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Risk Management and Assessment
Risk Management and Assessment

Section 4
Track #4 - Risk Assessment for Cutting:
The 'Fantasy' Technique to help Clients get Past the Pain

Question 4 | Answer Booklet | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

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It seems that a logical place to start is with the obvious. Why the teens become cutters.

On this track, we will examine the five reasons I have found why clients self-injure. These reasons are: to relieve anger; to indirectly retaliate; to test loyalty; to maintain control; and to induce caring responses from others.

5 Reasons Why Clients Self-Injure

Share on Facebook # 1 - Relieve Anger
As you probably have observed, self-mutilating clients tend to live with the myth that when someone gets mad, somebody has to get hurt. Usually, this stems from a childhood home that valued repressing angry emotions.

Crystal, age 16
stated "My family almost never showed any anger, but when they did, it sure got bad. My fantasies are that I want self-injury to the point of death. Sometimes I feel like if I self-injure, maybe someone will notice me." Crystal's emotionally repressive family left little room for self-expression. I felt Crystal's need for someone to notice her is a way for her suppressed emotions to make themselves known. Many times, Crystal believed that it was better for her to hurt herself than to hurt someone else, or to let someone else hurt her first.

Share on Facebook # 2 - Indirect Means of Retaliation
A second reason for self-mutilation in addition to a "notice me" kind of anger is it can serve as an indirect means of retaliation. In this case, self-injurers who have been abused as children think that mutilation of themselves will cause pain to their aggressor. Unable to express their feelings of wrongdoing coupled with their belief that those feelings would be ignored, clients like Sylvia repress their emotions until they're released through self-injury.

Sylvia, age 19... was abused by her father when she was 7. She stated, "My parents never publicly recognized the abuse. Every time I confronted them, they denied the whole thing. They really never addressed my feelings of betrayal or loss of trust. I thought 'I'll show them' and that's when I started cutting." At the end of this track, I will discuss how I how I utilized a "Fantasy" exercise with Sylvia's feeling of indirect retaliation.

Share on Facebook # 3 - Means of Control
A third reason for self-mutilation in addition to a "notice-me" kind of anger and indirect retaliation, I have found clients sometimes use self-mutilation as a means of control. Generally, this is a result of an abusive or traumatic childhood.

As you know, clients who experienced sexual manipulation have lost a sense of control of their environment and self-mutilation is a way to regain it. They decide when and how long the pain will endure, not their aggressor. Sylvia stated, "I felt that when I inflicted pain on myself, I was reclaiming what I had lost." Sylvia described her pain as a way of forcibly establishing a line between herself and her aggressor, in this case mainly her father.

Share on Facebook # 4 - Test Loyalty
A fourth reason for self-mutilation: Sylvia also used her self-injuries to test a person's loyalty to her. She would be very open about her self-mutilation. She stated, "One pattern in my life that I'd like to change is my need to sort of poke at people in order to see how much I can trust them and whether or not they'll leave me." Her loss of trust as a result of her childhood abuse caused her to feel alone and helpless.

Share on Facebook # 5 - Engage Caring Responses
Cutting herself and talking openly about it was her way of protecting herself from a second loss should someone she trusted betray her. As you are aware, many times, clients who reveal their self-mutilation in public also want to assert a personal declaration. Tony, age 17, stated, "I liked the attention I got from people. I felt like I was different or tough. I told myself that I was strong enough to take it and everyone else was impressed with my strength." In addition to relieving anger, maintaining control, indirect retaliation, and a test of loyalty, clients use self-mutilation to engage people's caring responses.

Kristen, age 18, stated, "When I knew someone would be seeing the cuts, I was hoping they would feel compassion and want to help me." There's a fantasy behind Kristen's line of thinking, that if the other person cared enough, he or she would prevent the mutilation from happening. In reality, her dramatic actions drive her loved ones away in understandable fear.

This only strengthens Kristen's view that the world is uncaring and apathetic to her needs. Also, clients like Kristen tend to rely on the therapist to rescue them from themselves. Ultimately, though, only Kristen can save herself. Eventually, when all human relationship disintegrated, Kristen looked to her scars and the instruments she used to self-injure as her friends. One way I helped Sylvia... to begin to overcome the abuse by her father was to help her express in words what her self-mutilation was trying to communicate.

To do this, I used a "Fantasy" technique. I had Sylvia who was abused by her father write down and identify the people she felt who wronged her, create a fantasy of revenge, and then imagine what actual apologies, punishments, or retribution might reasonably occur. In this way, Sylvia could express the things she needed in order to put her traumatic childhood behind her.

Share on Facebook "Fantasy" Technique, 2 Steps

Step 1: Identify People who have Wronged You
Sylvia wrote... "I feel that my mom hurt me as a child by ignoring my needs and focusing on my brother's needs. She heard my brother's cries but not mine. My dad abused me emotionally and sexually. I don't feel that any of my mom's actions have ever been talked about. I still feel that she loves me, but I still have problems believing that she loved me when I was younger and dad was going what he did."

Step 2: Create a Fantasy of Revenge
After expressing her feelings of wrongdoing, Sylvia went on to explain a necessary retribution for her reconciliation with her past. "I would like to see my dad go to jail for the crimes he did to me when I was younger. I would also like to see a confession from him, but that won't happen. I guess a confession from both of my parents would make me feel better." In articulating her emotions through the fantasy and words but not self-injury, Sylvia began to learn how the abuse was leading to her cutting.

On this track, we discussed the five reasons clients initiate self-injury. Those reasons were to relieve anger; to indirectly retaliate; to test loyalty; to maintain control; and to induce caring responses from others. Think for a moment of you self-injuring client do any of these reasons apply to them? If so which one? Would the fantasy technique I used with Sylvia be beneficial? We also saw how the "Fantasy" technique can help self-injurers express their emotions.

QUESTION 4
What are five reasons why your client may self-mutilate?
To select and enter your answer go to Answer Booklet.

 
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