Physical Pain Stops my Pain - Treating Teen Self Mutilation

On the last track, we discussed the various mental disorders with which adolescent self-mutilators are diagnosed. These include Axis I disorders such as depression, thought disorders, anxiety disorders, and post traumatic stress disorder, and the Axis II disorder of borderline personality disorder.

As you know, many times clients do not recognize that they have a problem with self-mutilation. They delude themselves with assertions such as the injury is not serious, that it doesn't affect them, and that it heals them.

On this track, we will examine various arguments that clients use to persuade themselves that they do not have a problem with self-mutilation. These include arguments of a personal event, of necessary emotional cleansing, and of communication. We will also include ways to address these arguments via the exploration of ramifications and analogies.

3 Arguments Clients Use to Justify their Self-Injury

# 1 - Personal Event
The first category of delusional arguments stems from the fact that much self-injuring is viewed as a private and personal event. These arguments include: "Self-injury doesn't hurt anyone" and "It's my body and I can do whatever I want". These two statements sum up how little self-injurers value their bodies and how little they understand the effect it has on their surrounding family. Elsa, age 17, gave me both of these arguments during one of our sessions to justify her self-mutilating behavior.

For her first claim, that of "Self-injury doesn't hurt anyone", I asked Elsa how her mother and father felt about her self-injury. I then pointed out to Elsa how her older brother had not spoken to her since she told her immediate family about the self-injury. Even though she was not physically hurting anyone, her behavior was destroying her very valuable familial relationships.

For Elsa's second statement, that of "It's my body and I can do whatever I want," I told her that yes, she could do whatever she wanted to do, but I then put these questions to her. I asked her, "Is it really what you want to do? Do you honestly understand why you want to do it? What are some the ramifications of the behavior?" In this way, I was able to help Elsa break down her illusions about self-injury and aid her in her recovery.

With the first category of delusional arguments, I used exploration of ramifications.

# 2 - Necessary Emotional Cleansing
With the second category of delusional arguments, emotional cleansing associated with self-injury; I used an analogy to diffuse the client's justification. One example of this type of justification is, "Giving up self-injury will only make me hurt more". Fifteen year old Lindsey was one such client of mine who used this validation regularly. Lindsey had always been afraid to try and quit due to the emotions that she felt would soon accumulate and overwhelm her.

I posed this analogy to Lindsey in order to point out the flaw in her argument. "Suppose you are diagnosed with a cancerous tumor and your doctor recommends chemotherapy. You don't feel sick, you're still functioning, but the symptoms of the tumor are interfering with daily routines.

"Then you start your chemotherapy, and you feel worse than you did on the first day you entered the doctor's office. The pain is so great that you feel you want to give up. At this point, you have to recognize that you're in the middle of an unfortunate process in which you're going to feel worse before you get better. After the treatment defeats the disease, you feel healthier and more productive than you did when you first sought help."

This analogy demonstrated to Lindsey the errors inherent in her argument, that although the recovery process is more painful than the self-mutilation itself, the reward of good mental health is far greater.

# 3 - Inability to Communicate
The third category of excuses that clients use to justify self-injury is produced by their inability to communicate with others.

Some examples of this type of argument are:
-- "It's the best way for others to see how much emotional pain I'm in;"
-- "It's the only way to know if people really care about me;" and
-- "Negativeattention is better than none."

As you can see, each of these statements stems from an inability to convey any kind of desire for contact and affection. Kara, age 17, used the argument of "It's the only way to know if people really care about me" to justify her self-mutilation. Kara had been sexually abused when she was 6 by her uncle. When Kara reported the abuse, her parents denied it, labeling Kara a liar and an attention seeker. Since then, Kara has had trouble relaying any emotional distress to close friends because she feels that nothing will come of it.

To test her friends' loyalty, Kara would harm herself in front of her boyfriend and judge his reaction. She told me, "I had broken a mirror and some figurines in my room during an argument, and I cut myself with some broken pieces, hoping he would also be shocked and would try to calm me down by holding me." Kara's violent acts were a result of her lack of trust and a test of her boyfriend to try and gauge how much he cared for her. Really, she was crying out for help and needed somebody to protect her from herself as no one had sheltered her during her sexual abuse from her uncle at age 6.

"Comfortable Presence" Exercise
To aid Kara in her realization that her actions are really driving the people who care for her away, I found the "Comfortable Presence" exercise beneficial. Her relationship with her boyfriend soon ended after she self-injured in front of him, thus increasing her intense feelings of loneliness and abandonment.

To address these feelings of solitude and to heal her destructive relational tendencies, I had Kara complete the following questions:
1. Describe in detail a time when you felt comfortable just being with another person.
2. Include as many details and specific memories about that time as you can, to highlight what the necessary ingredients are.

In her response, Kara talked about her grandmother, who had always been understanding and kind to her. She wrote, "Grandma and I would always watch old movies together and she would tell me things about her childhood. Whenever I spent time with her, we made popcorn and she fixed me sundaes. She really spoiled me. I felt really safe with her. I never felt the urge to self-injure when I was around her.

"She gave me the care that my parents were incapable of giving because they didn't trust me anymore. I guess we got along well because her husband died when I was young and I didn't have anybody either. We both became each other's companion. Right after she died, I started cutting. It was like my lifeline was gone and I had to replace her, but I couldn't find anyone I trusted."

Kara's grandmother had been essential to her stability as a person. Without the warmth and comfort of a sympathetic loved one, Kara's world collapsed and her issues with trust soon resurfaced.

On this track, we discussed three arguments that clients use to persuade themselves that they do not have a problem with self-mutilation via the use of exploration of ramifications and analogies. These included arguments of personal event, of necessary emotional cleansing, and of communication. We also included ways exploration of ramifications and "Comfortable Presence" to address these arguments.

On the next track, we will examine the ways in which cultural pressures have a direct effect on the adolescent self-injurer: the idea that pain is achievement; and the "tough guy" stereotype.

QUESTION 10
What are three types of arguments that many self-injurers use to justify their self-injury? To select and enter your answer go to Answer Booklet.