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
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 usefW 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
“But you are never with a guy except your guy friends. How
“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?”
“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
“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
“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?”
“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
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.
- Levenkron, Steven; Cutting: Understanding & Overcoming Self-Mutilation;
W.W. Norton and Company : New York; 1998
Reflection Exercise #3
The preceding section contained information about helping
a client achieve genuine communication with others. Write three
case study examples regarding how you might use the content of
this section in your practice.
Online Continuing Education QUESTION
Why was it important for Elaine to confront the girls in her
sorority about their teasing? Record the letter of the correct
answer the .