Psychotherapy is an opportunity for learning about healthy relationships: the relationship between therapist and patient teaches the self-harmer new ways of relating to herself and others. What is missing in the world of the self-mutilator is trust and healthy attachment to other people; these emotional building blocks can be developed within the therapeutic relationship.
Nurturant-authoritative therapy consists of therapist’s behaviors that are caring, supportive, guiding, and instructive. These behaviors also include, when appropriate, both praising and warning. The patient receives the caring, turns it into trust, and then utilizes the trust to develop the confidence to try new ways of coping (suggested by the therapist). Confidence grows with each success: it reduces self-loathing, leads to increased bonding, raises self-esteem, and encourages verbal reflection, which finally replaces the self-destructive acts.*
Nurturant-authoritative therapy has been developed to compensate for specific dysfunctions within family systems. These occur when parents become emotionally depleted and unwittingly communicate abandoning and dependent (needy) messages to their child. (In another form, parental neediness may include irritable, aggressive, and assaultive behavior.) The child believes that there is no emotional support available to her. She must invent a self-reliant support system, based on her own “successful” behaviors. The self-mutilator “succeeds” by tolerating pain; the anorexic by losing weight. The self-regulating behaviors replace support from others. Nurturant-authoritative therapy reverses this psychological process.
Often, though not always, the self-mutilator has a history of being hurt, harmed, or molested. When this is the case, mistrust is her security. She will constantly look for opportunities to mistrust her helpers. She often invites harming behavior from her helpers, thus confirming her need to mistrust them, as well as her need to hide and protect herself from those who seek to help her. She may do this in a passive manner by not talking during therapy sessions. Seeming to daydream in order to escape any connection with her therapist, she is in fact constantly testing. Her need to protect herself from others by mistrusting them could frustrate the less than determined helper.
The descriptions of therapy that have preceded this chapter have emphasized the positive, successful interchange between patient and therapist that has facilitated recovery. Now that a model for treatment has been illustrated, we must address what could go wrong. When therapy sessions or family interactions create a retreat to old symptoms, we need to understand why this has happened and how to get back on track again. There is rarely an instance of perfectly smooth treatment, or family change that produces a quick, steady recovery.
When treatment or family relationships seem to have retreated back to “square one,” conferences are necessary between therapist and supervisor, or therapist and family. The self-mutilator may cling to old habits as far as trust goes but she really does want to change her familiar security-seeking patterns.
Mona: Two Steps Forward, One Step Back
Mona was referred to me at the age of twenty-eight. She was living alone, and abusing and harming herself in many ways. She had innumerable cuts, dozens on each limb, as well as on her stomach and chest. She had two burns, both from a teakettle full of boiling water, one on each thigh. She wore only crewneck or turtleneck sweaters, even in summer. Her father paid for all of her living expenses, which gave her extraordinary privacy to neglect and harm herself. She had drifted away from her friends, was unemployed, and could be uninhibited and irresponsible about her appearance. There was no one to ask her about “suspicious”damage that might show up rarely should a sleeve ride past her wrist, or a button on a high-neck cardigan sweater come undone.
Her previous therapist had just retired from analytic practice and referred Mona to me. She warned me that Mona could be a difficult patient and that treatment would proceed slowly, since she was granted a “fortress existence” by her father that supported her resistance to change. The analyst also diplomatically informed me that Mona could be “quite independent at times.”
Mona entered the room with a pleasant smile, shook my hand, then became preoccupied with taking off her backpack, scarf, and coat. She placed them at the end of the couch, turned around to face me, and sat down. Her focus on the rituals involving in folding and placing her clothes and backpack, in blatant disregard of my presence, indicated her comfort with detachment from others. As she sat down, she resumed smiling, as if to say, “Now I have time for you.” It was all very natural and devoid of hostility.
Part of the referral information received from her previous therapist indicated a history of physical (not sexual) abuse and of neglect by her mother (divorced from her father for fifteen years and now remarried). The abuse had begun when Mona was a child and had continued through her young adulthood. Mona never received a birthday card, or any other greeting card, from her mother, even though she had sent her mother cards on Mother’s Day, Christmas, Easter, and her birthday without fail for the past fifteen years.
At our initial session, Mona sat there with a friendly smile, saying nothing.
I was aware that her previous therapist was comfortable with silences of up to ten minutes, so Mona didn’t expect me to speak for a while.
“I have been told by Dr. N. that you haven’t had much experience with having your feelings of warmth reciprocated by those closest and most important to you.”
She brushed my comment off with a frown and a shake of the head. “Whatever you grow up with, you think is normal. You just take it as it comes.”
For the first three weeks, Mona was pleasantly light in response to questions about her discomfort and loneliness. She told me stories of punishment, assaults, and not being let into the house after coming home from school on cold winter days. She seemed to regard me as sympathetic, which I had been, and easy for her to talk to. We appeared to have gotten off to a good start.
Mona came in for her seventh session with a frown on her face.
“What’s the matter?” I inquired.
“What’s the difference?” she snapped back.
“You look upset. I’m concerned. Maybe if we talk about it, we can improve the situation or how you feel.”
Her face still maintained its hard look.
“You’re concerned? You get paid. I think that you get paid for squat!”
“Why are you angry? Nothing has changed. I’ve always been paid. It never bothered you before.”
“Well, maybe this just isn’t good enough anymore.”
“Are you saying that you don’t want to continue therapy?”
“I’m saying that you’re not able to do anything for me. Look!”
She lifted her long sleeve and pointed to a cut, three inches long, on the inside of her forearm. It was still bleeding through the gauze and tape she had covered it with. I walked over to my bookcase, took down a bottle of peroxide, adhesive tape, and gauze pads, walked back to Mona, sat down, and removed the bandage. I was surprised by the size of the cut. I poured the peroxide up and down—it erupted as a lake of pink foam. After a second and third application, the foam was white. I made a tight bandage to close the cut as much as I could. The gauze stayed white. The bleeding had stopped.
“You will have to go next door to my dermatologist colleague to see if it needs stitches or other treatment after our session is over. What is this about?”
I looked up from the cut to find a tearful Mona. “Today’s my birthday.”
“No card?”
“No card.”
“Do you understand why you were so angry at me when you came in today?”
She answered me in a tone that suggested I should have known the answer.
“You are the only person I speak to about my feelings. Should I have been angry with the grocer?”
“That’s quite a cut,” I remarked.
“There will always be cuts,” she countered in a resigned tone.
We both stared at the white bandage. No bleeding observable. She rolled her sleeve down.
“Is that something you want to change?”
“The cuts? No, I want to be a mass of scars and bleeding my whole life, or until I accidentally kill myself.”
I allowed for the sarcasm—anger takes a while to dissipate.
“So we have the same goals for you?” I offered.
“Some of the same goals,” she grudgingly accepted.
Mona had come into her session angry, dissatisfied, acting as if she wanted to end the relationship. She did not have the relationship skills or the ability to reflect upon what was really bothering her. At the age of twenty-eight, she was doing what an early adolescent does: she yells at her mother or father for a grievance that belongs somewhere else. Ironically, Mona was snapping at me over a grievance she had with her own mother. Another birthday passing without hearing from her mother had been a painful reminder of her mother’s neglect.
Therapy offered Mona a new opportunity to learn that she could depend on another person. By dressing her wound, I did what a parent would do. This would deepen her trust and attachment to me and would provide me with more leverage to help Mona.
My goal was to develop her verbal expressiveness, which would in turn give her more insight into her own feelings, especially her anger and sadness. I knew from her symptoms she had no healthy outlet for emotional pain. I would continually push her to clarify the reason behind every self-harming act until the act itself became unnecessary.
Therapy: A Relationship Laboratory
Here again we see that much of the psychotherapeutic approach in treating self-mutilators is a kind of reparenting. This includes directing the patient, arguing with the patient, even apologizing to the patient. The therapy becomes a laboratory where the patient can experiment with new interpersonal behaviors and experience their outcomes in relative safety. This explains why therapists proceed with great care and planning as to their own behavior and responses. The nurturant-authoritative relationship is more real than most therapies allow for; it contains more risks of the patient acting out and in rare instances even terminating treatment. I say rare instances because most patients, like Mona, are looking for a person who will give them fair, caring guidance. On some level, these patients know that they need to acquire facets of personality development they are missing.
Life has taught the self-harmer not to trust anyone, or in less severe cases, to be extremely wary. She will set up many tests for a person to pass before taking even a limited chance to risk such trust.
If she interprets a person as suddenly undeserving of trust, she withdraws it and retreats. That does not mean that treatment and trust are not able to be restored. Parents have the same worry: If they say the wrong thing to their disturbed child, they will lose the child’s love forever. Neither is true. Behind the tough mask lies the need for trust and dependency. In other words, whether we are parents or therapists, they are rooting for us. Even when a patient pulls away in fear or anger, we can redeem their trust.
In the case of Mona, she would skip several sessions in a row, return for a half-dozen, and then fade out again for one or two meetings. I didn’t make an issue of her erratic attendance since she was an abused child who now was at an independent age, and would probably flee anyone who was critical of her. Her erratic attendance did persist for the entire first year of treatment; by skipping appointments, Mona was showing me how hard it was for her to accept care from another person.
In her second year of treatment she skipped less than one session in five, and her cutting occurred only twice, and they were minor cuts. But she remained erratic in her attitude toward therapy and questioned whether I could help her improve the quality of her life and feelings about herself. She could be withdrawn during a session, yet by the end of the first year she would attribute her mood to a situation beyond therapy rather than act it out on me.
Our relationship became more complex. Mona would ask for my advice, support, and guidance about issues that ranged from interviewing for a job to taking a trip with a family member or friend.
She did relinquish her housebound lifestyle and took two jobs so that she could achieve financial independence from her father. She gave up all self-harming behaviors, started on an antidepressant (which we first discussed for six months), contacted friends she hadn’t spoken to in years, and could by then be termed symptom-free.
Hazards on the Road to Recovery
We can expect certain situations and events to cause unevenness in recovery; they threaten treatment by destabilizing the patient’s perception of the therapist, or of therapy, and in turn demoralize the therapist with regard to his or her effectiveness. These situations include the family’s resentment of the time recovery takes; the amount of money it costs; and the inconvenience that traveling to see the therapist imposes on the family. And in more than a few cases, jealousy on the part of one parent of the therapist’s confidential relationship with his or her daughter can threaten or even end therapy.
Adverse statements to the patient by family members may make her feel guilty and withdraw from therapy. When the therapist notices poor attendance, or a continuing flatness in the patient’s voice demonstrating disinterest no matter what is being discussed, it is a good idea to question the patient about how the other members of her family see her being in therapy.
What follows is a case where a family secret created a roadblock to recovery.
Ainsley: Hiding the Harm
Ainsley was a precocious-looking fourteen-year-old who from the first session struck a pleasantly disengaged posture in answering all questions with either “I don’t know,” a shrug of the shoulders, or “I don’t know what you want me to say.” Her parents would not meet with me in the same room at the same time. They were uncommunicative with each other at home and seemed on the verge of separation. I referred them to a marital therapist, insisting that they do this to help their daughter. They agreed to begin weekly couple sessions.
Ainsley had made several severe cuts on her upper arms and the upper part of her breast. Two of these episodes landed her in a hospital. She had been transferred to psychiatric units where she proved uncommunicative, though pleasant. Psychiatric tests were ordered and they indicated that Ainsley “would not project”—in other words, she didn’t respond to the pictures presented to her. The technical conclusion was: “Unusual degree of constriction in thought and speech indicating depression with the possibility of childhood trauma which she cannot consciously cope with,” which indicated to me that Ainsley would have a very hard time expressing herself, or even thinking about her problems.
The psych report was accurate. She couldn’t seem to use our sessions to talk about anything that bothered her. Yet she came in without protest. Ainsley continued to attend sessions for a while without disclosing anything of consequence or for that matter initiating discussion about any subject or event in her life. Her facial expressions seemed in conflict with each other. On the one hand, she seemed to want to please me. On the other, she seemed to be prohibited from answering my questions.
Then the therapist who was working with her parents called me one day to tell me that Ainsley’s mother had made a comment during their session that he thought bore repeating to me. Her mother had said that she thought her daughter liked me, and went on to say that “he would be the kind of personality to tempt my daughter to cooperate with therapy.”
He thought her characterization of me as a tempting personality suggested the possibility of incest behavior somewhere in the family, though he couldn’t speculate who the parties involved were.
This information enabled me to rethink the behavior of this mysterious patient who seemed satisfied with our sessions even though they were devoid of any meaningful content. She liked the benign tone that existed between us, but did not dare embark on a path of communication that could eventually lead to disclosures that were forbidden. Disclosures that might cause family disruption and acrimony, that might damage parents. Even the beginning of disclosing communication, no matter how innocent the subject might be, might weaken Ainsley’s guardedness and allow for further drifting toward importantly secretive areas.
Finally, I decided to confront her.
“You seem to respond to me with great care,” I began.
She looked puzzled and a little alarmed. Could she have disclosed something? “What do you mean?”
“I have listened to your responses and interpreted them as behavior, instead of just focusing on the words that you were saying.”
Now she looked more worried (and more expressive) than she had ever looked in session before.
“You seem to react to my questions as if you don’t understand them or the answer to them could be yes or no. By saying this you are saying that the question doesn’t really matter, since the answer doesn’t matter.”
No response. Despite her obvious discomfort, I continued.
“It’s clear that you don’t permit yourself to say anything here that would really matter. That would be dangerous and therefore prohibited.”
“I don’t know what you want me to say.”
“You have often said that before, and I have usually responded by telling you that I had nothing special in mind and I was merely offering you a chance to talk about your thoughts and feelings. That’s over now. I’ll tell you what I want you to say.”
She looked frightened, but I had to help her let go of the secret that I suspected was destroying her.
“I want you to tell me if there are family secrets about physical and possibly sexual contact, or even sexual talk, at home? That’s a ‘yes’ or ‘no’ question because I am asking you if you have heard, heard about secondhand, or seen or experienced these acts I have just mentioned.”
I made strong eye contact with her so she could not slip away from the demand and intensity of the moment.
“I don’t know,” she replied shakily.
“This is a yes/no question. If you don’t answer no, then the answer is not no.”
She looked increasingly agitated. “Well, I don’t know . . . there might be.”
“Between whom?”
She looked down at the floor. “Not between anybody and me.”
“Between which person and which child?”
“Between my mother and my brother. And my mother and little sister, too. She’s eight years old.”
Her jaw was set. She looked angry.
“Are you angry about it? You look angry right now.”
“I guess so. I think that it’s wrong to do.”
“Who is doing what to whom?”
Ainsley looked straight at me. “I have never seen or heard anything happen, but my little brother complained to me a couple of times that he thought he was too old to be bathed by our mother at the age of twelve. He especially doesn’t like that she cleans his—you know—private parts.”
“Do you think that this is unnecessary, or improper?”
“I think it’s weird, maybe sick. I don’t think it’s good for my brother. If my father wanted to bathe me, I would run away from home, so I must think it’s pretty bad that she bathes him. What if my family is crazy? Will my mother go to jail because I told you? When she knew that my brother told me, because I asked her about it, she told me never to tell anyone about it or the family would fall apart. She told me never to trust anybody with any information about the family because it might lead to me telling about this. She was right, but I think I’m glad I did. I couldn’t talk about anything at all before.”
“To answer your first question, no, your mother won’t go to jail for bathing your brother, but she will have to answer to people about her behavior and your brother will be interviewed. If nothing else has occurred, your mother will be warned not to do this or anything like it again. She will either be mad at both you and your brother, or glad that she was finally stopped from doing what she knew was wrong. It’s too soon to say which.”
“Do you have to tell her that I said it?”
“Not directly. We’ll make sure it comes out. We will talk to your brother before we talk to your mother so what has been happening becomes a family disclosure, not someone telling on your mother.”
Ainsley looked relieved. “Maybe we can talk about real things now.”
“You’re entitled to,” I responded.
Ainsley delved into issues I had previously thought she wouldn’t. We discussed her precocious dress and manner. Her mother had led her to believe that children were supposed to evoke sexual ideas in their parents. In effect, Ainsley had adopted this seductive style in reaction to her mother’s behavior with her brother and sister, as well as the instructions regarding secrecy. Her mother’s behavior and conspiratorial manner are hallmarks of the incest victim, and indeed that was the case with this parent. After discussing this, Ainsley stopped dressing seductively and flirting in the style of an older teen.
She talked about cutting herself out of frustration with her mother’s behavior toward her siblings and her own feeling of being trapped with too many secrets. There was no way to get information from others about all her confusion. She always felt the pain when she cut herself. Sometimes if no one was around she would shout or grunt as if she were attacking somebody else.
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The course of Ainsley’s individual therapy demonstrates the struggle between symptoms (her cutting) and attachment (a therapeutic relationship with another person) and so will be discussed further in the next chapter.
As to family treatment, social workers interviewed her brother, and couple’s sessions were held with Ainsley’s parents in which Ainsley’s mother discussed the abuse she had received at the hands of her own father. Ainsley’s sister was seen by a child psychiatrist. The couple did become divorced and the father retained custody of the children.
Ainsley gave up her cutting and continued therapy for three years after that session. She remained in regular contact with her mother, though her brother had little to do with her until he was sixteen. He had not gotten over his anger toward her and went into therapy himself. Their father remarried and her mother became involved with an incest survivor’s group.
A number of factors can sabotage treatment and recovery, but often they are hidden from the view of the therapist. The therapist rarely has the opportunity to acquire information that the patient is keeping secret whether out of loyalty or fear. It is even more difficult when the unknown information is outside the patient’s awareness or consciousness. If patient and therapist are lucky, all the information necessary for treatment will finally emerge and help to promote recovery.
*This therapy was first explained in my book Treating and Overcoming Anorexia Nervosa (New York: Scribner, 1982).