CAUGHT BETWEEN SYMPTOM AND ATTACHMENT
When the barriers to trust between helper and helped are finally brought down and the self-mutilating behavior is nearly extinguished, the patient experiences relief as well as a sense of loss at the surrender of her symptoms. Relief comes through the newfound sense of trust that she has developed for her therapist, and others around her. Her new sense of trust, healthy dependency, and attachment become evident when she walks into her therapist’s office and begins with, “You’ll be so proud of me when you hear how I handled this situation with my friend—you know, the one who always gets her way and takes advantage of me.”
The ability to assert her needs may be an ordinary experience for a person who has always had many close relationships in which she feels accepted; but to the self-mutilator, this is a new experience.
At the same time she is experiencing pride and rising self-esteem over her new assertiveness, she is in conflict. She is still in mourning over the loss of her cutting behavior, which she has turned to for relief from emotional distress in the past. She may feel as if she has lost her most reliable friend.
The therapist must continually help the patient to maintain her attachment to him (or her) and never take it for granted. The patient, after all, still is in constant conflict between her desire for human attachment, trust, and intimacy on the one hand, and the isolation and mistrust that gave rise to her illness on the other. In many ways, she has been more comfortable in the role of being isolated and distrusting than that of being intimate, and she is still vulnerable with her new feelings about herself.
Mona (chapter 14) persisted in coming to therapy with cuts she had made the day before her session. They were still open and sometimes still bleeding through the bandage. There were two interpretations I could make about her behavior: the first was that she wanted me to see what she was doing to herself so that I could continue to take her seriously, which would reassure her that my own efforts on her behalf would not slacken; the second was that she wasn’t yet sure she could give up her safety behavior for the nearly abstract idea of interpersonal trust. Clearly she was in transition, caught between two emotional methods of survival.
One of the ways I could encourage the interpersonal choice to prevail was to intrude upon her cutting defense. I would notice if there were any new cuts, and if there were, I asked to see them. This might involve taking off a bandage or just a Band-Aid, but it is an experience that exposes the privacy of the defense of cutting by allowing another to see it, to make interpretations or judgments about it, or to scrutinize it.
This revealing of a once-secret defense devalues it. It should be done at the beginning of each session until the cutting stops. If the cutter is aware that a cut will be examined after each episode, she will begin to imagine that the therapist is attending the episode at the time of its occurrence and analyzing the reason for doing it. Eventually the anticipated analysis of the reason for it replaces the act of cutting.
When painful issues in the life of the cutter develop, she is more likely to resort to cutting and become angry at the therapist for her painful feelings and his failure to prevent them from happening or not banishing them immediately. This immature thinking on the part of the patient will mature as the therapy progresses. It is important for both the therapist and the family to have patience with the initial immaturity of the cutter’s expectations, as well as the rate at which she matures during the course of the therapy.
If we keep in mind that this kind of a disorder develops out of deficits in coping with painful feelings—whether they are caused by trauma, hereditary chemistry, family problems, or social, school, and educational problems, among others—then we are aware that building defenses to replace deficits and the symptoms that have filled in for them takes time.
If showing the therapist the self-inflicted injury is one kind of message, a more serious message to the therapist comes when appointments are canceled for insufficient reason, or simply failed when the patient doesn’t call and doesn’t show up. This usually means the patient is choosing her old mode of self-harming and is hiding from her therapist, who represents attachment.
When Mona didn’t show up for one appointment, I called her apartment, only to get her answering machine. I left the following message: “Mona, we had an appointment today at four. Please call me to explain why you didn’t come without notifying me so that I will know that you are all right. I confess that I am suspicious that for some reason you avoided me today, so let’s clear this up as soon as possible.”
After a while it feels as if there are three of us involved: the two facets of Mona, her healthy wish to be well and her disorder, and myself. In some sense the three of us argue while in session. Mona becomes the rope in a tug-of-war between her old posture (self-mutilation) and her new one of attachment encouraged by me.
For my part, I do my usual examination of the newest wound and occasionally point to or refer to all the older scars to remind her that this accumulation of scar tissue hasn’t produced anything lasting for her, just a batch of “quick fixes.” She acknowledges this and shrugs her shoulders.
“It seemed like the only thing to do at the time,” she responds.
“That time is over. This is a new time and you know there are alternatives,” I might mildly admonish her.
At this point, the style of our dialogue has changed. It becomes implicit in our relationship that I hold her responsible for her self-harming behavior. That doesn’t mean that I don’t expect her to do it any more, but there are rules or understandings that we have about cutting. She must tell me when she does it. She must show me the injury. We must then discuss why she did it. If she violates this understanding, then she is answerable to something like a scolding. Our agreement doesn’t demand total abstinence but it does demand total disclosure.
When this point is reached in therapy, then the patient is much closer to the “attachment” end of the continuum than to the isolated, self-mutilating end of it. It’s not the cure, but it’s progress.
Ainsley: Making Progress
With Ainsley, our difficulty was making initial movement toward meaningful contact as a prerequisite to attachment. Ainsley had instructions from her mother not to form a therapeutic connection with me and I was unaware of that until an outside person (her parents’ therapist) suggested the possibility to me.
Ainsley and I had interminable sessions where nothing important was said and I had my doubts about the outcome of this therapy.
When the major goals of therapy consist of changing the way the person relates to those around her in terms of trust, attachment, and dependency, versus the way she uses harming her own body to compensate for her inability to do so, unblocking the barriers caused by existing relationships is just as important as any insights she needs to develop about her own mental makeup.
As you recall, once the incest secret was out, I made it clear to Ainsley that my goal was not to make her like her mother less, or to take her place. She slowly became freer to talk. I also explained to her that nothing she said in the privacy of our meetings could possibly hurt her mother. She was leery of this but gave it thought and gradually began to discuss each member of the family with me.
We started with siblings—not looking for faults, just general descriptions of their personalities and the way each relates to other members of the family. We progressed to parents much in the same manner. We spent many months in the second year of therapy dealing with material about the family. She had a difficult time because in the privacy of the office she was making a critical statement about a member of her family.
“It gives me the creeps. I don’t really know how to talk about this. It’s not that I’m jealous of them. I feel so ashamed that there was something sick going on. I hate this—I feel bad even discussing it with you. My mother has always told me never to trust anyone outside the family or tell them anything about us.”
“Well, you’re going against her instructions. Are you sorry?”
“I’m nervous but not sorry. I still don’t know what to do about what happened between them.”
“What is your worst fantasy about their secret?”
She looked startled. “I could never say it . . . to anyone.”
“If you could never say it to anyone, because it’s so terrible and unspeakable, then you must feel somewhat alone in your house?”
She whispered, “I guess so.”
“And?”
“Angry and guilty.” She looked indignant. “After all the consideration I give everyone in that house, I shouldn’t have to contend with this.”
“It sounds like you feel that they’re being insubordinate or disobedient toward you.”
“I guess that’s not right?”
“It’s not that it’s right or wrong, but it does interest me. You can feel angry, jealous, left out, or worried. Any daughter or sister in your position would feel that. But the last part is more in the province of the head of the family, a parent. Do you feel like you’re a parent in your family?”
Shrugging, “Sometimes, I guess.”
“Parents get angry at their children. Do you get angry at other members of your family?”
“I get angry at myself.”
“Nobody else?”
“Never.”
“Do you punish yourself?”
“Yes.”
“Does that solve anything?”
“Temporarily. It solves whatever’s the issue at hand.”
“You were referred to me because of a secret you were keeping from everyone, cutting yourself. That is how you punish yourself, isn’t it?”
“Yes. I guess so.”
“Perhaps before we attempt to unravel anyone else’s secrets in the family, you and I need to uncover your secrets, within the confidentiality of our sessions.”
“How will that help?”
“When you punish yourself, you don’t really redress any of your grievances with another person. It doesn’t change any of their behavior toward you or even cause them to offer you an apology. When you confront them, something real happens between two people, not just between you and your skin.”
I was devaluing Ainsley’s solution of cutting herself and substituting her cutting with communication. After that session, she chose to violate her mother’s admonition. Ainsley discussed her father’s temper; memories of her mother’s going into trances and not remembering ordinary events of the day; and strange, conspiratorial glances exchanged between her mother and her sister. It was clear that Ainsley felt she had grown up in a house of strangers. If she adopted the role of nurturer, she would feel less dispensable in the family. In this way she had learned to repress, or ignore, her own emotional needs.
The entire family required extensive treatment to deal with this and other damaging issues, which did result (as we saw) in her parents getting divorced. Her sister started to talk about visual and auditory hallucinations she was experiencing. She was put on medication in addition to intensive individual therapy.
The family code of silence nearly prevented any therapy from being effective in bringing all of this to light. Ainsley had to choose between the risk of entrusting another person with her secret ideas, and her feelings over the cutting that she was using as a safety valve which allowed the family system to go on in its dysfunctional, destructive manner.
Cultural Clashes
Usually, a person elects to participate in psychotherapy. But there are exceptions: people who are either suicidal or pose a danger to others may be remanded by criminal or family courts to undergo psychotherapy or face various threats, involving custody of their children or even imprisonment. There are also people who have disorders that don’t fall into these categories but not to seek treatment is regarded as dangerous. Minors and their families may find themselves seeking psychotherapy for psychological problems, such as anorexia nervosa and self-mutilation, even when the very idea of psychotherapy is culturally or religiously repugnant to them.
Parents may fear that psychotherapy will alienate their children from the family’s religious roots. The immigrant family may feel that their cultural values will be compromised if their child trusts someone outside their own culture. It is important, whenever possible, for the therapist to address these fears with the parents of a minor before beginning individual therapy if there is the possibility that these concerns will polarize the family against the therapy. In such cases, the therapist is facing a quasi-voluntary patient or patients. A family that has these fears will look for a quick end to symptoms. They may remove their child from therapy prematurely, inviting a return of the original symptoms or other symptoms.
Tula, eighteen years old, came to the United States from Eastern Europe. Not unlike Fon (in chapter 13), Tula had difficulty with her English, living in Astoria, New York, where one can get along without speaking English except in school. She was referred to me by a pediatrician practicing in Astoria who was concerned about various cuts he had seen on her arms and thighs. At first he considered calling Child Welfare to investigate the possibility of child abuse, but given his position in the community and his evaluation that these were self-inflicted wounds, he decided to call me. I agreed to see her.
Tula sat on the couch in absolute stillness as she told her story. She was pale and thin, and her voice was barely audible.
Tula’s father was a religious man, who held his minister in great esteem. When his daughter, a recent high school graduate, was offered a job as assistant to the minister in a neighboring community, she took the position.
The minister was a likable man, always bringing her little gifts, boxes of chocolates and desserts. After a month, he began to make sexual overtures to her. Soon they went from subtle—his hand on her thigh—to more intrusive and invasive. He told her it was part of God’s plan and it would serve her well later in life as preparation for marriage.
Tula’s conflicts grew greater. She was sure that she was doing something wrong, but there was no one she dared ask. Like a trapped incest victim, she had nowhere to turn. She couldn’t go to her parents and make them choose to believe her and attack a reputable holy man.
She began to vent her anger at being exploited by cutting herself. She started the cutting high up on her thighs, partly as a rage against her sexual organs for attracting the minister’s attention and desire, but also with the unconscious hope that the cuts and scars near her vagina would repel him and cause him to lose interest in her. When that failed, she made cuts on her breasts, partly because of the pain it created, venting anger on this part of her body that attracted him, and again also hoping that he would find her unattractive because of these cuts and scars. He only laughed cruelly and offered to add to her cuts.
None of Tula’s behavior discouraged the minister from his sexual aggressiveness. When he raped her, she made a huge cut down the top of her thigh six inches long, which landed her in the emergency room of the local hospital. It was at that point that she told the admitting psychiatrist her story.
She was not a minor and requested that he not tell her parents. He did get her permission to call her pediatrician. In conference they decided that they could recommend psychotherapy as a requirement to keep her information confidential, and Tula readily agreed.
When she returned home from the emergency room, she told her parents that she had accidentally cut herself out of frustration from working for the minister. She described him as demanding, impatient, inappreciative, and grouchy. She told them that she hated working for him. They were surprised at their daughter’s reaction to a well-regarded man of their church, but responded by instructing her to get a paying job. (The church position was voluntary.)
When Tula told them that the doctor strongly recommended psychotherapy, her parents objected. They felt equally strongly that psychotherapy might replace church teaching and European traditions. Her parents were mystified and threatened: first Tula leaves her job within the church, and now a recommendation of “outside” help. But Tula insisted, telling them that she had done things like that before to herself, and that the doctor said she might accidentally kill herself if she didn’t go into therapy.
She felt both guilty about disagreeing with her family and relieved that they reluctantly gave their permission without finding out what really happened between herself and the minister. Her guilt would make it difficult to disclose her thoughts and emotions in therapy, since she felt that by talking to a therapist she was betraying her parents.
“This psychotherapy is not the way of our people. We turn to each other, or to God and His church.” Those were her father’s parting words to her when he dropped her off at my office and drove away.
Tula was frightened during the first four interviews. I understood that she probably feared the same behavior from me that she got from the minister. Her fear, coupled with her father’s disapproval, provided ample reason for her to prove unlikely to benefit from individual psychotherapy.
During the second month of sessions, Tula began to be forthcoming about the details of the minister’s behavior toward her. She spoke slowly, explaining, “I’m always afraid that you will think that I’m a liar and a bad girl. I never even had a date with a boy or a man before I met the minister or since. I don’t think that I ever will again.”
She was a modest girl, as befitted her European upbringing, and when talking about the incidents remained as vague as she could while making sure she was communicating what had happened. It was understandable that it would be difficult for her to impart this kind of information. It was her feelings that she had the most difficulty in expressing.
I said, “While you have explained that you are concerned with my opinion of you for the information you are giving me, I am wondering what you are feeling as you are telling me these things, or how this whole experience has affected you?”
She looked puzzled. “What do you mean?”
“While you have given me concrete descriptions about what has happened, I am left wondering what the girl in the story feels like because of this difficult experience.”
“I cannot talk about my feelings. They are private. I don’t talk to my parents about them. I cannot talk to you about what I have not already talked to my parents about.”
I was treading on dangerous ground. Tula saw me as asking her to be disloyal to her family by talking personally about herself to an outsider. Not only was I an outsider to her family but to her community. It would be some time before she would talk about the cutting she was doing. It would be a longer time before she would stop cutting, since a prerequisite to ending the cutting involved both sharing her acts and the feelings connected to them, and then cooperatively analyzing the reason for these acts and understanding how grievances can be redressed on an interpersonal level.
This process took about three years. It involved her family getting used to her talking to me, as well as their stating to her that it was all right to disclose whatever was necessary for her recovery. In addition, I had to help her develop a language in which to talk about these complex feelings. This language did not exist in her family’s vocabulary. Ultimately, she did acquire competence in self-reflection, and in interpreting her feelings and thoughts.
This issue of cultural or familiar loyalty should not be confused with resistance due to psychological blocking or conflict. It is actually a healthy, socially learned restraint to communication and indiscreet familiarity. It becomes obsolete in psychotherapy, however, and even hampers recovery, since a willingness to develop a rapport with the therapist is the first step in developing an attachment that can be used for therapeutic change.
Clearing Away the Barriers to Attachment
Very often the patient who seems unwilling to talk is hampered by barriers such as those discussed above: family secrets; family instructions not to trust anyone outside the family; family instructions not to trust anyone from a different ethnic, religious, or cultural group; and loyalty, defined by using the family to solve all emotional problems.
When a patient appears constrained, prevented by some invisible prohibition from either talking freely or responding with more than a “Yes,”“No,”or “I don’t know,”the therapist needs to ask the kinds of questions that will expose barriers to therapy.
Some of the many possible questions address these issues directly:
“How does your family feel about your being in therapy?”
“Is either of your parents embarrassed, ashamed, jealous, worried, or guilty about your coming here?”
“Are issues of cost, or insurance reimbursement, ever brought up by your parents?”
“Do you feel guilty because you’ve come to see me?”
“Have you been told not to tell anyone that you are coming here?”
“Has anyone else in your family ever been in therapy?”
“Do you worry about what others will think about what you might say here?”
“Do you worry about others finding out about what you say here, either because of a breach in confidentiality, or because you might slip up and report what you’ve said?”
Obviously, many more questions can be used to break the stalemate of lack of communication. Once that stalemate is broken, a dialogue will begin to develop that is the beginning of the attachment-trust-dependency relationship. This leads to the patient’s incorporating the therapist’s value system, one that proves that communication within a significant relationship makes self-mutilation unnecessary.