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

Section 28
Selected Readings Bibliography/ Authors/ Instructors

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

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Additional Readings

Exploring the inner world of self-mutilating borderline patients: A Rorschach investigation. By: Fowler, J. Christopher; Hilsenroth, Mark J.; Nolan, Eric. Bulletin of the Menninger Clinic, Summer2000, Vol. 64 Issue 3, p365, 21p; (AN 3508726)

Psychiatric patients who engage in self-destructive behavior by cutting, burning, or abrading their skin are currently one of the most difficult-to-treat groups in both inpatient and outpatient settings. The complexities of treating these patients, the risk factors associated with this symptom, and the rise in the prevalence of self-mutilation in America's adolescents and young adults provided the impetus for the current study. This article explores aspects of aggression, dependency, object relations, defensive structure, and psychic boundary integrity that may contribute to the genesis and maintenance of self-mutilation. Rorschach protocols from 90 borderline personality-disordered inpatients (48 self-mutilators and 42 non-self-mutilators) were scored using five psychoanalytic content scales. Results indicate that self-mutilating patients exhibit greater incidence of primary process aggression, severe boundary disturbance, pathological object representations, defensive idealization, devaluation, and splitting than did a matched group of non-self-mutilating borderline patients. Clinical theory and technical recommendations are considered in light of the current empirical findings. (Bulletin of the Menninger Clinic, 64[3], 365-385)
For the past 70 years, analysts have worked to comprehend the unconscious structures that are thought to be responsible for masochistic fantasies and behaviors of humiliation and physical pain (Bollas, 1992; Bonaparte, 1952; Deutsch, 1930; Doctors, 1981; Freud, 1923/1961b,1924/1961a; Kernberg, 1984; Menninger, 1938; Reich, 1940; Smirnoff, 1969; Stolorow & Lachmann, 1980). Masochism, in the form of bodily self-destruction, negativism, and negative therapeutic reactions, has consistently presented a perplexing theoretical problem and a serious challenge to effective treatment of neurotic, borderline, and psychotic disorders (Freud, 1924/1961a; Joseph, 1982; Olinick, 1964; Riviere, 1936). Modern clinicians are faced with similar theoretical complications in comprehending the underlying psychic structures of self-mutilating individuals. These patients frequently become embroiled in negative therapeutic reactions and masochistic transference impasses that destroy the frame of the treatment and can, in the most extreme cases, lead to the suicide of patients.
Self-mutilating patients are predominantly adolescent and young adult females who engage in self-destructive behavior by cutting, burning, or abrading their skin. Like masochists of Freud's era, these patients are currently one of the most challenging and treatment-refractory groups of seriously disturbed patients (Favazza & Conterio, 1988; Favazza & Favazza, 1987; Pao, 1969; Simpson, 1980). The impact of their sadomasochistic attacks on their body and on the frame of the treatment can be deeply disturbing to those who treat them. In short, countertransference fear, repulsion, and rage can interfere with the therapist's ability to consider the intrapsychic meaning of cutting as a defensive reaction, as a transference communication, or as a suicide attempt.
When therapists attempt to manage self-destructive actions without a clear interpretive frame for understanding and communicating their interventions, therapist and patient can fall into a reflexive mode of chronic crisis management (Sacksteder, 1997). The potential for transference enactments to go unanalyzed by the therapist is greatest at such moments because the primary task of treatment can be lost in the midst of crises. This type of disengagement from the interpretive task is a serious impediment to the treatment of a condition that is often erroneously considered simply "manipulative," but that has serious consequences for the patient.
Past research has shed light on the dangers and complexities of this phenomenon by exploring demographic and personal characteristics (Favazza, 1989; Feldman, 1988), the phenomenology of patients (Himber, 1994; Leibenluft, Gardner, & Cowdry, 1987), and clinical observations and treatment approaches (Kernberg, 1987; Stone, 1987; Tantam & Whittaker, 1992). The data on suicide rates for self-mutilating borderline patients are twice that for other borderline patients (Stone, Hurt, & Stone, 1987). Other risk factors include the potential for developing stereotyped and chronic self-mutilation due to increased release of endorphin metenkephelin (Cold, Allolio, & Rees 1983), contagion through modeling (Rosen & Walsh 1989; Walsh & Rosen, 1985), and the development of an identity as a "cutter" (Podvolt, 1969).
While the etiology is complex, self-mutilators frequently report childhood experiences of emotional and physical trauma, including sexual abuse, early traumatic invasive surgery, and neglect (Cross, 1993; Favazza & Conterio, 1988; Feldman 1988). These traumatic events are thought to create severe disturbances in object relations (Berliner, 1958; Chasseguet-Smirgel, 1995; Kernberg, 1984), in the capacity to symbolize experience (Muller, 1996), and in maintaining an ongoing experience of self that is free from derealization and dissociation (Favazza, 1992; Feldman, 1988; Rosenthal, Rinzler, Walsh, & Klausner, 1972; Soloff, Lis, Kelly, Cornelius, & Ulrich, 1994).
The purpose of this study is to investigate psychoanalytic concepts of self-mutilation empirically by exploring object representations, affect, and thought disorder manifest in two similar groups of inpatient Rorschach protocols. Assessing unconscious processes manifest in projective test data allows for an analysis of greater depth and breadth than do self-report data, while maintaining the advantages inherent in large-sample investigations. In order to narrow the range of unconscious processes to be investigated, we reviewed the vast array of psychoanalytic explanations of masochism and self-mutilation.
Modern ego psychology, object relations theory, and self psychology provide insights into the structural deficits and the underlying motivations that maintain self-mutilation. We have therefore drawn from several theorists' work (Doctors, 1981; Kernberg, 1984; Stolorow & Lachmann, 1980) as a springboard for constructing a study of the unconscious correlates of self-mutilation using Rorschach responses from borderline inpatients.
Kernberg (1984) proposed that patients who self-mutilate tend to be infantile, narcissistic, and "as if" personalities, functioning at an overt borderline level. In histrionic and infantile personality disorders, self-mutilation occurs in the context of some real or imagined failure or thwarted wish. The act is considered an unconscious coercive effort to gain control over the environment by inducing guilt in the frustrating other. Kernberg observed a more severe form of self-mutilation in "malignant narcissistic" patients. These patients tend to present as aloof and uninterested in others, rather than clinging. When their grandiose self-image is challenged, they experience intense humiliation, and in an effort to rid the self of unbearable humiliation, these patients physically enact, through self-mutilation, an unconscious triumph over the internal world of objects as they cheat death and pain. These patients flaunt their sense of superiority over their therapists when they discover that the therapist is chagrined or frightened by their self-mutilation. A third category of patient suffering from atypical psychoses is far more rare, and can be identified by the bizarre nature of the self-mutilation and the unusual degree of cruelty and idiosyncratic features. Each distinct subgroup suffers from primitive pathological object relations, primitive defenses, rage, and narcissistic vulnerabilities.
Stolorow and Lachmann (1980) have suggested that masochistic activity often occurs in response to a fear of fragmentation and that it represents an abortive (and sometimes sexualized) attempt to restore the cohesion and stability to a fragmenting self-representation. Building on decades of psychoanalytic exploration of masochism, the authors assert that the most violent and primitive expressions of self-directed aggression are found in individuals who are most vulnerable to narcissistic injury. Relatively minor frustrations such as the loss of control over a relationship and failed mirroring may threaten the structurally deficient narcissistic individual. In such cases, the need for experiences of acute pain, localized on the skin surface, may help buttress or protect against the derealization, sensations of falling apart, and dissociation that is commonly associated with a dissolving self-other boundary.
In a similar analysis, Doctors (1981) concluded that self-mutilating adolescents have not obtained emotional object constancy, exposing them to defensive splitting of good and bad part-objects. Furthermore, the lack of sufficient differentiation between self and objects results in an unstable array of internal representations in which even minor frustration can rapidly develop into intense rage that inundates the object world, and thereby spoils precariously maintained self-representations and object representations. This spoiling of the inner world, combined with a fragmenting ego boundary, further blurs the patient's tenuously held distinction between self and other. The breakdown in the capacity to maintain self-other differentiation has been linked to self-reports of falling to pieces, or feeling empty, unreal, and dead inside. According to this theory, a main unconscious motivation of self-mutilation is the effort to repair and restore a sense of self-cohesion and to expunge bad part-objects in order to restore good object representations.
Significant theoretical and clinical differences exist between ego psychology and self psychology, especially in the understanding of narcissistic and borderline disturbances. Despite these differences, there are fundamental similarities across theoretical orientations that are particularly important to this investigation. All three theories assume that the act of cutting is an unconscious effort to reestablish some degree of narcissistic equilibrium and self-cohesion. For Kernberg (1984), pathological affect and object representations set the stage for self-mutilation, especially when patients feel deprived, abandoned, or insulted by the therapist. The motivation to master and control another object is an effort to restore narcissistic balance, either through a dependent yet coercive object relation or through a coercive insistence on mirroring of the patient's grandiose self-organization. For Stolorow and Lachmann (1980), narcissistic injury produces intense rage in the structurally deficient ego, which can lead to sensations of fragmentation and boundary dissolution. For Doctors (1981), a narcissistic injury may precipitate an affective storm that inundates the patient's object world, transforming precariously maintained positive imagoes into malevolent objects.
These clinical theories find some support in descriptive studies and to a lesser extent in large-scale empirical research. For example, Stolorow and Lachmann's assertion that these patients use acute experiences of pain to bolster crumbling ego boundaries finds support in case descriptions (Cross, 1993; Doctors, 1981; Favazza, 1989; Gardner & Gardner, 1975; Miller & Bashkin, 1974; Pao, 1969; Simpson & Porter 1981). Researchers have found that self-mutilators are significantly more prone to derealization and drug-free hallucinations/delusions than are non-self-mutilating borderline patients (Soloff et al., 1994), and self-mutilators have higher rates of serious identity disturbance than the non-self-mutilators (Simeon et al., 1992). The clinical inference that aggression is a key factor in the act of self-mutilation has equivocal research support. Soloff and colleagues (1994) found that self-mutilating patients scored lower on the Buss-Durkee Hostility Inventory than did clinical controls, and that physical assaults on others were negatively correlated with self-mutilation. By contrast, Simeon and colleagues (1992) reported that self-mutilators produced significantly higher scores on the Minnesota Multiphasic Personality Inventory (MMPI) Psychopathic Deviance Scale (PD), yet did not differ significantly from controls on the Buss-Durkee Hostility Inventory. Finally, Rosenthal and colleagues (1972) noted that most of the 24 female patients reviewed in their study feared their own anger, described an inability to cope with these feelings, experienced derealization, then cut themselves in an effort to reintegrate. These equivocal findings may have more bearing on the patients' willingness or ability to report their subjective affect states than it does on the nature of their affective life. Thus aggression may be related to self-mutilation, but it has been unclear to what extent hostility and aggression are consciously registered, contained, and modulated by the ego.

Hypotheses


From the preceding clinical and empirical data, we have formulated the following hypotheses:
  1. Self-mutilation is associated with intense, unmodulated aggressive affects. As a result, self-mutilating borderline patients are expected to manifest more primary process aggression on the Rorschach than the other borderline group.
  2. Clinical reports describe most self-mutilating patients as excessively dependent and clinging; thus the self-mutilating borderline group may produce more oral dependent imagery on the Rorschach than the second group.
  3. The wish to omnipotently control a precariously held self-other distinction through self-mutilation is an unconscious expression of an imbalanced, malevolent inner world; therefore self-mutilating patients may manifest greater imbalanced, omnipotently controlling, and malevolent object representations than the second group.
  4. Defensive devaluation, idealization, splitting, and denial may play a critical role in self-mutilating patients' attempts to manage intense affects and reestablish narcissistic equilibrium. We expect self-mutilating patients to manifest greater degrees of these defenses.
  5. Self-mutilating patients are thought to experience more fragmentation and boundary disturbance and therefore will manifest greater degrees of self-other boundary disturbance than the second group of borderline inpatients.

Method Sampling and group classification


The initial sample consisted of 224 patients admitted to The Austen Riggs Center. Patient records from January 1993 to June 1997 (including identification numbers, diagnostic codes, detailed descriptions of specific behavioral manifestations of self-mutilation, and medical procedures performed in response to the self-destructive activity) were first masked to disguise patient identity, then downloaded from the Center's database. Behavioral records were then classified by Dr. Fowler into self-mutilating and non-self-mutilating groups prior to collecting archival Rorschach records. The data extracted from the medical records can be considered a reliable and relatively accurate representation of the patients' self-destructive activities during hospitalization because the nursing staff was required to record all incidents of self-inflicted lacerations and burns.
The primary diagnosis of borderline personality disorder (BPD) was established in a consensus case conference at the culmination of the initial evaluation and treatment phase 4-6 weeks following admission. Diagnoses were made using available sources of information, including an integration of interview data from the admission consultation, initial contact with the therapist and psychopharmacologist, consultations with outpatient therapists, prior hospital records, and interviews with relatives to clarify family history of psychiatric disorders, life history, and premorbid level of functioning. All patients were assessed by a board-certified and licensed psychologist and psychiatrist. Diagnoses were assigned according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994). This method of diagnostic practice approximates the LEAD (longitudinal expert evaluation using all data) standard of diagnosis (Pilkonis, Heape, Ruddy, & Serrao, 1991; Skodol, Rosnik, Kellman, Oldham, & Hyler, 1988; Spitzer, 1983). The diagnosis of BPD was confirmed in 100% of the cases by an independent rating conducted by either a psychiatrist or psychologist as an ongoing aspect of the hospital's performance improvement policy. It is important to note that in all cases the diagnosis of BPD was determined independently of Rorschach data. Although all patients in this study had multiple Axis I and Axis II disorders, those patients with a comorbid Axis I psychotic disorder were excluded from the study.
Criteria for inclusion into this study required a hospital stay of 6 months or more in order to obtain a representative sample of patient behavior. All patients had completed a battery of projective tests administered during the first 30 days of the index hospitalization. In addition, an act of self-mutilation had to occur within 60 days following administration of the Rorschach to ensure the temporal relevance of the Rorschach data. The final sample of 90 adult inpatients consisted of 2 males and 88 females with a mean age of 30.9 years (SD = 9.1) at admission. The average number of years of education completed by the patients was 14.96 years (SD = 1.9). A total of 54 patients were single, 24 were married, and 9 were divorced or widowed.

Rorschach scales and scoring


Administration and original scoring of the Rorschach followed the procedures articulated by Exner (1993). These protocols were later rescored on the Rorschach content scales by Dr. Fowler, who was blind to patient identity, group inclusion, and diagnosis. For the purpose of interrater reliability (Weiner, 1991), 20 Rorschach protocols were chosen at random and scored independently by Dr. Hilsenroth, who was also blind to all patient data. The two sets of scored protocols were then compared, and percentages of correct agreement and intraclass correlations were calculated. The resulting interrater agreement and intraclass coefficients are presented in Table 1.
Aggressive ideation was assessed using Holt's (1977) method for scoring primary and secondary process manifestations on the Rorschach. Holt's system differentiates two levels of aggressive content. Level I scores are related to primary process forms of primitive aggressive themes, specifically measuring murderous or palpably sadomasochistic aggression. Level 2 aggression scores are related to secondary process ideation and specifically measure indirect forms of hostility or aggression expressed in more socially acceptable ways. The Holt system has demonstrated high levels of test-retest (Gray, 1969) and interrater reliability (Fowler, Hilsenroth, & Handler, 1995), as well as construct validity in a number of studies (Blatt & Berman, 1984; Hilsenroth, Hibbard, Nash, & Handler, 1993).
The Rorschach Oral Dependency scale (ROD; Masling, Rabie, & Blondheim, 1967) was developed as a psychoanalytic content scale to assess oral/dependent imagery. A response is defined as oral dependent if it falls into any of the following categories: food and drinks, food sources, food objects, food providers, passive food receivers, food organs, supplicants, nurturers, gifts and gift givers, good luck symbols, oral activity, passivity and helplessness, pregnancy and reproductive anatomy, and negations of oral percepts (e.g., not pregnant; man with no mouth). The construct validity and interrater reliability regarding this measure have proven to be excellent in more than 90 experimental studies utilizing various populations (Bornstein, 1996).
The Mutuality of Autonomy Scale (MOA; Urist, 1977) assesses the thematic content of relationships (stated or implied) between animal, inanimate, and human representations in Rorschach percepts. The scale was developed to assess the degree of differentiation of object representations, focusing primarily on the developmental progression of separation-individuation from engulfing, fused relations to highly differentiated self-other representations. Scale points 1 and 2 reflect the capacity to construe self- and other representations as structurally differentiated and engaged in mutually interactive or parallel activity (e.g., "two people talking about grocery prices, pushing shopping carts"). Scale points 3 and 4 capture dependent and mirroring object relationships and often reveal an emerging loss of autonomy between figures (e.g., "Siamese twins connected at the waist"). Scale points 5, 6, and 7 reflect not only the loss of the capacity for separateness but also increasing malevolence (e.g., "an evil fog engulfing this frog ... smothering it"). Reliability data are excellent (Tuber, 1989), and the scale has demonstrated a high degree of construct validity with behavioral ratings (Ryan, Avery, & Grolnick, 1985; Urist, 1977; Urist & Schill, 1982), assessment of therapeutic change (Blatt & Ford, 1994), and multimethod assessment of the construct (Fowler, Hilsenroth & Handler, 1995; Urist, 1977). For this study, we chose a composite score of all level 5, 6, and 7 pathological scores (PATH; Berg, Packer, & Nunno, 1993) because it has been found to be a robust and stable measure of pathological object relations.
Defensive structures were assessed using the Lerner Defense Scale (LDS; Lerner & Lerner, 1980). This scale is based on Kernberg's (1975) theoretical conceptualizations and other commentators' clinical observations (Holt, 1977; Mayman, 1967; Peebles, 1975). Primitive defenses of splitting, idealization, devaluation, and denial represented in percepts of human, quasi-human, and human detail (Hd) responses were assessed for this study. The LDS has shown good construct validity and high interrater reliability (Lerner, 1991). To use more stringent parametric statistics in the analysis of those defenses that are ranked on a continuum from high to low order (devaluation, 1-5; idealization, 1-5; and denial, 1-3), defenses were weighted according to rank and then were collapsed into an overall score for that category. For example, if there are three instances of idealization on a subject's protocol, one Level 1 and the other two instances at Level 3, the subject would receive a total idealization score of 7 (1 + 3 + 3 = 7).
The Boundary Disturbance and Thought Disorder Scale (BDS; Blatt & Ritzler, 1974) assesses an individual's capacity to maintain distinctions between objects along cognitive/perceptual and affective dimensions. Blatt and Ritzler drew connections between the degree of thought disorder present on the Rorschach and the concomitant degree of ego boundary dysfunction. Drawing on Rapaport's indices of thought disorder, they proposed the following hypotheses: (1) Mild forms of ego boundary fragmentation or looseness of boundary (boundary laxness) could be measured by fabulized combination. (2) More severe problems of differentiating fantasy from reality (inner/outer boundary disturbance) would be represented in responses containing confabulations. (3) The most severe form of boundary fragmentation and disintegration (self/other boundary disturbance) would be captured in the severely thought-disordered responses known as contaminations. Several studies (Blatt & Ritzler, 1974; Lerner, Sugarman, & Barbour, 1985; Wilson, 1985) have found that borderline patients typically have greater difficulty with boundary laxness and inner/outer boundaries, whereas schizophrenic patients typically have greater difficulty distinguishing between self/other boundaries. The more severe self/other boundary disturbance may correspond to what many have described as the crumbling ego boundaries, dissociation, and drug-flee hallucinations observed in many patients who self-mutilate.

Results


Prior to assessing the main hypotheses, analyses of variance (ANOVA) were conducted in order to identify potential confounding variables. Contrasts of the two groups (see Table 2) revealed no significant differences in age (F = .86, p = .36), level of education (F = .26, p = .61), full-scale IQ (F = 1.6, p = .20), or Rorschach productivity (F = .12, p = .72). The groups were also well matched on gender (one male in each group) and marital status (predominantly single, never married). These well-matched groups ensure that results obtained in further analyses are most likely based on actual psychological differences between the groups.
Results of a multivariate analysis of variance (MANOVA) demonstrated significant differences across the two borderline groups using all content scales (F = 2.90, p = .004). Therefore the results of the univariate analyses (controlling for chance significance with Bonferroni adjustment) most likely reflect actual differences between groups. Univariate analyses (see Table 3) demonstrated that self-mutilating patients produced a greater number of primary process aggression responses than did non-self-mutilating borderline patients (F = 15.03, p < .0001), whereas no differences were found in terms of secondary process aggression (F = 1.9, p = .18). The estimated effect size for primary process aggression yields a medium to large effect size (Eta = .38) and accounts for approximately 14% of the variance between the groups.
The degree of oral/dependent imagery was not significantly greater for the self-mutilating borderline patients than for the other borderline patients (F = 2.97, p = .09). In the realm of object relations, self-mutilating borderline patients manifested more instances of malevolently controlling object representations as assessed by the PATH score of the Mutuality of Autonomy Scale (F = 10.63, p = .002). Estimated effect size for the PATH score reflects a medium to large effect size (Eta = .33) and accounts for approximately 10% of the variance between groups.
In assessing how self-mutilating patients manage powerful affects and conflicts, we contrasted the groups' use of primitive defenses measured by the Lerner Defense Scale. Of the four defenses as entered into the analyses, primitive splitting (F = 20.07, p < .0001), idealization (F = 14.0, p < .0001), and devaluation (F = 5.4, p = .02) were manifested in the Rorschach records of self-mutilating borderline patients with greater frequency and intensity than in the records of the non-self-mutilating patients. Primitive denial was not significantly different between groups (F = .35, p = .86). Estimated effect size for splitting reflects a large effect (Eta = .43) and accounts for approximately 19% of the variance between the groups, whereas idealization produced a medium effect size (Eta = .36), accounting for 13% of the variance. Devaluation yielded a small effect size (Eta = .22) and accounted for only 5% of the variance.
The final contrasts involved the boundary disturbance and thought disorder scale. Contrasts highlighted expectable similarities in that the groups were not significantly different in the degree of boundary laxness (F = .01, p = .91) or inner/outer boundary disturbance (F = 3.1, p = .08). A striking difference in the self-mutilating borderline patients' self/other boundary disturbance (F = 12.6, p < .0001) highlighted a higher incidence of self-other boundary disintegration than in other borderline patients. A medium to large effect size (Eta = .36) for self/other boundary disturbance demonstrated and accounted for approximately 13% of the variance between the groups.
A post-hoc stepwise logistic regression analysis was performed in order to identify the set of Rorschach variables that, combined, account for the greatest variance between self-mutilating and non-self-mutilating borderline patients. Results revealed that defensive splitting (R = .44; R2 = .19), primary process aggression (R = .47; R2 = .23), self-other boundary disturbance (R = .49; R2 = .25), and idealization (R = .51; R2 = .26) accounted for the greatest variance in discriminating between these two similar diagnostic groups.

Discussion


The Rorschach results provide evidence for the wide-ranging psychological differences between self-mutilating borderlines and other inpatient borderlines. The tendency for self-mutilating patients to invoke primitive defenses of splitting, idealization, and devaluation has been observed in various analytic encounters (Doctors, 1981; Kernberg, 1984). Kernberg, for example, observes a preponderance of part-object relations and primitive splitting, idealization, devaluation, and denial in these patients. In our investigation, massive idealization and defensive splitting were the primary modes of defense that differentiated self-mutilators from other borderline patients. Kernberg formulates the defensive functions of idealization and splitting as the primary mechanisms to ward off hate and envy. In the extreme case, these defenses are coupled with serious ego deficits and malevolent object/affect representations (including primitive superego elements); the result often reflects a grandiose self-structure in what Kerberg (1984) refers to as a "malignant narcissistic disorder" (p. 293). Novick and Novick (1991) come to a somewhat similar conclusion when they observe that grandiosity and delusions of omnipotence frequently underlie the masochistic activity of patients. These patients exhibit particular ego deficits in affect regulation that expose them to primary process hate and overstimulated libidinal impulses. These volatile affects then interact with "a fragile defense system and a deficient superego to produce the delusion that only they themselves were powerful enough to inhibit their omnipotent impulses, and then only by resorting to severe masochistic measures" (p. 311).
A second possible interpretation of the breakdown in idealization represented by self-mutilation relates to certain self psychology formulations (Stolorow & Lachmann, 1980). First, idealization of self objects is suggestive of a mirroring transference in which idealization is used to ward off potential narcissistic injuries that are inevitable in an exploratory treatment. In the case of an idealizing mirroring transference, a therapist's failure to live up to the idealization may result in massive frustration and rage that can further destabilize precarious ego boundaries. These failures can be as subtle as a poorly timed interpretation or the therapist's refusal to extend the session by a minute or two. At such moments of disappointment, it is common for therapists to feel the effects of splitting as they become the object of fierce rage and devaluation when they fail to live up to the patient's wished-for perfection.
The most consistently held hypothesis for why psychiatric patients self-mutilate is the belief that these patients experience intense episodic rage that is expressed through their masochistic attacks on their bodies. Past research linking aggression and self-mutilation has been inconclusive, most likely because these studies have relied on self-report measures that are transparent, and for which the illusion of affect control can be perpetuated (Shedler, Mayman, & Manis, 1993). In addition, self-report measures of hostility do not assess primary process aggression--a form of aggressive experience that is not readily available for conscious articulation.
When patients' conscious defenses are circumvented with a projective technique such as the Rorschach, it is apparent that self-mutilating borderline patients exhibit significantly greater problems with the control of primary process aggression than a matched group of borderline inpatients. In short, self-mutilators are prone to primary process rage, and whether patients experience such rage through ego-syntonic and consciously registered channels, or experience themselves as the victim of others' rageful attacks (through a process of disavowal and projection), it is clear that they struggle with rage. The repeated breakthrough of unmodulated sadomasochistic aggression can be interpreted as an indication of self-mutilating patients' failing capacity to bind aggressive affects through secondary process modes of expression. As is the case with most people, such intense affective states can tax the ego's capacity to process information through symbolic channels. In the case of the self-mutilating inpatients in our sample, it is conceivable that a predisposition for intense rageful affects can be triggered by frustrations that can lead to a spoiling of their inner world, eliciting primitive defenses and compromising boundary integrity.
The problem of thought disorder and boundary disturbance is evident in the frequency with which clinical reports detail a sequence of intense emotional turmoil, followed by sensations of emptiness, fears of falling to pieces, and experiences of derealization and dissociation (Rosenthal et al., 1972). These reports correspond to the manifestations of severe boundary disturbance demonstrated in the self-mutilator's Rorschach protocols. Whether these patients sustain narcissistic injuries or become overwhelmed by an upsurge in aggressive drive derivatives, it seems plausible to assume that such powerful affects tax their ego capacities for maintaining a clear understanding of internal and external affects, controls, and prohibitions. For the more disturbed borderline patient, this confusion of self and other leads the patient to engage in power struggles with others in an attempt to create some clearer boundary between self and other. Patients struggling to maintain self-cohesion may subject themselves to humiliation, pain, and even the risk death in order to re-create a stable sense of self.
Recent contributions by Muller (1996) and Gedo (1996) support the hypothesis that self-mutilation is enacted in order to ward of fragmentation of the self-organization. Muller (1996) has proposed that patients who compulsively self-mutilate do so in an effort to fend off merger into a dedifferentiated existence by creating a concrete marker of their outer boundary: "signifying that there is a boundary between the subject and the Real, it prevents a dedifferentiated existence" (p. 86). According to Muller, the collapse into dedifferentiation is due to a breakdown in semiotic structures, wherein signs and symbols are often corrupted by incest, violence, and a chaotic existence that disrupts the formation of a stable semiotic system. Gedo's (1996) comments on this phenomenon are also relevant to this discussion: "Clinical experience has taught us that embarrassment--even humiliation--is sometimes insufficient to override motivations stemming from the need to maintain the stability of self-organization.... One common example is that of compulsive self-mutilation" (p. 175). Again, the manifestation of masochistic activity can be linked to underlying structural deficiencies in ego boundary integrity.
Most modern theories (Cross, 1993; Doctors, 1981; Kernberg, 1984) of self-mutilation posit a fundamental disturbance in object relations, with particular emphasis on the self-mutilator's unconscious fear of being controlled by powerful malevolent forces. Often this fear takes the form of merging with, or being overtaken by, dangerous objects. The clinical corollary to this internal imbalance is the development of a hypervigilant and rigidly held fear of being influenced by passive experiences of desire and dependency, and fear of being influenced by others (Piers, 1999; Shapiro, 1981). The fact that self-mutilating borderline patients manifest more poorly differentiated and malevolently controlling objects than do other borderline inpatients provides empirical support to clinical experience of transference enactments in which these patients violently ward off any experiences of being influenced by therapists (Doctors, 1981). This finding also lends credence to Kernberg's (1987) observation that patients self-mutilate in response to "intense feelings of resentment, rage, and impotence in the effort to control an important person (including the therapist), and that the experience of self-mutilation is the relieving enactment of revenge" (p. 344).
Although self-mutilation is an unwelcome but expectable symptom in the treatment of some borderline and narcissistic disorders, the greatest danger in treating these patients occurs when transference enactments degenerate into ever-escalating self-destruction toward suicide. Clinical accounts abound in which patient and therapist become embroiled in struggles to contain and control the patient's self-destructive acts. One consistent observation in treatments plagued with recurrent countertransference impasses is the therapist's intolerance for hate in the transference. Those for whom hatred is an unacceptable response from patients will often resort to sentimentality as a means of dealing with an enraged and enraging patient (Fromm, 1995; Winnicott, 1975). Through their efforts to contain self-mutilation (e.g., through sympathetic offerings of transitional objects), these therapists may inadvertently communicate to the patients that they want them to be different than they are without a clear understanding of the meanings of self-directed aggression.
These results provide interesting evidence for the differences between two groups of inpatient borderlines; nevertheless, too great a reliance on statistical significance can obscure the complexity and the variations found in the self-mutilating group. For example, the great dispersion of scores around the group means is suggestive of great variation within the self-mutilating sample. This finding is not terribly surprising, given the fact that clinical experience has taught us that borderline patients rarely fit a prototypical pattern, and are perhaps best understood as a collective of patients at our boundary of understanding (Fromm, 1995).
In light of these limitations, we propose a tentative working model for understanding compulsive self-mutilation based on the "best fit" among clinical observations, psychoanalytic theory, and the results of the present study. Several preexisting conditions seem to place patients at risk for self-mutilation. A number of chaotic life events, such as physical traumas, and radically inconsistent environments may ultimately lead to overwhelming experiences of a malevolent and chaotic world. Boundary transgressions, lack of stable semiotic structures, and exposure to unbearable emotional experiences overwhelm the individual's capacity to integrate emotional experience and interfere with the establishment of a stable self-organization. Complications arising during puberty may have an adverse impact on the predisposed adolescent's capacity to differentiate from the mother (Chasseguet-Smirgel, 1995; Cross, 1993). Struggles over the psychic ownership of body and self may help to explain the sudden emergence of self-mutilation and eating disorders in adolescence--during puberty--when the young girl's body develops a likeness to her mother's. The formation and subsequent arrest in the development of defenses, and the internalization of precariously differentiated self- and other representations, further complicate the capacity to assume ownership of the body.
Noxious life events and their subsequent pathological adaptations make these patients vulnerable to ego fragmentation and psychotic regression. These vulnerabilities may lead patients to be extremely sensitive to any challenge to their self-integrity, and may lead to a defensive insistence on controlling their environment. Thus any challenge to their sense of control over themselves and the environment may upset their fragile narcissistic equilibrium, leading to rage and unmodulated aggression. Once in the midst of such rageful spoiling, patients may engage a series of primitive defenses such as idealization, splitting, and devaluation in order to ward off fragmentation. When these defenses fail, these patients may self-mutilate in a desperate effort to rid themselves of noxious affects, and unconsciously to assert control over their fused sense of body, the other, and the outer world. By cutting the outer boundary of the body, they may in fact create a concrete marker of their differentiation from the environment.
Such a tentative formulation precludes any definitive statement on treatment; nevertheless some technical recommendations may provoke further thought and inquiry into this treatment-resistant population. Integrating research findings from this study and Plakun's (1994) principles for the psychodynamic treatment of self-destructive borderline patients at serious risk for suicide has proven quite useful. While Plakun focuses primarily on the problem of suicide attempts that seriously threaten the continuity of the treatment alliance, we have successfully applied several principles to the treatment of self-mutilating patients.
At the outset of treatment, we recommend that the therapist set a frame about how crises will be managed, including the exploration of self-destructive acts as part of the interpretive process. These efforts to come to a mutually agreed-upon protocol for handling crises and an agreed-upon interpretive task will help to highlight the differentiated role and task for patient and therapist. We have found that this recommendation helps patients use the clearly articulated frame to temporarily reinforce their limited capacities for self-other differentiation and often eliminates the power struggle over interpreting the self-destructive acts.
A second recommendation, to metabolize countertransference reactions prior to responding to the suicidal or self-destructive behavior, is particularly appropriate when one considers the self-mutilating patient's disturbed object relations, vulnerability to narcissistic injury, and preponderance of primary process aggression. The capacity to acknowledge and tolerate countertransference hate is requisite for treating psychotic and borderline conditions, and has been particularly fruitful in our experience. This is not to suggest that therapists silence their reactions, but rather to modulate their responsiveness carefully to match the task of the treatment. The risks inherent in therapists' unmetabolized self-disclosures of guilt or rage are greatest because they may lead the patient to conclude that the therapist is out of control and dangerous. Equally disastrous is the patient's interpretation of the therapist's unbridled reaction as a challenge to the patient's autonomy.
Defense analysis and an exploration of the patient's experience of self-mutilation before interpreting the latent aggression may be particularly important because the patient's capacity for recognizing somatic sensations as emanating from within his or her own body as a signal of rage is often lacking. The timing and empathic delivery of interpretations of self-destructive acts seem particularly relevant, given our findings of self-mutilating patients' unmodulated primary process aggression on the Rorschach. Such unmodulated internal states need to be interpreted and opened for the fullest range of experience so that patients integrate these experiences of anger through secondary process channels of fantasy, reconstruction, and protest.
Once therapist and patient have explored the ramifications of the recent suicidal/self-destructive act as aggressive, Plakun (1994) recommends that both parties search for the perceived narcissistic injury that precipitated the self-destructive behavior. There are several interpenetrating reasons for this intervention, including the opportunity for the therapist to acknowledge accurately perceived failures (Cooperman, 1989). The crucial element, from our vantage point, is the exploration of the transference and the likely disillusionment and injury that occurred in the preceding sessions. By placing a premium on exploring the unconscious and conscious meanings of the self-destructive act, the therapist is holding to the therapeutic task and, in so doing, is reaffirming the requirements of the therapeutic frame to seek meaning. Following these principles will in no way eliminate the risk of provocative acting out and self-destruction. Rather, we hope these recommendations and the measured use of consultation and hospitalization will aid in the effective treatment of these patients.

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Alexithymia, Depression, and Self-Mutilation in Adolescent Girls. By: Lambert, Aurélie; de Man, Anton F.. North American Journal of Psychology, 2007, Vol. 9 Issue 3, p555-566, 12p, 3 charts; (AN 27729802)

Fifteen adolescent French girls with a recent history of self-mutilation and 18 adolescent girls without such a history participated in a study of the relationship between alexithymia, depression, and self-mutilation. Results of correlational analyses showed that depression and alexithymia -particularly its "difficulty in identifying feelings and differentiating them from bodily sensations" factor- were significantly related to self-mutilation. Sequential logistic regression analysis showed that depression and the alexithymia factor as a set reliably distinguished between those who self-mutilated and those who did not. Of the two independent variables, depression was identified as the better predictor of self-mutilating behavior. Although the "difficulty in identifying feelings and differentiating them from bodily sensations" factor of alxithymia did have an effect independent of depression, much of the relationship between this factor and self-mutilation appeared to be the result of mediation by depression.
Self-mutilation may be defined as "a volitional act to harm one's own body without intention to cause death" (Yaryura-Tobias, Neziroglu, & Kaplan, 1995, p. 33). This deliberate, physically violent but non-suicidal act done to oneself by oneself (Alderman, 1997) may take many forms. Some of these are culturally sanctioned (e.g., tattooing, body piercing) whereas others are pathological in nature (Favazza, 1996). Pathological self-mutilation may be categorized into major, stereotypic, and superficial/ moderate self-mutilation (Favazza, 1998; Favazza, & Rosenthal, 1993). Major self-mutilation involves acts which result in significant tissue damage (e.g., castration) and are usually associated with psychosis and intoxication. Stereotypic self-mutilation consists of stereotypic, rhythmic acts such as head banging and self-biting, commonly seen in conditions such as severe mental retardation and Tourette's syndrome. Superficial/moderate self-mutilation consists of superficial behavior such as skin cutting, burning, and scratching. The present study concerned itself with this last category. More specifically, it focused on adolescent girls showing self-cutting behavior.
Self-mutilation usually begins in late childhood or early adolescence and can continue for up to 20 years (Favazza & Rosenthal, 1993); the rates are highest among adolescents. Although the behavior has been observed in boys (Ross & Heath, 2004), the typical self-mutilator is a single, adolescent or young adult female (Favazza & Conterio, 1989; Pattison & Kahan, 1983; Raine, 1982; Suyemoto & MacDonald, 1995). Self-mutilation is repetitive in nature and distinct from suicidal behavior. Self-mutilators usually cut more than once (Bach-y-Rita, 1974; Himber, 1994; Simpson, 1980) but have no intention to cause death (Graff & Mallin, 1967). They distinguish between self-mutilative acts and suicidal ones (Herpertz, Steinmeyer, Marx, Oidtmann, & Sass, 1995), and, unlike suicide attempters, generally experience a feeling of relief following the act (Alderman, 1997; Favazza, 1996; Pattison & Kahan, 1983). Solomon and Farrand (1996) suggested that self-mutilation may be an adaptive alternative to suicide; however, those who cut themselves can have suicidal ideation which can lead to suicidal behavior. In fact, Stanley, Gameroff, Michalson, and Mann (2001) reported that between 55% and 85% of self-mutilators have made at least one suicide attempt.
Although there has been a growing interest in early trauma as a factor in the development of self-mutilative behavior (e.g., Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Low, Jones, MacLeod, Power, & Dugan, 2000; Van der Kolk, Perry, & Herman, 1991), relatively little is known about what motivates self-mutilators and many professionals are at a loss to understand the behavior (MacAniff Zila & Kiselica, 2001). Because tension relief is a correlate of self-mutilation, it has been speculated that the act is a specific method of coping with emotional distress that leads to an immediate reduction in tension. (Alderman, 1997; Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Van der Kolk, Perry, & Herman, 1991; Winnicott, 1989; Yaryura-Tobias et al., 1995). Van der Kolk et al. (1991) suggested that this is a way for individuals who lack more adaptive coping techniques to achieve psychological equilibrium. Self-mutilators generally are unable to verbally describe their intolerable affect (Zlotnick, Shea, Pearlstein, Simpson, Costello, & Begin, 1996), and the act of self-mutilation itself becomes an expression of these unspoken feelings of despair.
Individuals who cannot verbally express negative affects may be described by the term "alexithymia." The latter concept derived from clinical observations that psychosomatic patients were unimaginative and limited in their ability to verbally and symbolically express emotions (Ruesch, 1948). They were constricted in emotional functioning, had a barren fantasy life, found it difficult to differentiate feelings from bodily sensations, and had trouble talking about their emotions (Sifneos, 1972, 1973, 2000). Alexithymia therefore has been defined as a personality construct characterized by a difficulty in identifying and communicating feelings; a problem in distinguishing between feelings and bodily sensations; a relative lack of fantasy and imaginative activity; and a preference for focusing on external events over internal experiences (Taylor, Doddy, & Newman, 1981). Longitudinal studies suggest that it is a stable trait rather than a state effect of psychological or medical distress (Taylor, Bagby, & Luminet, 2000).
Alexithymia is highly predictive of a broad range of physical and mental problems. Associations have been found with hypertension (Todarello, Taylor, Parker, & Fanalli, 1995), inflammatory bowel disease (Porcelli, Zaka, Leoci, Centonze, Taylor, & Parker, 1995), chronic pain disorder (Lumley, Asselin, & Norman, 1997), somatoform disorders (Cox, Kuch, Parker, Shulman, & Evans, 1994), eating disorders (De Groot, Rodin, & Olmstead, 1995), depression (Grabe, Spitzer, & Freyberger, 2004; Honkalampi, Hintikka, Laukkanen, Lehtonen, & Viinamaki, 2001; Wise, Mann, & Hill, 1990), dissociation (Grabe, Rainermann, Spitzer, Gänsicke, & Freyberger, 2000), panic disorder (Zeitlin & McNally, 1993), anxiety, phobia, obsessionality, interpersonal sensitivity, aggression, paranoia, and psychoticism (Grabe et al., 2004).
Because alexithymia has proven to be such a strong predictor of a broad range of pathology, a relationship with self-mutilation might be expected. The inability to differentiate and verbally express emotions that characterize alexithymics is also a characteristic of self-mutilators (MacAniff Zila & Kiselica, 2001). It is therefore not surprising that, compared to non-mutilators, self-mutilators have been found to report a greater degree of alexithymia (Zlotnick, et al., 1996).
Many studies of the relationship between alexithymia and other forms of pathology have not integrated in their analyses an assessment of depression. It has been reported that alexithymia is moderately to strongly related to depression (Grabe, et al., 2004; Hintikka, Honkalampi, Lehtonen, & Viinamäki, 2001; Honkalampi, et al. 2001; Honkalampi, Hintikka, Tanskanen, Lehtonen, & Viinamäki, 2000; Speranza, Corcos, Guilbaud, Loas & Jeammet, 2005; Wise et al., 1990) and that the latter variable acts as a powerful mediator between alexithymic features (particularly the "difficulty in identifying feelings and differentiating them from bodily sensations" factor) and psychopathology (Honkalampi et al., 2000; Speranza, Corcos, Stéphan, Loas, Pérez-Diaz, Lang, Venisse, Bizouard, Flament, Halfon, & Jeammet, 2004). For this reason, the present investigation analyzed the relationship between alexithymia and self-mutilation while taking into consideration the possible mediating effect of depression in order to ascertain whether or not alexithymia makes an independent contribution to self-mutilation separate from depression.

METHOD
Participants


Participants were 15 adolescent French girls ranging in age from 13 to 19 years (M = 16.8, SD = .4) who had a recent history of self-mutilating behavior (i.e., cutting themselves with a knife, scissors, piece of glass, utility knife, tool, razor blade, pair of compasses, or paper sheet). This clinical group constituted a convenience sample of self-mutilators who over the course of a two-month period contacted the psychological health service of a hospital for assistance. The girls who showed physical signs of self-cutting and who reported that they engaged in the behavior were invited to participate in the study. The participation rate was 100%. Besides cutting themselves, 10 of the 15 girls had made at least one suicide attempt. The study further included 18 adolescent French girls from the same geographical area who ranged in age from 14 to 20 (M = 17.5, SD = .4) and had no history of self-mutilation, suicide attempts, or psychiatric problems.

Materials


Participants were asked for information concerning their age, the method used to cut themselves (clinical group only), and whether or not they had ever made an attempt to commit suicide.
Alexithymia was assessed with the French version (Loas, Otmani, Verrier, Fremaux, & Marchand, 1996; Loas, Parker, & Otmani, 1997) of the Toronto Alexithymia Scale (TAS-20; Bagby, Taylor, & Parker, 1994a, 1994b). This 20-item measure comprises three subscales: difficulties identifying feelings and differentiating them from bodily sensations (Factor 1), difficulties describing feelings to others (Factor 2), and externally oriented thinking (Factor 3). Responses to the items are scored on 5-point Likert-type rating scales ranging from 1 (strongly disagree) to 5 (strongly agree). The instrument provides an overall alexithymia score (overall TAS) as well a score for each of the three factors. The present study focused on the respective alexithymia factors. The Toronto Alexithymia Scale is a well-validated and reliable device (Bagby, et al. 1994a, 1994b) and is one of the most widely used measures of alexithymia (Taylor, 2000). Confirmatory factor analysis for the French version replicated the three-factor model of the English scale (Loas, et al., 1997). Concurrent validity was demonstrated by positive correlations (.61; .79) with two versions of the Bermond-Vorst Alexithymia Questionnaire (Taylor, et al., 2000). Internal consistency was evidenced by a Cronbach alpha of .79 and item-total score correlations ranging from .19 to .69 (Loas, Fremaux, & Marchand, 1995).
Depression was measured with the French version (Beck, Steer, & Brown, 1996) of the second edition of the Beck Depression Inventory (BDI-II). The BDI-II consists of 21 items, each with 4 answer options. Scores per item may range from 0 to 3; the maximum total score is 63. Alpha coefficients for the BDI-II were .92 for a sample of out-patients and .93 for students; item-total score correlations ranged from .39 to .70 for the first sample and from .27 to .74 for the second group. Test-retest reliability was .93 over a seven day period. Scores on the scale were significantly related to scores on the Beck Hopelessness Scale (.68), the Scale for Suicide Ideation (.37), the Beck Anxiety Inventory (.60), the Revised Hamilton Rating Scale for Depression (.71) and the Revised Hamilton Anxiety Rating Scale (.47) (Beck, Steer, & Brown, 1996).

RESULTS


A survey of the data showed a difference in age between self-mutilators and non-mutilators (M = 16.8 versus M = 17.5), but a t-test of the observed difference was not significant, t( 31) = 1.15. Because 10 self-mutilators had made at least one suicide attempt whereas 5 had not, the associations between presence or absence of suicide attempt and the variables of depression, overall TAS, and the three factors were assessed: no significant results were obtained. These findings indicated that it was not necessary to include age in the analyses nor was there a need to subdivide the self-mutilators into attempters and non-attempters.
The means and standard deviations for depression, overall TAS, and the three factors are presented in Table 1. Separate values for self-mutilators and non-mutilators are reported, together with corresponding t-test statistics. The mean depression score for self-mutilators was significantly higher than the one for non-mutilators. Using cut-off points provided in the BDI-II manual it was found that 40% of the self-mutilators reported moderate depression whereas 47% reported severe depression. In comparison, 72% of the non-mutilators reported minimal depression and 28% reported light depression. The mean scores for overall TAS and Factor 1 (difficulties identifying feelings and differentiating them from bodily sensations) were also higher for the self-mutilators. To assess their clinical significance, these scores were compared to normative scores provided by Parker, Taylor, and Bagby (2003). The self-mutilators' mean score for overall TAS fell more than 1 standard deviation above the normative score; the corresponding score for Factor 1 was 1.5 standard deviations above the norm. Sixty percent of the self-mutilators had overall TAS scores that were at least 1 standard deviation above the norm, compared to 22% of the non-mutilators. Similarly, 60% of the self-mutilators had Factor 1 scores that were at least 1 standard deviation higher than the norm, compared to 28% of the non-mutilators. No significant differences were found between the mean scores of self-mutilators and non-mutilators for Factors 2 and 3.
Correlation coefficients assessed the interrelationships between overall TAS, the three factors, and presence/absence of self-mutilation (see Table 2). Overall TAS and self-mutilation were significantly related.
Similarly, Factor 1 (difficulties identifying feelings and differentiating them from bodily sensations) was significantly associated with self-mutilation, but Factors 2 and 3 were not. Depression was significantly related to presence/absence of self-mutilation and to Factor 1; no significant relationships were found with overall TAS, Factor 2 or Factor 3. Because the latter two factors were not significantly related with self-mutilation and depression, and because overall TAS was not related to depression, these variables were excluded from subsequent analyses.
To test the mediational hypothesis, a sequential logistic regression was performed with presence/absence of self-mutilation as dependent variable and depression and Factor 1 (difficulties identifying feelings and differentiating them from bodily sensations) as predictors. Although the present study used a small sample, the rule of thumb that there should be at least 10 cases in the sample for each independent variable was met. Because the likelihood ratio test is considered more reliable for small samples than the Wald statistic (Agresti, 1996), the likelihood ratio test of individual parameters was used to assess the relative importance of the independent variables (see Table 3).
The test of the full model was significant, indicating that depression and Factor 1 make a difference in predicting presence/absence of self-mutilation. The model was run again with Factor 1 removed. The test for this reduced model was significant, but, more importantly, so was the difference between the full model and the reduced model. These findings indicate that the two models are significantly different and that it is not justified to drop Factor 1 from the model. The full model correctly predicted 86.7% of the self-mutilators and 94.4% of the non-mutilators, for an overall success of 90.9%. The histogram of predicted probabilities was U-shaped with 2 false positives and 1 false negative. Nagelkerke's R2 was .81 for the full model and .72 for the reduced model. The partial and semi-partial correlations for depression were .65 and .53 respectively; the corresponding values for Factor 1 were .36 and .24.
The sample size of the present study was small because, as is the case with many clinical investigations, practical restrictions limited access to participants. A small sample may present a problem in statistical analyses as it may reduce the ability to detect significant results, especially when effect size is small. Following Hepler's (1992) suggestion, post-hoc power analyses were performed to test the validity of the findings and to determine the sample size needed to obtain significance. The analyses produced an observed power of 1 and an effect size (f2) of 1.58. The sample size needed to obtain the observed statistical results with an alpha level of .05, a power level of .90, and an effect size of 1.58 was 12. The sample size of the present study was 33 and thus deemed sufficient.

DISCUSSION


The analysis of the means and the distribution of scores showed that the self-mutilators in this study are a clinically significant group. In addition to their self-cutting behavior, most of these girls have considerable depressive symptomatology and elevated levels of alexithymia, particularly in terms of identifying feelings and differentiating them from bodily sensations. Moreover, the majority has made one or more suicide attempts.
A survey of the correlations confirms that self-mutilation, alexithymia (overall TAS and Factor 1), and depression are interrelated. The observed relationship between self-mutilation and overall alexithymia is consistent with Zlotnick, et al.'s (1996) finding that self-mutilating women have greater alexithymia. Zlotnick et al., however, did not consider the three factors in their analysis. The present study did, and the results show that there is a relatively strong association between self-mutilation and Factor 1 (difficulties identifying feelings and differentiating them from bodily sensations). This suggests that self-mutilators particularly face confusing emotional perceptions which they cannot transform into meaningful feelings. The results further show that self-mutilation is related to depression, supporting Ross and Heath's (2004) finding that adolescent self-mutilators report significantly more depressive symptomatology than their peers who do not engage in such behavior. Depression, in turn, is related to the "difficulties identifying feelings and differentiating them from bodily sensations" factor. This finding is consistent with Speranza et al.'s (2005) observation that the correlation between this factor and depression tends to vary between .42 and .65.
Factors 2 and 3 are not significantly related to self-mutilation and depression, and overall TAS is not related to depression, leaving only Factor 1 of the alexithymia construct for inclusion in the analysis of possible mediation. This pattern of significant and nonsignificant relationships between the various alexithymia scores and the other variables is typical of measures of multifaceted constructs. Parker et al. (2003) noted that the TAS-20 factors show discriminability when they are correlated with constructs that overlap with one or two facets of alexithymia but not with the entire alexithymia construct. Hence, it seems that in the present study self-mutilation and depression overlap with the "difficulties identifying feelings and differentiating them from bodily sensations" aspect of alexithymia but not with the other features. The fact that the analysis identifies the (in)ability to identify one's feelings and to distinguish them from bodily sensations as the relevant variable, supports Haviland, Shaw, Cummings, and MacMurray's (1988) suggestion that this TAS-20 subscale captures the alexithymia construct better by itself than when combined with the other two subscales to create the total TAS score.
The outcomes of the logistic regression indicate that depression and the alexithymia factor as a set reliably distinguish (with a success rate of 90.9%) between those who self-mutilate and those who do not. The fact that the Chi-square difference (full model versus reduced model) is significant indicates that the "difficulties identifying feelings and differentiating them from bodily sensations" factor does have an effect by itself. However, the change in Nagelkerke's R2 (full model versus reduced model) and the respective values of the zero-order, partial, and semi-partial correlations show that depression is not only the more powerful predictor of the two, but that it also controls the relationship between the alexithymia factor and self-mutilation to a certain degree.
In summary, there is a relationship between the (in)ability to identify one's feelings and to differentiate them from bodily sensations and self-mutilation. Although the initial correlation analysis shows a relatively strong relationship between this alexithymia factor and self-mutilation, it is clear that a large part of this association is mediated by depression. This latter variable is of greater practical importance in differentiating between self-mutilators and non-mutilators. Nevertheless, the results show that the alexithymia factor by itself is associated with self-mutilation and as such may be taken as a predictor of the latter, independent of depression.

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Understanding and Counseling Self-Mutilation in Female Adolescents and Young Adults. By: Zila, Laurie MacAniff; Kiselica, Mark S.. Journal of Counseling & Development, Winter2001, Vol. 79 Issue 1, p46, 7p; (AN 4086829)

This article examines the syndrome of self-mutilation with specific attention given to self-mutilation in female adolescents and young adults. Causes, symptoms, types, definitions, and treatments are discussed. Included is an explanation of the lexical and conceptual confusion that accompanies self-mutilation. Implications and recommendations for counselors are addressed.
Acts of self-mutilation by female adolescents and young adults have received increased attention in the popular literature (Pedersen, 1996; Pipher, 1994; Schappell, 1995; Steinem, 1993; Todd, 1996), yet understanding and effective treatment of self-mutilation remain elusive. Self-mutilation is a phenomenon often associated with autistic children, schizophrenics, and those diagnosed with multiple personality disorder, but rarely addressed in discussions of female adolescents and young adults. The paucity of information available is apparent when trying to identify recent works on the topic. This lack of general knowledge and specific research regarding self-mutilation is detrimental to those who exhibit self-mutilating behaviors and those counseling professionals who may encounter self-mutilation in their clients.
In 1985, self-mutilation was discussed on a national television show (Favazza & Conterio, 1989). Viewers were supplied with an address to which they could write for more information. Over 1,000 letters were received. Favazza and Conterio used this group for a study on self-mutilation. Of the 254 people who responded positively to their request to participate in the study, 240 were female and reported 14 years to be the average age of their first self-injurious act. It is interesting that 91% had neither known nor read about self-mutilation before viewing the program, illustrating the need for more attention to the subject.
The extreme cases of self-mutilation that result in the need for immediate medical attention are usually the most familiar, yet these instances are far from typical. Many authors describe the typical self-mutilator as female, adolescent or young adult, single, usually from a middle- to upper- middleclass family, and intelligent (Favazza & Conterio, 1989; Pattison & Kahan, 1983; Raine, 1982; Suyemoto & MacDonald, 1995).
The purpose of this article is to educate the counselor on the many aspects of self-mutilation in female adolescents and young adults. Specific attention is given to its definitions, causes, symptoms, types, and treatment. There is also an attempt to address the semantic and conceptual confusion that accompanies self-mutilation.
Although self-mutilation does occur among certain populations of boys (e.g., among sexually abused boys; see Cabe, 1999), we have focused this article on self-mutilation in girls for two reasons. First, our review of the literature indicated that even less is known about self-mutilation in boys than is known about self-mutilation in girls. Second, we have counseled considerably more girls than boys who self-mutilate and have drawn from these clinical experiences in writing this article. Although the purpose of this article is to convey what we have learned about self-mutilation in girls, we hope that this article will assist other counselors in their efforts to study, understand, and help troubled boys who are also tortured by the distressing problem of self-mutilation.

DEFINITION OF SELF-MUTILATION


Defining self-mutilation is not a simple task (Pattison & Kahan, 1983) because it has not been widely defined as a syndrome and the accompanying signs and symptoms are not uniformly or systematically recorded. Although self-mutilation is the most commonly used term, researchers and counseling professionals have not agreed on one term for acts of self-inflicted injury. In 1979, Ross and McKay reported as many as 33 terms for the same behavior. A sampling of the literature attests to this with its many different terms: self-mutilation (Favazza & Conterio, 1989; Pipher, 1994; Raine, 1982; Ross & McKay, 1979; C. A. Simpson & Porter, 1981; Yaryura-Tobias, Neziroglu, & Kaplan, 1995), self-cutting (Greenspan & Samuel, 1989; Himber, 1994; Suyemoto & MacDonald, 1995), deliberate self-harm (Brittlebank et al., 1990; Pattison & Kahan, 1983), and self-destructive behavior (van der Kolk, Perry, & Herman, 1991).
The same situation persists when trying to classify those who perform acts of self-mutilation. They are defined as cutters (Graft & Mallin, 1967; Pattison & Kahan, 1983; M. Simpson, 1980), carvers (Ross & McKay, 1979), and wrist slashers (Graft & Mallin, 1967). Close to 30 years ago, Ballinger (1971) stated that the classification of this behavior is at its most primitive level, thus offering little on which to build. It seems that not much progress has been made since that time.
Definitions proposed by others are helpful, yet in some cases contradictory. For example, Greenspan and Samuel (1989) defined self-mutilation as an act that superficially scratches the skin due to cutting with a sharp object. However, M. Simpson (1980) stated that cuts resulting from self-mutilation vary in depth from superficial scratches to deep lacerations. Another problem with this type of definition is that it fails to address acts of self-mutilation that do not involve cutting and exclude the use of an instrument.
Although cutting of the wrists or forearms is the most commonly reported form of self-mutilation, Ross and McKay (1979) have reported cuts to the face and genitals. In addition, Himber (1994) observed cuts to the thighs, legs, abdomen, and breasts. The instruments used for cutting range from needles, fingernails, and food bones (Ross & McKay, 1979) to razors and knives (Himber, 1994; Pipher, 1994).
Many other forms of self-mutilation have also been documented. Another typical act of self-mutilation is burning of the skin, usually with matches or cigarettes (Favazza & Conterio, 1989; Pattison & Kahan, 1983; Pipher, 1994; van der Kolk et al., 1991). Other reports have documented interfering with wound healing (Alderman, 1997; Favazza & Conterio, 1989), constricting air passages or blood flow to parts of the body, inserting objects under the skin or into bodily orifices, biting and abrading the body (Ross & McKay, 1979), and hitting the body with objects or other parts of the body (van der Kolk et al., 1991). Acts of self-mutilation vary greatly and are limited only by the means and imagination of the self-mutilator.
The most inclusive definition is offered by Yaryura-Tobias et al. (1995): "Self-mutilation is a volitional act to harm one's own body without intention to cause death" (p. 33). This explication is broad enough to capture the essence of self-mutilation and its many possible categories. Also helpful is Alderman's (1997) summary of characteristics of self-mutilation as an act that is done to oneself, performed by oneself, physically violent, not suicidal, and intentional and purposeful.
An area of agreement in defining self-mutilation is that of its repetitive nature. M. Simpson (1980) observed that individuals who self-mutilate cut more than once and that most have dozens of scars on their bodies. Bach-y-Rita (1974) found an average of 93 scars per self-mutilator. Himber (1994) also reported on the repetitive nature of self-mutilation.

SELF-MUTILATION AND SUICIDE


One of the difficulties faced by researchers in the area of self-mutilation is that much of the early literature on it is buried in reports and statistics on suicide. Although suicide and self-mutilation share some obvious connections, they are by no means one and the same. Perhaps the first to point this out was Karl Menninger in 1938 (as cited in Favazza, 1996). Menninger described self-mutilation as the focusing of a suicidal impulse on part of the body instead of the whole body to avoid actual suicide. He went on to speculate that in the future, counseling professionals would talk about self-mutilation as separate from acute, generalized self-destruction. Over half a century later, there are still reports of clinicians who believe that the intent of all self-mutilation is suicide (Himber, 1994; M. Simpson, 1980).
Graff and Mallin (1967) asserted that self-mutilation is distinct from suicidal behavior in several ways. Suicidal clients want to end their lives, individuals who self-mutilate do not. A suicide attempt most often elicits an active response from members of the individual's environment, which serves to diminish the number of subsequent attempts. Self-mutilation, on the other hand, prompts others to react to the client's behavior with hostility and disgust, and the frequency of self-mutilation does not diminish. Furthermore, suicidal clients often improve when they are removed from stressful situations; clients who self-mutilate tend to continue their patterns of destructive behavior despite efforts to change the level of stress in the environment.
Pattison and Kahan (1983) noted other distinctions between suicidal behavior and self-mutilation pertaining to lethality, change in affect, and mind-set. Self-mutilation is considered an act of low lethality as opposed to the high lethality of a suicide attempt. Self-mutilation is generally followed by a sense of relief for the self-mutilator, whereas a suicide attempt typically offers no such relief. Furthermore, although suicidal behavior evokes persistent thoughts of death and dying, self-mutilation rarely does so.
Statistics illustrate differences in the aforementioned areas as well as age of onset and sex ratio, with suicide more prevalent in middle-aged men and self-mutilation in female adolescents and young adults (van der Kolk et al., 1991). In one example, even the individual who self-mutilated distinguishes her behavior from suicide: "The objective wasn't to make myself bleed to death, just to let go of the ugly feelings holding me hostage--feelings that would leave at the sight of blood" (Pederson, 1998, p. 64).

WHAT CAUSES SELF-MUTILATION?

General Findings

Hypotheses regarding the motivations for self-mutilation are as varied as the acts themselves. An early report of self-mutilation by Offer and Barglow (1960) proposed several explanations but emphasized the major dynamic as aggression turned against the self to retaliate against a "bad mother" (p. 109). It is interesting that this theory came at a time when communication patterns (particularly those between children and mothers) in families with children who have schizophrenia were being reported that tended to "blame" the mother for schizophrenia in her child (Goldenberg & Goldenberg, 1996). This form of linear thinking (i.e., mother "causes" child's behavior) may have influenced Offer and Barglow's cause-effect explanation. Although ultimately too simplistic to explain self-mutilation, this explanation provided a start for other researchers.
Ross and McKay (1979) provided an extensive list of possible causes of self-mutilation including ritual and symbolism, sex, regression, existential statement, manipulation, risk taking, attention seeking, retaliation, frustration, depression, tension relief, inappropriate communication, self-punishment, and low self-esteem. The most commonly supported of these theories are ritual and symbolism and tension relief.
Ross and McKay (1979) explained ritual and symbolism in descriptions of self-mutilation that are laden with religious overtones and symbolism. Favazza and Conterio (1989) concurred with this theory, citing frequent references to the need to atone for sins by those who self-mutilate. Himber (1994) found a common theme of self-purification among these individuals. Influence of the Bible, identification with Christ, sinfulness, heavenly commands, demonic influences, and religious commands were reasons offered by Favazza (1996) for more extreme cases of self-mutilation.
Many support the theory of tension relief as at least a partial explanation for self-mutilation (Alderman, 1997; Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Winnicott, 1989; Yaryura-Tobias et al., 1995). This idea postulates that an act of self-mutilation brings an immediate diminution of tension that results in a relaxed state. Ross and McKay (1979) and van der Kolk et al. (1991) believed that this is a way for those who lack more adaptive means to achieve psychological homeostasis. Himber (1994) saw this as a type of affect modulation in which self-mutilation is used to modulate intolerable emotions.

Sexual Identity Issues and Sexual Abuse

Sexual identity in the context of a discussion of self-mutilation must address several points: sexual experience or abuse, attitude toward one's gender, body image, and self-mutilation as a form of masturbation. The common theme throughout these separate but integrated issues is sexual confusion.
Graft and Mallin (1967) reported sexual confusion among nearly all of their study's participants. Although some had extensive sexual experience, including same-sex and incestuous activity, others were inordinately prudish. Pao (as cited in M. Simpson, 1980) emphasized the repugnance his group of self-mutilators exhibited toward their female sexuality as well as their uncertainty about sexual identity. In referring to his group composed of individuals who self-mutilated, Pao (as cited in M. Simpson, 1980) emphasized the group members' repugnance exhibited toward their female sexuality as well as their uncertainty about sexual identity. More than half of the participants in Favazza and Conterio's (1989) study reported the presence of troublesome sexual feelings: 34% hated their breasts, 56% strongly hated having a pelvic exam, and 10% indicated they would be better off without a vagina.
The onset of menstruation often correlates with adjustment problems for female adolescents and young adults. For the self-mutilator, this time is frightening and often even repugnant. Rosenthal et al. (as cited in M. Simpson, 1980) reported 65% of participants in their study had negative, unhappy, or disgusted reactions to menarche. Almost half of this group had irregular menstrual periods and frequent amenorrhea. Favazza and Conterio (1989) reported that 58% of their participants hated their periods. Those with more abnormal menstrual patterns more frequently exhibited self-mutilating behaviors. Yaryura-Tobias et al. (1995) reported a correlation between the onset of self-mutilation and the return of the menstrual cycle.
Just as the onset of menstruation often precipitates confusion for the girl who self-mutilates, so does the associated issue of emerging sexuality. Self-mutilation is often associated with the inability to deal with one's sexuality due to earlier or ongoing sexual abuse, or rape. C.A. Simpson and Porter (1981) hypothesized that these experiences somehow change normal physical and emotional responses to both sex and pain. Greenspan and Samuel (1989) studied three young women whose self-mutilation began shortly after they were raped. The backgrounds of the first two individuals were void of any previous abnormal sexual experiences, but the third had a history of incest. In their study of 19 self-mutilating young women, Yaryura-Tobias et al. (1995) noted that 70% of them reported childhood sexual abuse.
In a longitudinal study of 74 clients, van der Kolk et al. (1991) examined how histories of childhood trauma contribute to self-destructive behaviors such as self-mutilation. The authors found a strong correlation between a history of childhood physical and sexual abuse with self-mutilation. They recommended that therapists working with clients who self-mutilate should be prepared to deal with past issues of childhood trauma as well as the effects of such experiences on current relationships.
Daldin (1988) proposed that the sexual component of self-mutilation is primarily masturbatory. Self-mutilation is seen as representing a self-stimulating activity that combines sexual gratification with punishment for the impulse to self-stimulate. Again, the idea of a distorted sense of pain and pleasure is addressed as is that of a distorted body image. C. A. Simpson and Porter (1981) agreed that self-mutilation might be a form of body stimulation.

Eating Disorders

The body image aspect of sexual identity extends to the subject of what these young women will go through to control their bodies. This issue of control often takes the form of an eating disorder. M. Simpson (1980) noted the connection between self-mutilation and anorexia nervosa, citing similar origins for both behaviors. Disturbance of body image, self-directed aggression, and indirect self-destructive behavior were the key correlates. Favazza and Conterio (1989) reported that 61% of participants in their study admitted to having or having had an eating disorder, with the average age of onset being 16 years. Of study participants who engaged in self-mutilation, C. A. Simpson and Porter (1981) found only 1 of 20 to be within the normal range for weight-height ratio.
M. Simpson (1980) also found that substantial symptoms of dysorexia (a bad or depraved appetite) may be quite common among those young women who exhibit self-mutilation and that acts of self-mutilation are frequently associated in time with binge eating or its associated vomiting. According to Yaryura-Tobias et al. (1995), within 2 years after improvement of anorexia and elimination of amenorrhea, study participants manifested a compulsion for self-mutilation. At times, self-mutilation and eating disorders coexist, whereas at other times, one seems to replace the other.
Alderman (1997) suggested that patterns associated with both self-mutilation and eating disorders are connected by the commonalties of trauma and disassociation. The relationship between self-mutilation and eating disorders is not cause and effect; self-mutilation and eating disorders are separate choices for coping with similar situations.

Substance Abuse

Some researchers have investigated the relationship between self-mutilation and substance abuse. There is some disagreement about the nature of the relationship between substance abuse and self-mutilation. Pattison and Kahan (1983) and Graft and Mallin (1967) believed that drug and alcohol abuse are major predisposing factors for self-mutilation. However, Ross and McKay (1979) proposed that the ingestion of drugs and alcohol is itself an act of self-mutilation and that a drug-induced state may actually trigger self-mutilation because of impaired judgment, reduced pain perception, and fantasy stimulation.
Regardless of which hypothesis is correct, it is important to be aware of the frequency of reported substance abuse among those who self-mutilate. Although 59% of Favazza and Conterio's (1989) study participants reported that no self-mutilation occurred while they were under the influence of alcohol or drugs, 28% were concerned with their drinking, 18% considered themselves alcoholics, and 30% had abused nonprescription drugs. M. Simpson (1980) reported that amphetamines were popular among those who self-mutilate because of the drug's ability to amplify sensation and-stimulate body awareness. Similarly, C.A. Simpson and Porter (1981) found that a majority of their study participants abused alcohol, nonprescription drugs, or both, and they gave comparable reasons for this and for their acts of self-mutilation, "to feel good ... to make the bad feeling go away" (p. 432).

Disturbed Childhood Attachments

The absence of appropriate attachment and nurturing during childhood may contribute to the onset of self-mutilation. Favazza and Conterio (1989) found that more than half of their study participants selected the adjective "miserable" to describe their childhood, and 62% noted childhood abuse. Kafka (1969) reported clients recalling early experiences of abandonment and a lack of maternal handling during the very early stages of childhood. Lack of social support, isolation, and family disruption were present in almost half of Pattison and Kahan's (1983) sample. How does this information apply to a study of self-mutilation?
Himber (1994) postulated that growing up abused, neglected, or both makes accepting comfort and help from others difficult. Consequently, individuals who self-mutilate learn to rely on their own resources. C. A. Simpson and Porter (198 l) found that many of those individuals did not know how to maintain meaningful interpersonal relationships. Many of their study participants frantically looked for important attachments, yet refused to form them. Rosen, Walsh, and Rode (1990) regarded lack of attachment in early life due to the loss of a significant other, particularly a parent, as hindering the development of a stable capacity for love. New losses are seen as recapitulating the original loss and its accompanying emotions.
Alderman (1997) viewed self-mutilation as a way to keep others at a distance, both physically and emotionally. Emotional distance results from the shame and secrecy that accompany self-mutilation. Individuals who self-mutilate do not discuss their behavior with others, which can lead to a feeling of emotional isolation. The sensation of physical disassociation with oneself that often accompanies self-mutilation can extend itself to a lack of attachment to others. Physical distancing from others can also occur as a way to avoid exposing wounds and scars. This may result in the self-mutilator refraining from sexual or intimate contact with others.
Another theory, supported by Ross and McKay (1979), was offered by Graft and Mallin (1967):
As the child matures and can distinguish verbal from nonverbal communication, it still demands both when it is injured. Only with greater maturity can it subsist on verbal messages of comfort in lieu of physical messages. We view the behavior of the cutter as a manifestation of a breakdown in this developmental system. (p. 40)

THE ACT OF SELF-MUTILATION


Although self-mutilation is detrimental, it may serve a type of "therapeutic purpose" for its participants. Ross and McKay (1979) considered the act of injury to be a highly effective form of adaptation, bringing immediate beneficial results and allowing the self-mutilator to again experience painful emotions. M. Simpson (1980) observed that self-mutilation was a way of "achieving swift reintegration, repersonalization, and ending a very unpleasant sequence" (p. 269). Similarly, Pipher (1994), in her work with female adolescents who self-mutilate, found self-mutilation to be cathartic for them.
In the absence of better coping strategies, self-mutilation becomes a way to calm down. It is a means of escape from an unbearable state of emotion. After self-mutilation, the individual reports feeling better; less confused; and more real, normal, and in touch (Raine, 1982). One of Himber's (1994) study participants reported the following: "it almost physically lowers my heartbeat.., it puts me into a bit of a dissociated state which is comfortable and calming" (p. 623).
This dissociated state often combines a lack of pain during the act of self-mutilation and the accompanying need of those who cut to see their blood flow, as an indication of when to stop cutting. Although there has been some study of potential biological causes for this (Favazza, 1996), the research has yet to reveal any substantial data. All that is known for certain about individuals who self-mutilate is that most experience anesthesia during the act of self-mutilation (Himber, 1994; Ross & McKay, 1979; Yaryura-Tobias et al., 1995) and that those who cut themselves indicated that the sight of blood is often an important component of their self-mutilation (Greenspan & Samuel, 1989; Raine, 1982). However, what precipitates the act?
Most research, based on studies compiled by M. Simpson (1980), indicates that self-mutilation is often preceded by what the individual considers to be an emotional impasse or threat of abandonment or loss by a significant other, such as a breakup with a boyfriend or an argument with a parent. Others report overwhelming tension, frustration, depression, rejection, restlessness, and then ultimately numbness, emptiness, and total self-absorption and depersonalization (Raine, 1982; Ross & McKay, 1979). The confusion of self and not self is frequently reported, and the body is described as a reference point to help the individual distinguish between the two. By harming the body, the individual highlights the distinction.

COUNSELING THE INDIVIDUAL WHO SELF-MUTILATES

Underlying Symptoms

The main issue for young women who self-mutilate is usually a combination of difficulty with verbalization and functioning from a false self (Pipher, 1994; Winnicott, 1989). Verbalizing emotions often seems impossible to the self-mutilator: "I just cry and get hysterical when I try to talk" (Offer & Barglow, 1960, p. 104). Himber (1994) found that individuals who self-mutilate function developmentally at a preverbal level. Therefore, the initial goal of counseling should be to provide a relationship that is "sustaining enough to help contain the flood of overwhelming affect" (p. 627).
Graff and Mallin (1967) stressed that the aim of counseling should initially be to assist the patient's maturity process to the point where she can use words rather than destructive gestures as a sign of emotion. Others (Rosen et al., 1990; M. Simpson, 1980) reported that an improved facility in verbal emotional expression was associated with clinical improvements and cessation of self-mutilation. Roeback et al. (as cited in Ross & McKay, 1979) found that reinforcement of social responses of these individuals combined with a multifaceted counseling approach was a key to eliminating self-mutilation.
Pipher's (1994) notion of the false self is an important concept related to addressing the expressive difficulties of individuals who self-mutilate. According to Pipher, the false self emerges when girls fail to acknowledge their own feelings. Winnicott (1989) theorized that the emergence of a false self results in a psychological state characterized by a lack of spontaneity and blunted affective experience. Among those who self-mutilate, the denial of the true self, the emergence of the false self, and the concurrent masochistic patterns of behavior may be triggered by early childhood trauma, such as sexual abuse (van der Kolk et al., 1991). Consequently, a critical goal of counseling is to promote the reemergence of the true self by talking about these patterns of behavior, gently and patiently exploring any early traumas, and encouraging the genuine expression of previously denied feelings. Throughout this process, the counselor must assist the individual who self-mutilates to stay connected to her feelings and slowly work through any turbulent, psychological changes that may be prompted by the counseling (Pipher, 1994).

Professionals' Reaction to Self-Mutilation

The limited information regarding self-mutilation frequently hinders its proper treatment. Many counselors, psychologists, marriage and family therapists, and medical professionals who encounter individuals who self-mutilate are often at a loss to understand their behavior. These professionals may feel frightened, repulsed, frustrated, and find it difficult to ask in sufficient detail about the self-mutilation (Favazza, 1996; Himber, 1994). Offer and Barglow (1960) even observed how confusion and frustration regarding self-mutilation among staff members of an inpatient facility led to staff arguments, fragmented and inconsistent treatment, and resulted in an environment for the young women that was not therapeutic. M. Simpson (1980) attributed this type of response on the part of professionals to the strong sense of bewilderment that surrounds self-mutilation.
Individuals who self-mutilate are aware of the reactions their behaviors elicit. Favazza (1996) encountered many such individuals who, because of previous harsh and unsympathetic treatment, falsely admitted to suicide attempts in order to be treated with more humanity. Conversely, Himber (1994) told of a woman who had a long-standing relationship with her physician who set regular appointments with her to examine and treat her wounds, which she felt was a contributing component of her eventual recovery.
Even for those professionals who attempt to properly care for self-mutilation, problems often arise. When counseling strategies aimed at getting the client to stop self-mutilation fail, the client frequently experiences a sense of being misunderstood, and the counselor frequently perceives himself or herself as being ineffective and overwhelmed (Himber, 1994). Ross and McKay (1979) found that only after conceding that they did not understand self-mutilation were counselors then able to suspend clinical judgment and allow the young women to explain their behavior. This process worked for two reasons: The young women felt empowered by becoming part of their own recovery, and the insight gained by the counselors allowed for more appropriate techniques.

Unsuccessful Counseling Techniques

The array of unsuccessful attempts at controlling self-mutilation may seem disheartening. However, if counselors are aware of strategies that have been tried and have failed, they will not disappoint their clients or themselves by trying them again. Cited examples of ineffective treatments are physical restraint, hypnosis, chemotherapy, no-cutting contracts, faith healing, group psychotherapy, relaxation therapy, electroconvulsive therapy, family therapy, educational therapy, and even chiropractic care (Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Ross & McKay, 1979).

Cognitive Counseling

Cognitive therapy shows clients the connection between their thoughts and their self-mutilation. This approach addresses both the difficulty these young women have with verbalization and their choice to revert to a false self Walsh and Rosen (as cited in Favazza, 1996) established four categories of thought that lead to self-mutilation and need to be addressed in cognitive therapy: self-mutilation is acceptable, one's body and self are disgusting and deserving of punishment, action is needed to reduce unpleasant feelings, and overt action is necessary to communicate feelings to others. Pipher (1994) also stressed the need for these young women to think about how to proceed and alter their thought processes so they do not need to harm themselves.
Pipher (1994) illustrated a successful example of cognitive therapy. He described the case of Gail, a 15-year-old artist and musician who became overwhelmed by "world issues" such as homelessness and AIDS as well as more personal issues like not fitting in and being ridiculed by her peers. She eventually resorted to burning herself with cigarettes.
To address her feelings of hopelessness and helplessness, Pipher (1994) encouraged Gail to work directly with the homeless at a soup kitchen. This was a tangible way for her to address some of the issues that were consuming her. In addition, when feeling overwhelmed, Gail wrote down what was disturbing her until the desire to burn herself subsided. Instead of reverting to destructive thoughts, she addressed exactly what and how she was feeling. These strategies, in combination with talking extensively in therapy about her pain and learning how to ask her parents and counselor for comfort, assisted her efforts to stop self-mutilating.

Behavior Modification

Various attempts have been made to use behavior modification techniques in counseling those involved in self-mutilation. It is interesting that methods used to treat obsessive-compulsive disorder (OCD) were tried by both Gardner and Gardner (as cited in Raine, 1982) and Yaryura-Tobias et al. (1995), the latter with greater success. Gardner and Gardner found it difficult to find an alternative form of tension relief for their clients due to the overwhelming attainment of this through self-mutilation. Alderman (1997) suggested alternative behaviors that mimic the effects of self-mutilation without the accompanying physical harm, such as submersion of the arm (or other body part) in ice water. Yaryura-Tobias et al., on the other hand, reported decreased intensity and frequency of self-mutilation after 8 weeks of intense behavior therapy consisting of exposure and response prevention, which is also effective with clients who exhibit OCD.
Ross and McKay (1979) applied Training Alternative Behaviors (TAB), which essentially involves attending to and reinforcing appropriate, desired behavior and generally ignoring the self-mutilation. A major obstacle to TAB is that it is not possible to control the behavior of other persons, including parents, who may interfere with the treatment. If the reinforcement regimen is not followed consistently, it fails. Yaryura-Tobias et al. (1995) warned that caution must be taken when using any form of reward/punishment techniques because of issues of side effects, adaptation, and ethics.

Alternative Counseling Approaches

Other effective measures in treating self-mutilation in young women have been reported. Wexler (1991) practiced Alternative Hypothesis Therapy (A-H) to assist his clients in reframing frustrating situations and conflicts. Instead of resorting to self-mutilation as a means of coping with their stresses, individuals are encouraged to become aware of when the need to self-mutilate occurs and then to identify alternative behaviors that will allow them to productively deal with the given source of stress. For one young woman, this included charting her ability to accept others' behavior. When she reached her "bottom line" (p. 180), or limit of tolerance, she had to act to maintain her self-respect. This helped to broaden the range of behaviors she could deal with and gave her a way to stay in control. She was so excited by her success that she went on to teach the method to others who self-mutilate.
Ross and McKay's (1979) research analyzed the efficacy of many singular counseling techniques and found that there were limited benefits to clients when counselors adhered to one approach. More effective, they concluded, was a multifaceted approach consisting of modeling, assertiveness training, and teaching and reinforcing socially acceptable ways of expressing negative feelings. Similarly, in a survey of 500 mental health professionals, Suyemoto and MacDonald (1995) found that a majority of therapists favored such multifaceted approaches. The models most often reported as useful in understanding and treating self-mutilation included those that addressed the client's need to express or control what they perceived as overwhelming affect. Also reported as useful is understanding self-mutilation as a way to create boundaries between self and others and to protect against depersonalization or the fear of loss of identity.
Due to the variety of causes recorded for self-mutilation it is not surprising that there is little agreement on how to treat it. There are, however, suggestions on how to identify underlying issues. Himber (1994) recommended asking about details of the acts of self-mutilation. This not only establishes that the counselor is able to hear and really wants to know what is happening, but may offer openings for understanding each individual case and its roots. Yaryura-Tobias et al. (1995) suggested screening the self-mutilator for symptoms of OCD and eating disorders. Greenspan and Samuel (1989) believed that sensitive questioning about rape and incest should be a part of the initial evaluation.

DISCUSSION


Self-mutilation is a perplexing phenomenon, but its increasing prevalence--particularly among female adolescents and young adults--needs to be addressed. An increased awareness of self-mutilation by the general public and counseling professionals is a start. However, many seem resistant to accepting the concept of self-mutilation, perhaps because of the bewildering and bizarre nature of the syndrome. Favazza (1996) had to present his manuscript to 15 publishing houses before Johns Hopkins Press accepted it. The opposition to accepting the idea of self-mutilation is detrimental to those who exhibit its symptoms and to those who may be called on to treat it. Unless more is known about self-mutilation and its treatment, it will continue to remain a mystery and those who experience it will continue to be treated improperly.
The first step, as suggested by Pattison and Kahan (1983), should be the inclusion of self-mutilation in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. This would not only validate the existence of self-mutilation but also allow for its identification by counseling professionals. Regardless of whether this happens, more research into the causes and treatment of self-mutilation is required. Perhaps educating counseling students and professionals on self-mutilation will provide a ground level acknowledgment and understanding of it. Recognition of the problem must be followed by compassionate counseling designed to help individuals who self-mutilate to acquire insight into their complex and blunted emotional states and to replace their self-destructive behaviors with effective coping skills.
Ultimately, counselors must play a role in confronting the societal forces that may contribute to self-mutilation among young women. Many of the world's societies are filled with images of unattainable physical perfection and quiet compliance as the ideal female aspirations. This may lead to a perception of limited acceptable expressions of self and a dichotomy between who one is and who one is supposed to be. A shift in defining the role of young women to that of capable, strong, independent-thinking, and pertinent beings might eliminate the need for destructive coping mechanisms. Providing an environment in which self-expression and individualism in young women are acceptable and encouraged might assist in decreasing the prevalence of self-mutilation. Through this article, we seek to open the door on the discussion of self-mutilation, yet many more doors need to be opened before self-mutilation and those who experience it receive the treatment they deserve.

 

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- Instructors: Kim Harrison M.S. Ed; Suzanne Degges-White PhD LMHC


 
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