ANALYZING AND CONFRONTING THE PAST
Although it is not fashionable to blame others for one’s problems, certain problems are unmistakably linked to the awkwardness, ignorance, indifference, insensitivity, and yes, even malevolence of a family member and others in close proximity to the victim. The milder adjectives at the beginning of this list require less intense confrontations between family members.
Where serious confrontations are necessary, often it is better to have them take place in a therapist’s or family counselor’s office. This type of family session is especially important when destructive acts, such as physical abuse, have to be dealt with.
Incest and Physical Abuse
Confronting the person who inflicted the original physical or sexual abuse allows the victim to stop hurting herself. Remember, the victim thinks that she deserved the abuse, or that the abuse was normal and therefore should either be continued by others (battering husbands) or self-inflicted.
In confronting the abuser, the victim reinforces what she has learned in therapy: that adults are responsible for their actions toward children and that there is no excuse for blaming the victim of abuse. It is important to focus her anger on the perpetrator, pending an apology, so that she can heal from all past experiences. This will enable her to give up subsequent disorders that were developed in order to adjust to the original damage, as well as to repeated attacks.
When confrontation is not possible—whether because of a lack of willingness on the part of the perpetrator, geographic unavailability, the extreme age or death of the person (or persons) involved—the recovery is far more difficult to achieve. These confrontations are extremely difficult for all parties involved; it is important to understand that they are not held for purposes of revenge but to clarify responsibility. At these meetings the perpetrator must confess to wrongdoing; assume sole responsibility, with no excuses; and apologize to the victim.
Confronting the Shame of Having Had a Mental Disorder
Recovering patients, in the last stages of their therapy, often express feelings of profound shame about having had a mental disorder. They are regretful about the time lost, which may amount to many years. They feel that they are behind others their own age as a result of being “out sick” for so long, and worry that they will never “catch up” in the sense of achieving emotional maturity, job or career development, social skills, and romance.
All of these issues must be dealt with before therapy can be considered complete. People who have recovered from a mental illness need to be reminded of their enormous achievement, and the unusual and valuable education they have acquired in the therapeutic process. Generally, it is helpful if a therapist, or a member of the person’s family, can coach them on how to deal with issues that may now arise in the real world, to role-play solutions, and to follow up with a review on how the person fared with putting the strategy into practice.
Self-help groups exist for people who have experienced mental illness and have recovered but still are left with feelings of low self-esteem due to their illness. If the person has been hospitalized in a psychiatric facility, the stigma and accompanying feelings of anger and shame are intensified. Some hospitals even offer post-discharge meetings to cope with these issues.
Blaming
The issue of why a person became ill in the first place is something that most recovered people think about occasionally. However, when someone is preoccupied with thoughts of who to blame, they are bound to act such thoughts out—either against others or against themselves. If they continue to blame themselves for lack of an apparent villain, they may sabotage their own success.
Self-blame is caused by feelings that the individual doesn’t really deserve to recover or to be treated as a success. Beneath successful behavior toward others may lurk the uneasy feeling that “If they really knew who I have been, and who I may be [a fraud], they would lose all respect for me.” As self-esteem increases, this fear will diminish.
A major issue for the recovering cutter, as for persons recovering from other mental disorders, is a lack of appreciation for just how much they have been through and what they have overcome. Self-confidence can develop when friends and family take note of this achievement. Letting go of blame—whether of oneself or others—is an important aspect of the healing process.
The Fear of Incomplete Analysis
Most of us believe that we will never understand ourselves completely. People who have recovered from psychiatric problems sometimes are concerned that if certain unconscious insights have not been uncovered, they will remain vulnerable to more problems or even to a relapse. This is a two-sided issue. If there are serious feelings that have not yet been explored or interpreted, they may indeed prevent permanent recovery, since the individual will not be aware of behaviors or situations that reflect past, destructive experiences.
On the other hand, over-analysis can lead to a person becoming so preoccupied that the search turns into a useless obsession, even inducing problems that did not exist before. Endless speculation about oneself creates a style of self-absorption or narcissism that produces social penalties. After the intense experience of self-exploration provided by therapy, the recovered cutter should remember that perfection is never a healthy goal, even in recovery.
The Scars
Unlike many psychiatric and psychological disorders, cutting leaves scars, literally. This is permanent proof that the person had the disorder. Anorexics, after they have gained their weight and recovered, look like anybody else. They may be left with an excessive fear of becoming overweight, and keep themselves a bit too thin, along with other idiosyncratic eating patterns. But this fact is not as obvious as the actual scars that recovered cutters must contend with.
There are only a limited number of explanations that the former cutter can make up to explain away such scars. Some include in-line skating accidents or skateboard mishaps, but even these are limited to appropriate places on the body.
Scars, then, become the most visible and explicit stigma for the recovered cutter to deal with. One has to choose between the deceptive—“I hung out with a group of kids who were into this crazy scarmaking” (disassociating oneself from its former meaning)—or telling the truth. The truth is often the best explanation, though the information should be limited.
When a person is referring honestly to the origins of scars, it is important that the interrogator does not merely pose questions in order to gratify their own curiosity. Answering questions like, “Did it hurt?” or, “Did you know what you were doing to yourself?” leave the recovered cutter feeling humiliated and exposed, and often create tensions that resemble old feelings and anxieties.
An exception might be made for a patient’s long-term best friend, fiancé, or spouse. Even then, any questions should be minimal, unless the desire to make the disclosure comes from the former self-mutilator herself; otherwise, the information is none of the questioner’s business. A good way to respond to such questions or offer an explanation is to say, “These are scars from a very painful time in my life. I’m grateful that it’s in the past.” Within a really close relationship, of course, increased sharing should be a natural and gradual process.
The Persistence of Hereditary and/or Chemical Disturbances
People who are blessed with very calm nervous systems, who come from families with little or no history of mental illness, are the least likely to develop mental or emotional disorders. Family life has a powerful influence on a child’s developing emotional stability. Yet in the same family we often see one child who grows up with relatively few emotional problems while another develops significantly greater problems and is diagnosed as mentally ill. There are some families in which all the children have severe psychiatric problems.
The recovered cutter not only retains her physical scars but the neurochemical/hereditary factors that contributed toward her predisposition to become mentally ill in the first place. Patients who are put on medication always ask me, before starting it, “Will I have to be on this for the rest of my life?” I have no way of knowing for certain, nor does anyone else. Some people use medication for a year or two, to help overcome their “mental crisis period,” and then can stop using it. Others find that when they do discontinue their medication, overwhelmingly painful feelings return. If these are not reported promptly, cutting or other symptoms can reoccur. In such a case, the person will need to be on medication for an open-ended period of time.
Individuals who have recovered from their symptoms do not “recover” from their chemistry. Even if they have discontinued their medication and feel that they can do so without experiencing abnormal emotional pain, they still find themselves wondering whether they remain vulnerable to relapse due to their nervous system.
I usually explain that each of us develops a way of coping with emotional pain, whether it’s a safe way—getting lost in a hobby, workaholic behavior, and so on—or an unsafe way—impairing or destructive behaviors, cutting, anorexia, alcoholism, and many other “choices.”When the pressures and problems subside, we are freer to give up our unsafe coping mechanisms. Some can simply be relinquished; others may require treatment in order to give them up.
When someone has overcome one of the unsafe coping behaviors, like cutting, and is considered recovered, some future overwhelming event or catastrophe might produce a short temporary relapse. The likelihood of this is greater if the person has “vulnerable” chemistry. But the more complete the treatment, the recovery, and the family support available, the less likely the relapse, despite this unchanged hereditary chemistry.
Medication and Self-Esteem
For the recovered cutter who continues to have to use medication because without it she had relapsed either into cutting or into other behavioral problems such as depression or anxiety disorder, special issues have to be addressed.
“Can I call myself recovered if I have to stay on medication until God-knows-when?”
This question comes up often because the recovered cutter has a major issue involving self-esteem. One does not recover from one’s heredity. If medication is required to normalize hereditary/chemical problems, the patient needs to understand that we are maintaining a normalization of her nervous system, but that she still has been victorious in defeating the symptoms generated by this genetic impairment.
Medication alone “cures” very few behavioral psychiatric problems, only those that are purely neurological in origin. Cutting is not in this category. When medication alone, or medication with a minimum of psychotherapy, is used to treat these symptoms, a relapse is more likely for several reasons: people miss the symptoms (even if they are the self-infliction of pain) that they have used to soften unbearable feelings. They most often need a therapist to help them let go of, or mourn the loss of these “loyal” and familiar symptoms. If they were treated only with medication, usually when they stop taking the medication that was relieving their need to experience or perform their symptoms, those symptoms will return.
Treatment involves an exchange. If the patient is experiencing a form of relief from her unwanted feelings by using a symptom (what we call symptomatic relief), someone will have to give her a compensating way of obtaining relief from the unwanted feelings. This compensation may be a different behavior, and/or a different quality of relationship with one or more other people (especially in cases where she is feeling alone, unable to trust and depend upon another). Medication alone does not satisfy either of these two issues. A helping relationship must be added to the mix.
When the patient has overcome her problems, using both psychotherapy and medication, she needs to receive recognition for having used the therapeutic relationship to find and accept a healthy alternative to her “symptomatic solution” for her unbearable feelings. The medication must be credited for freeing her from anxious, irritable, fearful, and depressed feelings that crippled her ability to use therapy. But she also is realistically entitled to credit for struggling through the unfamiliar emotional territory she has crossed on her way to recovery, as well as for her refusal to give in to the temptation to slip back to her familiar “old friend,” the symptom.
It is this recognition—by her family, friends, and therapist—that supports the patient’s newfound self-esteem. Parents and friends should certainly feel free to make positive comments: “Beth, you’ve been so brave to make this change,” or, “I’m glad you’ve been telling me how you really feel—I know your recovery wasn’t easy. I’m so proud of you.”
It is important that the patient understands that the continuing use of medication is simply a regulating or normalizing device she is using as she might for any chronic illness. The medicine acts as a general chemical support. The changes were made by her as a person, not created by the medication.
Outgrowing Old Attitudes Toward One’s Self
When the old symptoms have been eliminated and other external social behaviors and relationships with one’s family improved, the self-mutilator would seem to have recovered. But there is still one more important change that must occur. That change involves the value that the person places upon her own self, her personality and character traits.
When someone begins treatment, I generally ask, “How do you feel about yourself?”
“What do you mean?” is the usual response.
“Do you think that you’re smart, pretty, clever, interesting, patient, generous, caring, tough, likable, thoughtful, stubborn, or any other traits you’d like to throw in?”
In the early stages of treatment, I get the same profile of answers. I get a yes to “caring” and “stubborn,” and a no to the rest of them. Some patients alter my list, including “boring, ugly, stupid, selfish, unlikable,” among other negatives. Some include “tough” as an attribute that they possess.
Toward the conclusion of treatment, we take stock again, and the overall picture is much more positive.
The most significant comments that patients make about changes in themselves concern feelings they lived with all the time and that they now don’t experience any more. These are best summed up by one girl who stated, “I used to always feel empty, like there were no words or ideas in my head. I would look in the mirror and find, in my reflection, a stranger. It was hard for me to care about that stranger. Now I feel that I know myself, and I do care.”
What this young girl is saying refers to the change she feels about her sense of identity. Over the course of treatment, she learned a new language which enabled her to think about herself and express herself, and eventually to believe in what she was saying. In effect she is saying, “I didn’t used to feel like I had a self. Now I do.”
Regret
Regret is related to blame but even more to frustration. “How could I have done this to myself? I must have been crazy. Look at these scars! I’ll have to get a plastic surgeon to remove some of them. I used to be so proud of them—they showed I could take pain. Now I want to throw up when I look at them. I hate taking baths. At least in the shower I don’t have to really look at my skin.”
The regrets expressed by many ex-cutters are interwoven between the general state of illness they experienced, and the physical confrontation of the scars. It becomes important here to deal with the relationship between blaming, regret, and the scars themselves.
The key here is for all those who are involved to help the recovering cutter forgive herself for making an honest attempt to find a solution, no matter how maladaptive it turned out to be and finally how obsolete it became upon recovery. Again, positive comments from friends and family can be an invaluable source of validation. The helping person can be direct in their support: “Beth, I hope you don’t blame yourself for everything you’ve been through. I know your cutting was an attempt to solve a problem you didn’t understand.”
Individuals who “adapt,” as children, to unbearable feelings, and dysfunctional aspects of their family, by employing what later becomes termed psychologically disordered behavior, upon recovery may have a hard time forgiving themselves. It becomes a major task for those helping them to convince them that they simply did the best they could under difficult circumstances, with no trustworthy guidance available at the time.
The Family’s Recovery
The aftermath of the cutter’s recovery varies greatly. Some families find the nature of the causes (especially incest) reason for divorce or breakup, whereas others remain in a state of apprehension, wondering when the illness will strike again. “Has it gone underground temporarily, or is she really over it?” one mother asked me anxiously. In a way, the family’s reaction to recovery is often similar to the doctor’s declaration after cancer surgery. “We got it all,” says the doctor, “but we’ll know for sure if it doesn’t reappear for seven years.”
If the family reacts to the recovered cutter as if she may relapse at any time, they are emphasizing their alienation from her. They are almost watching her from afar. Earlier, we saw how a failure in the attachment-dependency-trust axis can erode security in the family relationship. Success in these areas leads to incorporating family values and developing and maintaining feelings of security. Watching one’s daughter suspiciously after recovery produces a separation, a suspicion, almost a paranoia, on the part of parents toward their child.
It is unrealistic to expect parents to forget the terror and heartbreak that they have been through as a result of their daughter’s (or son’s) illness; but improved communication and closeness—rather than watchfulness—will slowly erase these fearful feelings.
I am of course recommending behaviors and attitudes suitable for families when recovery does seem to have taken place, and not while the illness is still active.
Each family needs to examine the past and understand, undefensively, what went wrong for their child. Like the recovered cutter, family members have to deal with events and relationships at an earlier time in the family’s history that blocked the parents from extending the invitation and the emotional safety to the child to communicate his or her feelings. Such a climate would have eliminated the development of the illness in most cases.
This kind of exercise is useful for the family in that they have to remain vigilant about the reoccurrence of the family’s dysfunction instead of the child’s illness. In this way, they create and maintain dialogue and closeness within the family, instead of fear and suspicion.
The most important family behavior is communication. Ask yourself the following questions:
• Do I sort out my feelings before I speak?
• Do I take responsibility for how I affect others?
• Do I deal directly with each family member in a considerate manner?
• Do I apologize when I’m wrong?
• Am I honest in expressing what I want and need from other family members?
These healthy behaviors were probably not role-modeled for parents in their own families, so they should be sure to get professional guidance if such changes are too difficult for them to achieve or maintain alone.
Warning signs of relapse include a renewed sense of isolation or lack of commitment on the part of the self-harmer; a superficially cheery manner that seems “unreal”; or an increase in excuse-making for withdrawing from normal activities.
Regaining One’s Lost Social Place
It is typical for the recovering cutter to feel disheartened at times, complaining: “Nobody calls me anymore. When I call people I used to be friends with, they don’t return my calls. Even when they do, which is rare, they just make light talk and get off the phone as soon as possible. I feel like I’ll never have friends again.”
In return, I might respond that “I think your peer community has learned over the last four years to become afraid of you. They’ve seen your scars. Apparently, your family, in their own despair, have turned to their friends, some of whom are your friends’ parents, and word got around. My guess is that at first you were seen as suicidal, then after a while people began to see these repeated attempts at ‘suicide’ as frighteningly crazy.”
I have heard of parents telling their own children to stay away from another child in the community who exhibited signs of emotional problems or mental illness. They may have been afraid that the illness, especially in the case of destructive acts, would be “catching,” or at least influence their own children negatively.
Aside from parental influence, peer pressure develops to stay away from cutters because they have mental problems (especially if these last for years). People may feel that their own esteem in the peer group would be lowered if they are seen hanging around with a self-mutilator.
Finally, there’s the individual friend’s fear that the cutter is “lost to them” by becoming unpredictable. Her “mystery behavior” frightens them. They have been frightened of her for years now; that’s how they think of her. It’s going to take a while to teach them, repeatedly, that the self-mutilating behavior is over.
I returned to my discouraged patient with some instructions. “You will have to indicate, to your chronically frightened community, even announce, ‘Hey, I’m back! You don’t have to be afraid of me anymore.’ ”
“Won’t that sound even weirder? It might scare them further away from me.”
“I’m suggesting that you say something like this in your own words, but playfully. I think you will have to disclose that the behavior that everyone understandably backed away from is long gone; over. That gives you a chance to tell your friends that you don’t blame them for backing away from you.”
In a session several weeks later she grumbled a bit in our discussion of her “social return.”
“I’ve noticed,” she began, “that for a while it did work. I called everybody again and again until I got return calls and even invitations to go out with my friends. It’s still not the same as it used to be. If there are three of us going somewhere, two of them quickly jump in the front seat of the car, leaving me alone in the back. It’s not that they don’t talk to me at all, but they seem to have so much more in common with each other—stuff that happened when I was sick, guys they met when I was ‘out of it’—so that I still feel left out.”
“When we started this ‘social reentry’ program, your friends weren’t returning your calls. Now you’re at a disadvantage in terms of social information and inclusion in discussions. It doesn’t sound great, but it does sound like a lot of progress.”
“Yeah.” She nodded grudgingly.
The Future: Patience with Process and Progress
It takes only an instant to cut yourself. Cutters learn to expect instantaneous relief; they have no faith in gradual change. They feel that if a change does not take place now, then it will never occur. As one patient commented to me, “You often talk about the gradual progress I’m making. The trouble with thinking about the meantime, while I’m waiting to complete my recovery, is that the ‘meantime’ is such a mean time.”
A major part of helping a self-mutilator involves remaining realistically encouraging and realistically complimentary. These positive but realistic responses provide a milepost, a finite point where a bit of completion has occurred. When one is emotionally separate, it is difficult to experience achievement or change because there is no one to verify it, nobody one has trust in. The concept of a slow process throws most cutters into despair. Once they have established the attachment-trust-dependency axis mentioned throughout this book, they can use a helping person to calm them down, allowing for the mean time to elapse while they recover.