ACHIEVING GENUINE COMMUNICATION WITH OTHERS
Assertiveness Testing
As recovery progresses, the patient has learned how to translate her feelings into words, rather than act out these feelings in self-harming behaviors. She has learned to utilize help from another person to do so, and now has the emotional leverage of this relationship with which to test out her new verbal thinking and talking skills, with others, outside the protective setting of therapy or any other caring relationship with which she has accomplished these achievements.
Her therapist or other helper must now encourage her to express her likes and dislikes to others, both within her family and in social settings. The results of this stage of treatment are reviewed in meetings with the helper or therapist.
Typically, such a patient has a history of not being able to confront others, or even to disagree with others over such routine matters as which movie to see or which restaurant to eat at. She has usually been more comfortable as a secret dissident follower, unhappily acting as if she agreed with other people’s choices. Throughout, she has remained compliant, obedient, passive, and falsely cheerful about decisions that include her and demands made upon her. She has learned not to care about her own needs, or to develop opinions and choices about minor as well as major issues that affect her.
Her “assignment”therefore becomes developing assertiveness, whether it is to initiate a plan with friends or family, or to disagree with a plan initiated by another if it displeases her, i.e., defend her personal rights. She has been most comfortable in the role of one who nurtures, supports, and agrees with others. A more assertive role at first will make her uncomfortable and anxious, fearing that she will be disliked if she is seen as demanding.
This issue has to be discussed at length and weekly reports of appropriate shifts in her behavior toward others should be reviewed. She is not asked to become a troublemaker or manufacture false issues with which to disagree, only to protest decisions that are truly to her disliking.
Coaching and Role-Playing
A therapist or other helper can coach her as to how to handle an anticipated conflict. Role-playing becomes very useful here. In this exercise, therapist and patient have practice discussions, often exchanging roles, to prepare for possible confrontations. Let’s see how this is in fact done.
Elaine: Role-Playing in Action
Elaine, who had given up both her anorexia, prior to entering college, and her cutting, during the first month of her freshman year, was still unable to be assertive. She joined a sorority. It quickly became apparent to the other girls that she didn’t drink alcohol and that she was not on “intimate” terms with boys yet. She was liked by the other girls but teased as the “virgin goody-goody.” Elaine needed to prepare a response to her sorority sisters, one that could express her real thoughts and feelings without alienating them.
In sessions, we discussed her lack of readiness for romance and her unwillingness to drink alcohol. She could feign drinking by pouring herself club soda with a twist of lemon, so she wouldn’t be teased, or try the alternative—demand that the other girls simply accept that she doesn’t drink. She preferred the latter, so we role-played her statement of her choice, with myself playing the part of her friend.
“Elaine, what’s the big deal about having one drink and loosening up a little? It might even help you be more relaxed about guys.”
“I don’t need to be high to enjoy myself. I don’t need any artificial ‘loosening up,’ as you put it, to enjoy a guy. I can do that all by myself, without the help of alcohol.”
“But you are never with a guy except your guy friends. How come?”
“Because there isn’t a guy I met yet that I want to be more than friends with. Maybe I’m just fussier than everyone else. I’m not saying that’s better than anyone else, or worse, for that matter, it’s just who I am. Can you deal with me being that kind of person?”
I felt that this last demand would stop the other person from harassing her on those two issues, so I called an end to the role-playing.
“Elaine, that was very good. It only took us three times for you to get to that level of assertiveness. Do you think that you could say that in the sorority house if you’re teased about those issues again?”
“I don’t know. I was a little surprised at what came out of my mouth just then.”
“Was it sincere?”
“Yes.”
“Then why not try telling others who you really are?”
“What if I get them mad at me?”
“What is the worst scenario you imagine about them getting mad at you? They already tease you. Do they dislike you?”
“No. I think that they like me okay.”
“Then you think that this kind of conversation would make them change the way they feel about you?”
“Probably not. It’s just not me . . . to be disagreeable.”
“Would you rather the teasing went on until all the boys involved with the sorority joined the girls and you became ‘defined’ by that phrase you complained about before?”
“So there is no easy way out?”
“I think that when you’re changing your style and posture with others it has to make you tense, but that’s better than putting up with what was happening before.”
“You think I’ll lose progress if I don’t change?”
“What do you believe?”
“I think I’ll want to hurt myself—because I’ll get so mad at them.”
“What you’re saying is that if you don’t get assertive with them, and stop them from treating you like you’re inferior and not grown-up enough, you’ll get inwardly angry at them and take it out on yourself. And that can’t possibly change their behavior toward you or redress your grievance in any realistic way.”
“I guess I hardly ever think that I can change anybody’s behavior toward me.”
“I guess it’s time you gave it a try. Oh, and don’t worry. They can’t hear your heart pounding from nervousness.”
Elaine had her confrontation, much along the lines we practiced, and it produced the results she hoped it would. The girls backed down on their teasing and her self-esteem rose.
Elaine could now attend socials at school without fear of being called the “virgin goody-goody.”After a while most of the talk behind her back dropped off.
Elaine felt a sense of victory and was pleased to see that boys who came to the sorority mixers approached her, not having been warned off her by gossip. Within a year of this change, and a few light dates, Elaine became involved with a boy who was as shy and inexperienced as she was. This involvement raised her status among the other girls in the sorority and everyone stopped noticing that she didn’t drink alcohol. Her own self-confidence was growing.
One day she came into my office looking serious. “I have to ask you something important.” I nodded and waited.
“You know how many scars I have. What do I tell Bill about them? How much do I tell him about my problems? I haven’t even told him that I’m in therapy. Should I tell him?”
“What is your greatest fear about telling him about the scars, past problems, and that you are in therapy?”
“That he’ll think I’m crazy, mistrust me, or even break up with me.”
“I imagine that he’s already familiar enough with you physically to have seen many of your scars, is that accurate?”
She blushed a bit and nodded.
“Has he ever asked you about them?”
“No, he’s not the pushy type. I mean, we exchange information about each other, but we know to wait for it to be offered. Neither of us asks for what hasn’t been brought up by the other. We’re both equally private and shy, I guess.”
“Do you know if he’s ever been in therapy?”
“No.”
“What would you think if he told you that he is, or has been in therapy, and has had problems in the past, and still has unresolved problems that he’s working on?”
“I guess I would wonder what they were and would want to know about them.”
“Why would you want to know about them?”
“I guess I would want to know that he wasn’t a killer, or a pedophile or anything perverted like that.”
“Do you think that your problems fall into the category that you just mentioned?”
“No, I guess not. But I am ashamed that I did those things to myself.”
“Do you think that you’re attractive?”
“I guess I’m okay but nothing great.”
“Do you think that Bill thinks that you’re attractive?”
“He’s always saying that he thinks I’m gorgeous. I think he’s crazy, but I like hearing it.”
“Do you think that you are a harsher judge of yourself than Bill is?”
She nodded in resigned agreement. “So I should tell him?”
“It’s a big secret to keep. I think it will be hard for you to feel secure with him if you feel that he’s in love with a false personality you have created. I don’t recommend that you tell someone about this on your first date, but if you’re seeing each other for months and maybe getting serious about your future together, it might be time to get ready to tell him.”
“But what if he leaves me?”
“I don’t believe that he will leave you, but I can see you’re worried.”
“Do other girls feel like this? You know, ashamed of themselves? Scared about new people in their lives finding out about the cutting?”
“Your fears are understandable, Elaine. But don’t lose sight of what you know—Bill cares about you. And in many ways, we all have scars.”
Elaine decided that we would discuss this in future sessions, until she felt ready to tell Bill.
Echoes from the Past
Elaine’s questions and feelings are representative of those expressed by many people who have been through therapy. Though they consider themselves recovered, they still feel frustration and regret that they ever had the problem to begin with. They also feel sad about the lost years when they might have enjoyed their adolescence, or their young adulthood, or some other segment of their lives.
The last part of therapy should address these issues, especially with people who have had what I term behavioral disorders, which were obvious to others and at the same time crippling to their development. During her illness, those around the self-mutilator wanted to shout at her, “Are you crazy? Why don’t you just stop hurting yourself?”The recovered cutter forgets what she was going through at that time and now asks herself the same questions: “Why was I so crazy for all those years? Why didn’t I just stop it?”
Those who remember the turmoil remain sympathetic to the person that they used to be, and have less regret to deal with. Forgetting may buy one kind of peace but produces other problems, just as being currently unaware of emotional pain can produce mental illness.
Elaine had achieved a good level of recovery and was using her therapy and role-playing to prepare for real-life relationships. Other self-harmers need a longer time to recover, and their milestones of recovery are marked by an increase in communication, first with the therapist, then with others. We see this with Sonia, whom we first met in chapter 3.
Sonia: Communicating with the More Troubled Patient
Though some self-mutilators recover, do not resort to their old self-destructive behavior again for long periods of time (several years might serve as a criterion), and are not tempted to cut or burn themselves, others find the behavior persistent. Even with effective treatment, they could be described as chronically recovering as opposed to recovered. This is not to suggest that the patient will never achieve recovery. That will vary from individual to individual. But the behavior and temptation to do it again will persist for an indefinite period of time.
Sonia, the cellist, had experienced so much neglect and verbal, emotional, and physical abuse throughout her formative years and after that complete recovery for her would be years in coming, if ever.
One day she came into session looking very unhappy. It had been four months since she had cut herself; she was beginning to think of herself as recovered, finally. She hadn’t carried anything with which to cut herself for a year and had only scratched herself once in the previous eight months. That was the incident four months earlier. We had both discussed it as being one of the mildest, in terms of damage to herself, that she had ever done. It was a bump in an otherwise nicely progressing recovery.
Today, she looked sullen, weary, hopeless. Silently, she shook her head. She sat down, continuing to shake her head, staring at the floor. It was clear that I would have to break the silence.
“Sonia, you are showing me with many gestures that something is seriously wrong. Now I would like you to tell me what that is.”
Sonia’s style had always been to express herself with gestures first and words last. Postponing talking as long as possible, she pulled up her left sleeve to show me the underside of her forearm, which had a two-inch diagonal cut, clearly made with some sort of blade. The cut was crossed at three points with adhesive tape strips that ran almost completely around her arm for maximum anchoring. She had fashioned three butterfly clamps to reseal the slit that the sharp instrument had made in her skin.
I remained silent as I looked closely at the cut.
“I’m never going to get better. . . .” Her voice trailed off. “I really believed that I was finished with it. Now it’s back. The cut is deep. It’s long. There was a lot of bleeding at first, until I sealed it as hard as I could. I even put an icepack on to stop the bleeding as soon as possible. I almost used a tourniquet, but it was too awkward, so I held my arm above my head, taped, with an icepack on it. I wanted it undone, not to have happened, to go back in time!”
I didn’t steer her away from her bad feelings too quickly. That would have made her angrier at herself and angry at me for making light of it.
Matching her seriousness, I responded with, “This is the most serious damage you’ve done to yourself in a year.”
“So, you see. I’ll never get better. After all the new insights I’ve developed, the new coping mechanisms I’ve substituted for cutting, the new language I’ve learned to express my feelings [all said in mocking sarcasm], here we are!” she shouted, waving her injured arm at me.
“You are as angry at me as you are at yourself. You are feeling that both of us have failed. If I had not failed you with that list of ‘growth items’ you just named, this would have never occurred.”
She looked alarmed. I was the closest person she had ever expressed anger at directly. And this was the first time.
“No, you misunderstand me! It’s not your fault! It’s me. I’m hopeless. You have good methods. It’s just that nothing will work with me.”
Sonia was frightened to see me as less powerful and all-knowing than she had come to expect of me. Our relationship had parent-child elements to it and no child wants to see her parent devalued. Then she would be alone, parentless. Sonia had to make it exclusively her fault if she were to be able to keep me intact as a dependable person. She yelled at me as a child blames a parent when she is angry at herself.
I had to help her reestablish the value of her therapeutic progress in her own mind.
“Is the way you reacted emotionally after cutting yourself, and the actions you took immediately afterward to treat the wound, the same as you would have done three years ago—before we began treatment?”
“No,” she responded grudgingly. “I would have watched the blood run down my arm, even stain my clothes. I would have wanted to take a bath in my blood. I would have cleaned it up and concealed it afterward to avoid getting caught.”
“Were you in immediate danger of getting caught this time? Is that why you took such quick and effective steps to end the episode?”
“No. Nobody else was home. My mother would not be home for hours.”
“So why the rush? You could have let yourself do some more bleeding before repairing it.”
“Because I don’t feel the same way about it anymore. I hate it now!”
“Could we call that progress?”
Relief swept across her face. The devaluation she had conferred on us both was receding.
“So does that mean I’m not hopeless?”
“It means that your recovery is slow and uneven, which is frustrating to you, but not hopeless.”
“So when is this going to be over?”
“You want the date?” I smiled. Sonia returned the smile.
“Yeah,” she replied, nodding for emphasis.
_______
Sonia’s scenario demonstrates a slower rate of progress than Elaine’s. Many issues affect these differences in progress. Elaine was not abused by her family. Though there was some parental friction, it could not be considered severe. The presenting symptoms of these two girls contrasted strongly in the area of communication, and the degree of acting-out behaviors. There may even be genetic or chemical differences in their respective predispositions toward anxiety, panic, and depression. That, of course, is purely speculative since we have no way of measuring this factor.
There is also a contrast in the emotional health of these two girls’ parents, as illustrated by the differing behaviors directed toward each by her parents: Sonia’s parents were abusive and Elaine’s were not. I am not suggesting that Elaine and Sonia are at opposite ends of the spectrum. There are cutters healthier than Elaine and sicker than Sonia.
Sonia had made remarkable progress in her communicating skills with me (sarcastically alluded to above), but had a great deal of difficulty in confronting others and verbalizing her dissatisfaction with their behavior or choices. Her wishes had been so violently denied and crushed in childhood that the risk of expressive communication with others outside the therapy office terrified her. This last cut was in reaction to a boy who came an hour late for their date, took her to a movie she didn’t want to see but was afraid to object to, and wanted to return to his apartment with her to “fool around” sexually, with which she also passively complied.
We spent the next few months role-playing situations where she would have to say, “No,” or, “I’d rather do something else,” or, “What I’d really like to do is . . .”
Whereas Elaine could risk a new “script” with others, Sonia, due to her past history, needed much more reassurance and practice, to state her wishes or objections to others.
Our meetings involved role-playing similar to the work I did with Elaine, but I had to begin by playing both roles at once. For example:
“John asks you to go to a bar with him for a drink. You answer, ‘No, I’m underage and I don’t have a phony I.D.’
“He assures you that they are casual at this club and won’t check.
“You reply, ‘I don’t like to drink anyway. It makes me uncomfortable.’ ”
Sonia looked worried as soon as I explained the script. Reflecting her worried look back to her, I asked, “Is there anything in this script that doesn’t represent your true feelings?”
She shook her head as if all speaking was suddenly dangerous.
“Sonia, say, ‘I’m underage and I don’t have a phony I.D.’ ”
She stared at me for a minute.
I went on, “We are not up to the part where you object yet. We are building up to that with an excuse to see if he takes the hint.”
That seemed to make it easier.
Slowly, almost inaudibly, she began, “ ‘I’m underage and I don’t have a phony I.D.’ ”
“Sonia, that was good. Now try it again louder.”
Eventually she would get so used to repeating the answer that she would be more comfortable with its confrontational nature.
After a month of rehearsing various statements of objection, and choices, Sonia walked into the office one day with a big smile on her face.
I responded with “Yes?” in anticipation of good news.
“You’re going to be so proud of me! Wait until you hear this! He did ask me to go to a bar and I said all the stuff we went over, and he backed down because I said it made me uncomfortable. I didn’t think that my feelings or wishes were reason enough for anyone to change their mind about anything!”
“Do you think it will be easier for you to tell people what you want or don’t want to do in the future?”
She chuckled and rubbed her hands together. “Yeah, you bet. This is only the beginning. I know I won’t always be able to do it, but I bet I do most of the time.”
“I think that you’ll discover that once you believe that you can express your needs and get them met, you’ll take more chances in getting closer to people. You will have faith in yourself that you can protect yourself from others, should the need arise.”
Sonia seemed transformed from the shy, frightened victim I met three years ago to someone who was anticipating a bright future. She still understood, however, that her recovery would be a bit bumpy and that she would experience some of her old feelings, especially in times of stress.
The issue of whether or not someone will never repeat her symptomatic behavior again in her life is simplistic. We all learn to express our hurt through certain actions and reactions very early on in life. If life is good to us, we will never have to reexperience old feelings and reactions that we have outgrown. If life presents us with extreme disappointments, tragedies, catastrophes, on the other hand, then we may react to previously outgrown actions temporarily until the situation has passed. We do not go back to square one. We have a setback and then it passes.
Sonia began to make rapid progress in improving her social life with both girls and boys her own age. As new conflicts arose, usually about minor issues, Sonia would come in and announce the conflict, then she would request a role-play with me to “solve the problem.” When the “script” succeeded, she would come in the next time all aglow: “I did it! It worked!”
Eventually these requests diminished and we reviewed situations she could approach without a script.
For many individuals whose social development was impaired by their withdrawal into mental illness, therapy must not only help them to become healthier within themselves, but must teach them how to cope better outside the therapeutic environment. Whether they have been in a hospital, a residential treatment center, or an outpatient therapist’s office, their recovery must include coping better with the rest of the world.