What course should treatment take once the behavioral symptom of self-mutilation has stopped? Is the patient cured? We have examined the growth of self-mutilation from feature to disorder and described this process. As a full-blown disorder, it poses cosmetic, medical, and life-threatening dangers. The treatment process that leads to recovery is not a shortcut from disorder to health, but rather a shortened reversal of the first process.
Medicine, when faced with an inoperable brain tumor, tries to utilize nonsurgical techniques to shrink the tumor until, hopefully, it is operable. Psychology and psychiatry must shrink the disorder, self-mutilation, back to the feature it was when it began. When the patient has decreased the use of this symptom for the relief of anger, hopelessness, terror (in the case of incest), or despair, then other preexisting problems will reemerge.
Usually, self-mutilation is the last in a chain of symptoms to develop—probably because short of violent suicide, it is the strongest experience of all symptomatic behaviors from the standpoint of pain, and of visually witnessing one’s own blood.
If this is the case, self-mutilation is at the top of the pyramid of psychological problems that an individual may suffer from, the tip of the iceberg. Underlying it reside all the disorders and problems that it hides. As psychotherapy shrinks this “psychological tumor,” instead of healthy tissue, or mental health, being uncovered, we enter the areas of hidden problems it had formerly masked.
One of the most common of these problems is anorexia nervosa, or bulimia, referred to as “the eating disorders.”As someone reduces or eliminates cutting, in the case of the anorexic, she then begins to lose weight. In the case of the bulimic, she increases or resumes her binging and vomiting. It must seem to many therapists and families that the reward for success in one area is a demand to tackle many other problems and crises.
One of the major arguments posed against behaviorist treatments of many psychological disorders is that they invite the next level of the mental illness pyramid to emerge. Without an indepth understanding of the disorder on the patient’s part, not only will another symptom come along to replace it, but the originally identified disorder is likely to return repeatedly as well.
Successful treatment requires that all behavioral change be accomplished within a trusting treatment alliance, meaning a trusting therapeutic relationship, otherwise the change is superficial, fragile, and usually temporary.
For the patient, psychotherapy is no less than an undertaking to change one’s mental and emotional personality organization. As if that isn’t a big enough commitment, add to this the feeling that the person who makes the commitment doesn’t know what changes are waiting for him or her around the next corner.
Melanie: A Dissociated Self-Mutilator
Melanie, nineteen years old, had been hospitalized in three separate psychiatric hospitals and had been in outpatient individual psychotherapy for three years. She had been diagnosed originally with anorexia nervosa, then with bulimia, then for cocaine and alcohol abuse, and lastly with an unclear diagnosis lying between suicidality and self-mutilation. Due to the severity of some of this mutilation, it was difficult for the psychiatrist to decide whether the cuts represented frank suicide attempts or were deliberately self-inflicted for reasons discussed in previous chapters.
Her answers to questions at the admitting interviews at the hospitals amounted to: “I don’t know if I wanted to kill myself. I can hardly remember how I felt or even what I did to myself.” These answers are typical of the dissociated self-mutilator, the more disturbed of the two categories.
As treatment progressed in therapy with Melanie, she was able to express more of her revulsion at the pronounced an ugly-looking scars that covered her arms and shoulders. She resolved never to cut herself again and in fact her cutting diminished rapidly. In the first six months of treatment with her, I recall two incidents of minor cutting and then none in the following year.
As her cutting diminished, however, I noticed that she was becoming thinner. When I asked her about her eating and weight, she replied that she had allowed herself to gain too much weight and that she hated being in her body, or looking in the mirror at this weight and appearance. She was five foot five inches tall and weighed one hundred and seventeen pounds. When I asked her what her goal weight was, she said that she intended to reduce to one hundred pounds.
These urgent feelings about her need for weight reduction were not expressed while she was cutting. Though she could not make a cause-and-effect connection between giving up cutting and experiencing an intensification of her anorexia (and bulimia), the timing of the shift in Melanie’s symptoms was more than coincidental.
During this same period of time that she started losing weight, she began occasionally to use cocaine and would call me in a state of severe inebriation to jokingly suggest suicide.
Using medications to lessen her anxiety and mental disorganization was a tricky process. Since her past history consisted of mixing alcohol and street drugs with her medication, a physician dispensed her medication in three-day doses to avoid overdosing and “mixing.” This wasn’t a guarantee, since Melanie had been known to hoard her medication until she had enough to put herself at risk if she resorted to combining it with alcohol.
The two modes of treatment for such a difficult patient were hospitalization, or inpatient living, which at some point became financially unfeasible; or frequent outpatient visits (three times a week) to maintain a “competitive attachment” to therapy, versus symptomatic behavior. The latter was chosen, as she had used up all her hospitalization insurance. Medication was administered as described above.
The next stage of recovery for Melanie was her giving up cocaine and alcohol, which was accomplished over the following year, during which she entered college on a part-time basis.
The last stage of recovery, which will be the longest, will involve giving up her obsession with eating and weight and the concomitant disordered behavior: limiting her calorie intake, abusing laxatives, and vomiting, along with dangerously strenuous exercising.
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If the treatment alliance is not carefully maintained through each stage, ideally with the same therapist, recovery can quickly reverse itself right up the ladder of relinquished behaviors. When this happens, therapy must be intensified to stop the relapsing.
When a patient suffers a setback and a symptom that was improving worsens, or more seriously when a relinquished symptom returns, both the therapist and the patient’s family can become very discouraged. They need to remember that recovery is uneven and such setbacks are not necessarily an indication that the treatment is failing. Each setback has to be analyzed in terms of external events—what has gone wrong? Identifying the various stress factors has the effect of calming the patient, the therapist, and the family.
Confidentiality and Behavioral Disorders
When a person has been exposed to a cutter, she enjoys very little confidentiality so far as her symptoms are concerned. Often scars or bleeding are spotted by members of the family; sometimes hospital emergency rooms are involved to repair damage done to the skin, nerves, and tendons.
If a patient has sought therapy for mild anxiety or depression, the progress he or she is making is subtle, as is the unevenness of that progress—subtle enough to elude the observations of others, even family and friends, on a short-term basis.
The cutter, the anorexic, and other behaviorally disordered individuals, however, cannot conceal the success, stagnation, or worsening of their problem. It is apparent to all those close to them.
In addition, both the therapist and the family experience more worry when they don’t perceive steady progress, and can be thrown into desperation, even panic, if they see a relapse. This is due in part to the dangers associated with behavioral disorders and the sense of urgency to complete recovery. Everyone involved wants assurance that the symptom is gone, never to rear its frightening head again.
Because the symptom is so clearly observable, two important confidentialities are jeopardized: the patient’s and the therapist’s. I am not suggesting that therapists are not accountable for their success or failure, but the extra pressure of the family’s sense of urgency can hamper progress. In order to preserve patient confidentiality and to reassure the family, the therapist should let the parents know that they will be informed if there are any dangerous setbacks or injuries.
Dual Diagnosis
If the patient has more than one disorder that has been diagnosed, we classify this person as presenting a dual diagnosis. This term characterizes the patients discussed above—for instance, a person who self-mutilates and also has an eating disorder or drug abuse problem. These people are the most difficult to treat and pose the most dangers to themselves. In addition, they have the least even rate of progress toward recovery, the most conspicuous combination of symptoms, and therefore the least confidentiality. They also need the greatest number of specialists—often two for each disorder:
• The cutter requires a psychotherapist, a psychopharmacologist for prescribing medication, a physician to make medically necessary repairs, and occasionally a surgeon if the damage needs it.
• The anorexic requires a psychotherapist, often a psychopharmacologist, an endocrinologist, a gynecologist, and a nutritionist.
If drug addiction and alcoholism are involved, add to the above lists a detoxification unit, and specialized group meetings for members with the same problems.
It is less common, but not rare, to encounter a dual diagnosis patient with all of the symptoms mentioned requiring all these specialists and services, if the likelihood of recovery is to be maximized.
This can prove overwhelming for the parent to orchestrate, especially if the patient becomes reluctant to cooperate. Ideally, the psychotherapist should coordinate the various helpers as well as convincing the patient of their importance.
I entitled this chapter “Moving Backwards to Recovery” to emphasize that cutting is not just a bad habit at the optimistic end, or total, hopeless mental illness at the pessimistic end. It is a highly complex collection of mental defenses, which manifest themselves through behaviorally self-destructive physical acts but conceal a host of emotional problems and developmental deficits.
Holly: The Dual Diagnosis Cutter
Holly came for treatment at fourteen years of age. She was wellgroomed and unusually articulate. Her parents were both academic research psychologists at prestigious universities. She was just at the end of that awkward stage of puberty—braces on her teeth, legs too long for the rest of her body, feet and hands too large for her limbs, and with a gangly way of walking and gesturing.
She was referred to me for two problems, cutting and anorexia nervosa. She had recently been released from a psychiatric hospital with the warning that if she lost five pounds, she would be re-hospitalized. When I weighed her, I realized that she had been pushing the limits assigned to her. She was five foot two and weighed ninety-two pounds. Her hospital discharge weight was ninety-six.
Holly’s physician, while doing a routine physical examination, took a stethoscope to her chest only to find parallel cuts three inches long across her newly developing breasts. He did not make the assumption that this was a suicide attempt, though he reflexively shifted his eyes to her wrists, where he saw no cuts. Instead, he matter-of-factly asked her, “How come the cuts?”
Holly, who often used playfulness for deflection from confrontation, responded, “Mostly boredom, I guess. I don’t think they’ll scar. I bet they go away, not like tattoos—they’re permanent.”
The physician, keeping his cool, responded with, “Oh, we should be grateful that they’re not tattoos now?”
She shrugged. “Could be worse.”
The time for playfulness was over. “You’re charming and likable, Holly,” he admonished her, “but those red lines are a road map to severe trouble. Thanks for the smiles, but we have to refer you to someone who will change the direction you’re secretly heading.”
She offered no resistance. “Okay.”
“Do you want to talk to me about it?”
“Nah, too long a story. You don’t really have the time and I don’t want to ruin a good day for both of us.”
“You’re a good caretaker, Holly. Maybe too good. I’ll have to tell your mother about these,” he said, pointing to her chest.
She looked at him, alarmed. “Do you really have to? I’ll catch hell at home.”
Two weeks later, she came into my office with the same cheeriness she used to fend off the world from identifying her unhappiness.
“Hi. I’m Holly and Dr. Gilbert says that you’re a good therapist.”
Holly presented a seamless picture of the well-adjusted early adolescent. There was nothing in her likable demeanor to suggest the turmoil beneath this facade. She looked more like the finished product of a successful course of therapy. As her therapy began and continued she would look less mentally healthy. This was to be a trip backward, from the shiny facade to the well-disguised pain.
I addressed her opening comment. “I’m sure that Dr. Gilbert wants good care for you.”
She slumped a little in her chair as the realization sank in that she was already identified as a person in need, an identity she concealed to the best of her ability.
“I have a few problems that bother everybody else.”
“Are you saying that your problems don’t bother you?”
“Not quite. I’m saying that I wish they didn’t bother everyone else so much. I think that I can keep them to myself and take care of myself.”
I pointed to the stack of hospital reports on the desk. “It seems that whether you like it or not, others, professionals who might have a clearer perspective on your problems than you do, including a pediatrician who has known you since you were born, disagree with you.”
She shrugged, a bit more timid this time.
“So why don’t you, instead of all the others,” I gestured to the stack of papers on my desk, “tell me who you really are and what hurts you so badly that you have had to resort to cutting and anorexia?”
“I guess Dr. Gilbert is right. You sound better than the last two shrinks and I’ve only been here a few minutes.”
“I can see that you’re funny, very smart, and psych-lingo savvy. But all these traits haven’t helped you. Your symptoms keep screaming, ‘Help!’ ”
“My parents are both psychologists. That doesn’t help.”
“No, they’re not. When it comes to you, they’re parents. I’m the only therapist in the picture.”
“So, what are you going to do for me that they can’t?”
“Find you.”
“You might not like what you find.”
“I will probably like what I find and have a tough time convincing you to like and accept who you are.”
She stared at me unflinchingly, making intense eye contact. It looked like skepticism, but I kept going.
“Beware of me. You’ll have a tough time coping with me because I won’t let you hide in here. You can’t be alone when you are in the same room with me.”
“But I’m good at being alone.”
“Are you starving when you’re alone?”
“I’m also good at starving.”
“I’m sure you are. I see tears of starvation in your eyes.”
“What other choice do I have?”
“I’m going to invite you to depend on me.”
“What if I’m too difficult? Will you quit?”
“What do you think?”
She looked at the floor, watching her tears fall. “I hope not, and I hate to hope.”
“I am inviting you to hope. It will be okay.”
“Nobody ever said that to me before.”
Holly came to therapy three times a week for the first two months, eager to fill me in on her complaints about her parents’ empty marriage, their mutual but separate professional conferences and research projects. Her complaint was that they both ordered her around and yet seemed intimidated by her at the same time. She complied with their demands for fear of wounding them.
Her posture toward me and the therapy sessions began to change. Her eagerness, positive attitude, and talkativeness gave way to increasing withdrawal, and “yes”or “no”answers to open-ended questions.
Her cutting had ceased. Her pediatrician verified that in his two examinations spanning six weeks there were no new detectable scars, lacerations, or burns. But she had lost that fifth pound. This gave her no leeway to avoid rehospitalization should she lose any more.
I had asked Holly about her cutting and weight without mentioning her weigh-ins or the hospital possibility. She answered sardonically that I shouldn’t worry, she had both areas under control. This kind of withdrawal was not unusual for a patient who had surrendered so many long-term symptoms for a comparatively new relationship. She was not feeling relief from her underlying feelings of insecurity, of not belonging, of having no one to depend upon emotionally at home. At home she was simultaneously contemptuous of both her parents and compliant toward most of their wishes so as not to overpower them, at least in her own mind.
In withdrawing from me, Holly was doing what she did with her parents. She had no experience with being a trusting, dependent child, so she would move away from anyone who couldn’t make her feel secure enough for her feelings of distress to diminish. In the case of her parents, the insecurity was caused by their obvious unhappiness and their inability to rise above their own emotional exhaustion and depletion in order to offer her reassurance, warmth, and comfort when she required it.
In the case of her relationship with me, her insecurity stemmed from the limitations of the timed session, the scheduled visits to my office, her awareness that I had other patients, and that I was paid a fee to meet with her.
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Adolescents who are neediest for attachment experience the most suspicion that the therapist will be more interested in another patient; many even pretend to themselves that they are the therapist’s only patient. Their fantasy is that the therapist’s sole motive in seeing them is his or her caring for them, and they block out the issues of illness and recovery that brought them together to begin with.
Just as older symptoms often return in the “progress” of therapy, the therapeutic relationship goes through a critical period of reversal as the patient sees her fantasies of being quickly and totally rescued from her own negative feelings (and sometimes from her parent’s) evaporating. She begins to detach from the therapist and the process of therapy. She cancels appointments, comes late, leaves early, resorts to extensive periods of nonresponsiveness, and may discourage the therapist just as her returning symptoms discourage her family.
Are We Going Back to Square One?
It is at this point that a member of the family usually calls to find out why their daughter seems to be getting worse instead of better. When this occurs, it is a good idea for everyone to get together for a family meeting. Holly had shown me one side of her personality for the first two months. Now she was beginning to let her more angry side be seen by me. The family therapy session posed a sudden threat to Holly since her parents would be in the same room with me and she had been posturing differently to us. She would not know which posture to take, or which Holly to be. She was not yet ready to reveal the full extent of the sneers and other forms of rage that she directed at her parents, even though she was beginning to offer me samples of them.
Holly and her parents were expressionless in the waiting room when I went out to greet them. As they entered my office, their family faces emerged. The father was attempting a smile; the mother looked mildly annoyed at her husband, but when she turned in Holly’s direction, she looked sad and intimidated. Holly looked like the proverbial ice queen. Her jaw was set, her eyes narrowed, her lips tight against each other. Her head was turned at a forty-five-degree angle toward her mother. It was quite clear who her expression was aimed at.
“I see lots of different moods in the room,” I began.
Holly’s father responded affably, slowly, in a philosophical style, “Well, we’re a complicated family filled with complicated people.”
It was difficult to tell whether he was finished talking or was being interrupted when his wife commented, “Oh, all the other families seen here are simpletons?”
Holly looked in my direction and rolled her eyes in response to her mother’s comment, or to their interchange. “We are also a family in which each member is from another planet,”she said sarcastically.
Both parents turned toward their daughter, whose chair was between them. They looked embarrassed. Holly had been afraid that her other self would be revealed to me, but in reaction to the setting she decided to ally with me and embarrass her parents.
I looked at Holly’s father and addressed his description of the family. “It seems that you are an angry family suffering from a lot of disengagement from each other.” He nodded in agreement. Holly’s mother looked sad and Holly began to cry. I had never seen her cry before.
Then she said: “If I wasn’t born, there would be no family. You two never would have married, or you’d be divorced by now. If I’m the reason that you’re staying together, please accept my permission to get divorced. Look!”—holding up her arms—“I don’t even cut myself anymore. If that was keeping you together, it’s over. Yes, I know that I have other problems, and I’m not making any promises about them going away, but I hate living in our family.”
Her father, trying to be the voice of reason amid the turmoil in the room, intervened. “Holly, honey, what kind of change would make you want to live in our family? We are capable of change, if that would help you.”
“I don’t think that the two of you are capable of the kind of change necessary. I don’t think that you two love each other anymore, but I think that you’re both doing an excellent job of being civilized about it. We don’t have fighting in our family, we rarely disagree; as a matter of fact we—correction—the two of you hardly talk to each other at all. You don’t have to be a psychologist to pick up on that.” Holly reached for a handful of tissues.
At the end of the session, Holly’s mother assured her that they would work on their relationship with a marriage counselor and attempt to improve it as much as possible, or consider divorce, but things would not continue the way they were. Each of them gave Holly a hug and a kiss separately as they left.
In the sessions following the family meeting, Holly resumed a positive attitude toward her therapy. She had adjusted her expectations of therapy and our relationship to a more realistic perspective.
She remarked during the first session after the family meeting, “First it looked like our relationship was going backwards. Then it looked like my progress was going backwards, and it still might, a little more, but I’m trying. Now it looks like my parents are going backwards. What’s next?”
“I don’t know, but I guess we’ll keep digging until we hit bottom and there’s nowhere to go but up.”
“I hope we can hit bottom fast so we can start going up.”
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When a patient presents with cutting as a feature of her entire collection of psychological disorders, it is less deceptive both for the family and for the therapist to understand clearly how complex the treatment(s) will be, and how lengthy the amount of time that this will take.
If the self-mutilating has reached the status of disorder, it conceals the other problems that lie beneath it—from the patient herself and from those around her. Over time, as the self-mutilating symptom diminishes and the other psychological symptoms appear, it may feel to the family that there is no end of sickness possible. As a result, they may become discouraged.
A therapist familiar with the patterns this disorder can take will need to anticipate the emergence of other problems and communicate them to the family—ideally, before they show themselves. This minimizes discouragement on both the patient’s and the family’s part, as well as pressures on the therapist’s optimism and morale. It also avoids a split between the therapist and the family that would hamper recovery, especially in cases where many specialists are involved in treatment.
It is essential to maintain a unity among all the helpers in the face of this daunting illness.
In previous chapters cutting oneself and other forms of self-mutilation have been described as either features of other primary disorders subtyped as anger, depression, self-loathing, or dissociation.
In the next case I would like to emphasize cutting behavior as the tip of the iceberg.
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In previous chapters cutting oneself and other forms of self-mutilation have been described as either features of other primary disorders subtyped as anger, depression, self-loathing, or dissociation.
In the next case I would like to emphasize cutting behavior as the tip of the iceberg.
Polly: Cutting as a Clue
Polly was referred for treatment of severe or “gross cutting” by her physician and parents.
Polly’s presenting complaint was her phobia of one-eyed people and others who were missing limbs, toes, or fingers. She feared that this might happen to her as well, which would make her one of them. Polly was nineteen years old, five foot one, blond, moderately attractive but with a facial expression that varied only from blank to sad.
She explained that she had had this missing-limb phobia since childhood, beginning when she was eight years old. Her method of finding relief from the distress of seeing, or believing she had seen, such a person was to cut herself, often quite seriously, as if to copy the mutilation of the person just seen. If she saw a person she thought was missing a limb, she would make a deep cut on her own limb without remembering doing it. Polly was a gross cutter and an endangered one as well. More frightening still, her provocations were often not real. Triggers for Polly’s reactions were actually misinterpretations of what she saw or were imagined. She explained: “The cuts would just appear.” They seemed to be executed during dissociative states.
“It’s like I’m afraid of anyone who is broken, physically damaged, or deteriorating. I guess I would really be afraid of lepers,” she joked.
“Are people with these conditions—missing eyes or limbs—people you see often?”
“Oh, you don’t know how this works. When I get on a bus, or even a crowded elevator, I have to check everyone in sight to make sure they aren’t one of them. Often I see a shadow on someone’s face and think it’s a missing eye, or the seat on a bus obscures part of someone’s leg. I think it’s missing and I panic. I have to walk over to where he’s seated and make sure he has all of his leg. I’ve only cut my face once [she indicated a small cut extending from the corner of her right eye]. Sometimes it’s embarrassing, and people look at me like I’m weird. I guess I am. My mother always tells me, when I complain about this fear to her, that these are rare occurrences. She says I shouldn’t be nervous. Once she even said to me, ‘There’s no such thing as nervous.’ It made me feel crazy and doubt all my feelings. That’s another problem I have, I doubt all my feelings or my right to have them.”
Just then I noticed Polly suddenly sit up straight, pull in her stomach, and broaden her shoulders. Her voice became deeper and more assertive. Her jaw was set, her eyes narrowed, and her mouth turned down in an aggressive manner. She had a determined look on her face.
“I wish she didn’t have these silly problems. Sometimes she sounds like such a sissy. It embarrasses me.”
“Polly?” Her change of demeanor made her seem like a completely different person. Her reference to herself in third person immediately suggested the presence of another personality. “Is that you, Polly?
“No, it’s Skip.”
“How long have you known Polly?”
“I can’t remember, probably as long as she’s been a sissy. Look at these cuts. I’m not afraid of that stuff. Once I nearly cut off my arm or at least nicked an artery. My earliest memory is when Grandpa put his hand under my underpants and poked his fingers around down there. And even though they didn’t fit he would jam them into me.”
Polly had developed dissociative identity disorder (formerly, multiple personality disorder). Her grandfather had frequently molested her until she was six years old. This occurred when she was left with her grandparents to allow her parents to go out for the evening or even to take vacations for up to two weeks, providing ample opportunity for her grandfather to baby-sit her while her grandmother went shopping or left the house for some other reason. Polly did not understand the meaning of his molestations and didn’t know if she had grounds to complain about them. (Remember her mother’s squelching of her emotional expression: “There’s no such thing as nervous.”) She repressed or forgot the abuse, so it disappeared from her consciousness. His behavior stopped when she started school, and her feelings about what happened evolved into states of isolation and low self-esteem. She started cutting at sixteen, when boys began paying attention to her and flirting with her. Her phobias were in keeping with her fear of her grandfather, who had diabetes, and suffered from blindness in one eye and the loss of several toes due to his condition. She developed Skip as a full-fledged personality when she was eighteen to express her anger in the masculine style that she probably felt was more appropriate. Skip’s cutting was a mystery to her that occurred during “lost time” or while she was in a dissociated state. Cutters with dissociative disorders are the most endangered since they are out of conscious control and are for the most part victims of child/adolescent sexual molestation or rape, often by family members or close friends of family members, including baby-sitters.
Polly didn’t remember any of her grandfather’s abuse at the time treatment began. It would be my task to become trusted by both personalities in order to help Polly accept her assertive side and not fragment into another personality in order to express that assertiveness.
After months of treatment I could ask her by name to become either personality. I began telling Polly about Skip, which surprised her at first. I tried an exercise where Polly would “send a message to Skip” and he would reply. Gradually I reduced the amount of time each personality was speaking with me. Ultimately this involved her changing so rapidly from one personality to another that at one point the boundaries between the personalities finally broke down. Polly went though an experience of severe distress, she cried intensely and took out a knife to cut herself. Since she never cut herself as Polly, I asked “Polly”who was holding the knife at that moment.
“My grandfather!” she responded between sobs. The memories of abuse came flooding back. Skip disappeared permanently. We interpreted her phobias as relating to people whose deformities reminded her of her grandfather’s. It took us four more years to integrate all the facets of her personality as well as the intense meaning her grandfather’s abuses had taken. Her cutting abated somewhat within six months, diminishing in seriousness to small, inconsequential cuts. By then we both agreed that in time she would be able to give up cutting completely.
Aaron: Cutting as a Result of Heartbreak over Failed Romance
Unlike Polly, Aaron did not experience trauma or abuse but did suffer a painful loss—the breakup of a teenage romance, which profoundly impacted his self-confidence and emerging masculinity. He was especially vulnerable because he had had an emotionally isolated childhood.
Aaron was a nice-looking boy of sixteen with oddly unkempt hair deliberately arranged in an eccentric look, which was his interpretation of the tousled and moussed look of young male movie stars.
Aaron had been made fun of in elementary school due to his slight build and meek, timid temperament. Girls never paid any attention to him, even though by the time he was a sophomore in high school he wished for a girlfriend. Finally his wish was granted by a fellow sophomore—a rather dependent girl who made him feel masculine and heroic. Their adolescent romance involved lots of sexual “fooling around” but no loss of virginity. For Aaron, the sexual aspect of their relationship was thrilling, as it was a new discovery for him. When his girlfriend broke it off for another boy, he was crushed. He began by punching his head, banging his fists on brick walls, and finally discovered cutting—with a vengeance. He had to be hospitalized several times since his cuts were deep and were endangering him from both loss of blood and nerve severing. Aaron did not seem to have any aspects of the array of psychological disorders accompanying most cutters. He complained of painful feelings of severe loneliness and an inability to have serious conversations with others or get close to them.
Therapy with Aaron involved supporting his sense of maleness, discussing topics that included everything from bodybuilding to girls, who were complete strangers to him as personalities. He would come to sessions full of talk about conversations he had with girls and questions he had about them, which I answered. As therapy progressed, he talked of his own feelings of inadequate masculinity, and we focused on his growing understanding of girls and how to reduce his shyness around them. In order to promote confidence and develop a positive aspect of his masculinity, I also encouraged Aaron to pursue bodybuilding, which he seemed to enjoy. His cutting subsided and stopped within one year.
“I look at these large ugly scars on my arms and I can hardly believe I made them. I guess they will never go away and I’ll always have to explain them to people. I’ll just limit that to saying that ‘it was something I went through and am glad it’s over.’ ”
Aaron went off to college after only a year and a half of treatment and has been doing well for the past three years.