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In the examples involving both obsessive-compulsive disorder and anorexia nervosa, we saw a gradual transition from mental health to mental illness, followed by a deepening of that illness. Self-mutilation, on the other hand, often starts in its pathological or “sick” form immediately, within an already existing illness. It begins as a sick feature from its onset, but may develop or deepen into such a frequent and severe form that it overshadows the illnesses from which it sprang. When I state that self-mutilation starts as “sick,” I mean that the illness does not evolve from a mild, acceptable form of behavior like nail-biting into picking up a blade, scissors, or match to harm oneself.
Reconciling Brain and Mind
When these are positive achievements, we call them learning. If they are destructive or self-destructive, we call them disorders. Though these behaviors are labeled disorders, they are born from the same mechanisms as positive learning. The major difference between the two is that positive, healthy learning is most often taught by one person to another person, instructively.
Maladaptive learning, on the contrary, is inferred and may be need-based, or copied from a role model without direct encouragement or instruction. This kind of learning is, in effect, self-taught. It is often unconscious as well. When one person is taught by another person, that child, adolescent, or adult remembers the teaching experience as well as the guidelines and limitations involved in attempting the new behavior. We usually can easily remember who taught us how to swim, or cook. But the child who is learning by inference and not by instruction is often doing so in order to survive physical or emotional unpleasantness, and does not have the guidelines that will tell her what is enough, when she can stop, or when she will be safe. Take, for example, a ten-year-old girl told to stifle a sad feeling or fear, who then carries a box of fudge to her room and eats the whole thing. She has just taught herself comfort through binging.
As different as they appear to you and me, both of these kinds of learning are treated in the same way by the mind. That is, as the thoughtfulness involved in producing the skill or behavior is abbreviated, the process becomes automatic. When the behavior, or skill, has been developed over a long period of time, we say that the person who does the positive behavior or performs the skill is “experienced?’ The experienced person will often seek to increase his or her skill by trying out more difficult forms of it- whether ice-skating, skiing, mountain climbing, or playing a musical instrument.
Similarly, when a person who has developed a disorder that originated with negative, inferred learning has had this disorder for months or years, that person is more likely to push the self-destructive behavior further. For the self-mutilator, that means doing more damage to herself. This increased damage becomes incorporated as normal or usual as it occurs slowly over a period of time.
Just as there are reasons attached to increasing achievements, to pushing skills to their limits, so the mind looks for further avenues to intensify disordered behavior. In the case of anorexia, it is: • How thin can I get? • How much weight can I lose? • How much willpower do I have to deal with deprivation? • How much attention can I attract? • How much exercise can I do on very little nutrition?
In the case of self-mutilation, a slightly different set of rationales is applied to deepen the disordered behavior: • How much pain can I take? • How much disfigurement of my skin can I tolerate? • How much bleeding can I stand?
In these cases, the individual has already established the disordered behavior, and now wants more relief, more satisfaction from it. The victim starts thinking like one who is addicted to a substance: more is better. The more disordered the behavior, the greater the escape from emotional pain.
The mind in each case has adjusted to the existing level of behavior or achievement, and is now seeking to increase intensity in order to maintain the rush of reaching the current level that was once new. Let us contrast two examples—one of early detection and one that was chronic.
Katerina and Carla
“Sure, on my arms and breasts.”
During the rest of Carla’s first year of treatment, there were only two more incidents of cutting and they were much milder. In fact, the second incident was scratching, and the results were barely detectable. After that, they stopped entirely.
Early detection, as with nearly all developing problems (medical or psychiatric), offers the best prognosis and outcome, with the help of skilled treatment and a supportive environment. While Carla and I were working to reverse the development of self-mutilation, we were able to reduce the addictive behaviors that precede the formation of the disorder. From there we worked to fill the deficits in her emotional development that invited these symptoms.
With Katerina, it was a long time before we could
get her to stay aware of her environment throughout a session,
to focus on our dialogue, and even longer before we began to reduce
and eventually stop her severe self-mutilations. It was two years
before we got to the point I had reached with Carla in the first
four months of treatment.
Reflection Exercise #1
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