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DVD - Interventions for Cutters Substituting Self Control for Self MutilationCutters continuing education MFT CEUs

Manual of Articles Sections 15 - 29
Section 15
Case Studies: Katerina and Carla

CEU Question 15 | CEU Answer Booklet | Table of Contents | Self-Mutilation
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs 

What is the beginning of the loss of perspective that leads to cutting or burning oneself? Do we perceive a person who begins with nail-biting and then goes on to doing mild damage to her nailbeds by picking at them self-mutilation Cutters social work continuing educationas being sick? Do we see the nervous habit of biting one’s lip go out of control and lead to self- mutilation? Rarely, if ever.

In the examples involving both obsessive-compulsive disorder and anorexia nervosa, we saw a gradual transition from mental health to mental illness, followed by a deepening of that illness. Self-mutilation, on the other hand, often starts in its pathological or “sick” form immediately, within an already existing illness. It begins as a sick feature from its onset, but may develop or deepen into such a frequent and severe form that it overshadows the illnesses from which it sprang. When I state that self-mutilation starts as “sick,” I mean that the illness does not evolve from a mild, acceptable form of behavior like nail-biting into picking up a blade, scissors, or match to harm oneself.

Reconciling Brain and Mind
Today, the chemical nature of the human brain is being understood as never before; yet it is the human mind that we inhabit and experience. We all try out new behaviors haltingly, awkwardly, full of concentration and hypervigilant. As we practice these behaviors repeatedly, we become less halting, less awkward, our need to concentrate is less necessary; and we grow more casual and more efficient at the same time. Whether it is learning to walk, swim, ride a bike, drive a car, or parent a child, the progression of the learning experience usually follows the same pattern.

When these are positive achievements, we call them learning. If they are destructive or self-destructive, we call them disorders. Though these behaviors are labeled disorders, they are born from the same mechanisms as positive learning. The major difference between the two is that positive, healthy learning is most often taught by one person to another person, instructively.

Maladaptive learning, on the contrary, is inferred and may be need-based, or copied from a role model without direct encouragement or instruction. This kind of learning is, in effect, self-taught. It is often unconscious as well. When one person is taught by another person, that child, adolescent, or adult remembers the teaching experience as well as the guidelines and limitations involved in attempting the new behavior. We usually can easily remember who taught us how to swim, or cook. But the child who is learning by inference and not by instruction is often doing so in order to survive physical or emotional unpleasantness, and does not have the guidelines that will tell her what is enough, when she can stop, or when she will be safe. Take, for example, a ten-year-old girl told to stifle a sad feeling or fear, who then carries a box of fudge to her room and eats the whole thing. She has just taught herself comfort through binging.

As different as they appear to you and me, both of these kinds of learning are treated in the same way by the mind. That is, as the thoughtfulness involved in producing the skill or behavior is abbreviated, the process becomes automatic. When the behavior, or skill, has been developed over a long period of time, we say that the person who does the positive behavior or performs the skill is “experienced?’ The experienced person will often seek to increase his or her skill by trying out more difficult forms of it- whether ice-skating, skiing, mountain climbing, or playing a musical instrument.

Similarly, when a person who has developed a disorder that originated with negative, inferred learning has had this disorder for months or years, that person is more likely to push the self-destructive behavior further. For the self-mutilator, that means doing more damage to herself. This increased damage becomes incorporated as normal or usual as it occurs slowly over a period of time.

Just as there are reasons attached to increasing achievements, to pushing skills to their limits, so the mind looks for further avenues to intensify disordered behavior. In the case of anorexia, it is: • How thin can I get? • How much weight can I lose? • How much willpower do I have to deal with deprivation? • How much attention can I attract? • How much exercise can I do on very little nutrition?

In the case of self-mutilation, a slightly different set of rationales is applied to deepen the disordered behavior: • How much pain can I take? • How much disfigurement of my skin can I tolerate? • How much bleeding can I stand?

In these cases, the individual has already established the disordered behavior, and now wants more relief, more satisfaction from it. The victim starts thinking like one who is addicted to a substance: more is better. The more disordered the behavior, the greater the escape from emotional pain.

The mind in each case has adjusted to the existing level of behavior or achievement, and is now seeking to increase intensity in order to maintain the rush of reaching the current level that was once new. Let us contrast two examples—one of early detection and one that was chronic.

Katerina and Carla
Katerina had started with small cuts on the underside of her arm. They were half an inch long and just deep enough to draw blood. Over a five-year period, she upped the ante to larger, deeper, and wider cuts. Sometimes she would resort to burns with a cigarette, match, or candle. Once she pressed a hot teapot full of boiling water against her thigh; another time she bit a gash in her own arm. By this point she was emotionally and mentally disintegrating into dissociated states and experiencing amnesia during the incidents. Her behavior went undiscovered for four long years.
Carla, fourteen, came into treatment for anorexia and depression. Her diagnosis had been made within the last year. I asked her if she cut herself.

“Sure, on my arms and breasts.”
“How long have you been doing this?”
“For about three months.”
“Why these two areas?”
“The skin is very sensitive and tender in both areas. You can get a lot of pain with very little damage.”
“Why do you want the pain?”
“I’m the only one I allow myself to hurt.”
“Does anyone else know?”
“That would defeat the whole purpose. It would hurt both my parents to find out I do this.”

During the rest of Carla’s first year of treatment, there were only two more incidents of cutting and they were much milder. In fact, the second incident was scratching, and the results were barely detectable. After that, they stopped entirely.

Early detection, as with nearly all developing problems (medical or psychiatric), offers the best prognosis and outcome, with the help of skilled treatment and a supportive environment. While Carla and I were working to reverse the development of self-mutilation, we were able to reduce the addictive behaviors that precede the formation of the disorder. From there we worked to fill the deficits in her emotional development that invited these symptoms.

With Katerina, it was a long time before we could get her to stay aware of her environment throughout a session, to focus on our dialogue, and even longer before we began to reduce and eventually stop her severe self-mutilations. It was two years before we got to the point I had reached with Carla in the first four months of treatment.
- Levenkron, Steven; Cutting: Understanding & Overcoming Self-Mutilation; W.W. Norton and Company : New York; 1998

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about how mutilators learn to self-injure. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 15
What is the reason the author gives for the escalation of disordered behaviors, such as self-injury? Record the letter of the correct answer the CEU Answer Booklet.

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