those who would be helpers should expect differing levels of efficiency, different levels of success.
Looking for Behavioral Changes
In the area of behavioral change, which refers to eliminating self-harming behavior, placing someone in a psychiatric hospital produces nearly one hundred percent success immediately. The reason for this is that there is a staff of professionals observing the patient twenty-four hours a day, seven days a week, in an environment where nothing sharp is permitted and the windows are made out of plastic. Most conversations are with professionals who have therapeutic change as the goal of these conversations. Of course, hospitalization is temporary.
The outpatient therapist can be effective during the session, but the carryover after the patient leaves the therapy session depends on the level of communication and trust she establishes with those around her.
Family members who try to help a self-mutilator will experience much less efficiency in terms of how much their communication has improved the patient’s frame of mind. There are several impediments to efficiency here. The first is their fear of causing an increase in frequency and severity of the dangerous behavior. The second stems from the first. Their fear leads to anger, which leads to guilt, which leads back to fear. For example, a mother notices a fresh cut, bandage, or bleeding. She questions the self-harmer, demanding an explanation. When none is given, she exclaims, “I wish you didn’t have to do this to yourself! We’re getting you help but you’re still cutting yourself. Don’t you see how crazy this is—I don’t know what we’re going to do with you.”
The parent has expressed anger, frustration, and hopelessness—understandable but not helpful. Instead, he or she could make a statement demonstrating their understanding of the self-harmer’s feelings: “I see you’re having a bad time again. Do you want to talk about it with me? Maybe first we should go into the bathroom and put some disinfectant and a bandage on your arm.” Here the parent has demonstrated empathy and also exercised restraint in keeping their own feelings in check so that they could bring a sense of calm to the situation. In this way, family members can be a valuable part of their child’s recovery, but they must be supported by, and in communication with, mental health professionals.
Family counseling serves two purposes: first, it provides a continual flow of information and instructions; and second, it furnishes emotional support since the child’s “careful” behavior is self-conscious and extremely draining of energy. As if this weren’t difficult enough for family member-helpers, they are still coping with their own previous habits in relating to the troubled adolescent, which have to be revised. They usually are experiencing feelings of guilt and blame as well. This gives the patient leverage to use “angry cutting” as a weapon for release of built-up rage, when it exists.
If family members have expectations that a change on the part of parents or outpatient therapy will produce instant results, these expectations need to be addressed. Parents can become angry and frustrated when they believe they have acted in helpful ways, have changed much of their style of communication for the better, and their ungrateful child still hasn’t improved. In retaliation, they may revert to their former postures and style of communication. They have, at that point, lost sight of their child as a mentally ill person. But she is not in a reasonable state, therefore, reasonable expectations are unreasonable.
Unless those who would help the self-mutilator are aware of these tactical considerations, the helper can become the hopeless. Expressions of helplessness or emotional demands placed on the patient can impede progress. The process of recovery is in any event lengthy and uneven. If the helper can maintain a hopeful and calm presence, he or she will be making a great contribution.
When Privacy Becomes Isolation
Earlier, I stated that the profile of the effective helper could be described as that of a warm but bossy parent, unflappably calm in the face of self-destructive behavior. A bossy but caring person is sometimes intrusive when the occasion warrants—and self-mutilation is just such an occasion. Privacy is highly valued in our society and is usually a healthy part of one’s life. But for the cutter, who is an emotionally isolated person, privacy becomes a way of hiding. Therefore, intruding into the patient’s privacy is an important part of treatment.
The first level of struggle with the illness is the effort to diminish and finally eliminate self-harming behavior. Cutting and burning oneself requires privacy, which serves several purposes:
• The absence of others means the absence of those who might interfere and stop her.
• Privacy means the absence of those who would distract her from going into a trance or from experiencing the anger that drives her to harm herself.
• Awareness of the presence of family members makes the cutter sensitive to the feelings of others who might react with anger, sadness, or fright. This would defeat the purpose of the behavior—to release unconscious pain in a manner not connected to others.
Though minimizing privacy is important, a therapist or family member cannot always be present when the act of self-mutilation is occurring. But examining the damage done, on a regular basis, creates the anticipation of nonprivacy or the expectation of discovery while the act is being committed. This makes the cutter less inclined to commit the act; emotionally, she is less isolated. Also she feels as if the self-inflicted pain is not going unnoticed. If someone she loves or depends on recognizes that she is hurting herself, this says something to her. It tells her that she is cared for and loved; that she isn’t invisible.
The therapist needs specifically to question the patient as to whether or not there are newly inflicted injuries. If the answer is yes, or merely a shrug of the shoulders, the therapist asks to see the injury. This observation, when done consistently, creates the anticipatory sense of loss of privacy.
At the same time it induces a bonding on the part of the patient to the therapist, who by showing interest in and acceptance of the patient’s “ugly [physical] side” will eventually be trusted to share the hidden emotional side.
Of course, the therapist has to maintain a level of talk consistent with this expectation. After all, the therapist is not a dermatologist whose interest is skin-deep. Since the therapist also is not a physician, damage to the skin whose seriousness is questionable should always be referred to a doctor. This will protect the patient from infection, excessive scarring, unrepaired tendons, and other consequences, as well as protecting the therapist from taking on more responsibility than he or she can handle.
If a therapist reacts to the damage by revealing their inability to treat the injury medically, this could lead them to show fear, anger, exasperation, and even to plead with the patient to discontinue such behavior. All of these reactions weaken the therapist’s trustworthiness in the patient’s eyes. The therapist should intervene by getting the patient prompt medical care, while dealing with the emotional issues.
In summary, routine discussions of the injuries and deciding what to do about them increases trust, begins to integrate the personality’s sense of relationship to another person, and replaces self-mutilation with attachment.
Again, the personality of the therapist is critical here. The goal of this process is to have the self-mutilator relinquish her privacy and isolation for something more attractive—the connection to another person. This connection has to be safer, more secure, than the patient has experienced for a long time. The criterion of the security of the connection is how much self-harming behavior is exchanged for talk about feelings.
Of course, the real test of the therapeutic relationship is evaluated by how comfortably a patient can reveal, both verbally and visually, the results of her behavior. This presumes that her motives are not exhibitionistic, that she is not bragging or showing off. Ordinarily, self-mutilators are shy and ashamed about showing their handiwork to another person, especially someone who would know that the injury was self-inflicted, not accidental.
The process of unraveling the core of the disorder—that which holds it together and hides the real causes of unbearable feelings from the consciousness of the individual—increases the patient’s discomfort. She has lost her “anesthetic” and has to cope with the emotional pain, the discomfort that her disorder has shielded her from. Now the relationship between patient and therapist is really tested. Will she go back to her former shield or tolerate the new discomfort in favor of the support, security, and trust that she receives from the new relationship? If she chooses to continue her recovery behavior, the relationship has passed a critical point and much more than her self-mutilating behavior will change.
Trust is being established, but the therapist helping her through this transition will have to expect some backsliding, both as an emotional testing by the patient and out of her fear of losing her safety shield. Unconsciously, the self-mutilator is afraid that the therapist will disappoint her and turn out to be untrustworthy. So she continues to test the strength of his resolve to help her.
The cutting may return after it has disappeared for a while, or it may take a turn for the more severe after it has diminished to minor scratches. Usually, it will not return to the kind of injuring that poses jeopardy and requires medical intervention. Through all of these changes the therapist, and hopefully the family, with professional support, can maintain a balanced, caring attitude. The self-harmer is more disappointed with herself than they may realize.
*See Erik Erikson, Childhood and Society.