Mona was referred to me at the age of twenty-eight. She
was living alone, and abusing and harming herself in many ways.
She had innumerable cuts, dozens on each limb, as well as on her
stomach and chest. She had two burns, both from a teakettle full
of boiling water, one on each thigh. She wore only crewneck
or turtleneck sweaters, even in summer. Her father paid
for all of her living expenses, which gave her extraordinary privacy
to neglect and harm herself. She had drifted away from her friends,
was unemployed, and could be uninhibited and irresponsible about
her appearance. There was no one to ask her about “suspicious”
damage that might show up rarely should a sleeve ride past her
wrist, or a button on a high-neck cardigan sweater come undone.
Her previous therapist had just retired from analytic
practice and referred Mona to me. She warned me that Mona could
be a difficult patient and that treatment would proceed slowly,
since she was granted a “fortress existence” by her
father that supported her resistance to change. The analyst also
diplomatically informed me that Mona could be “quite independent
at times.”
Mona entered the room with a pleasant smile, shook
my hand, then became preoccupied with taking off her backpack,
scarf, and coat. She placed them at the end of the couch, turned
around to face me, and sat down. Her focus on the rituals involving
in folding and placing her clothes and backpack, in blatant disregard
of my presence, indicated her comfort with detachment from others.
As she sat down, she resumed smiling, as if to say, “Now
I have time for you.” It was all very natural and devoid
of hostility.
Part of the referral information received from her
previous therapist indicated a history of physical (not
sexual) abuse and of neglect by her mother (divorced
from her father for fifteen years and now remarried). The abuse
had begun when Mona was a child and had continued through her
young adulthood. Mona never received a birthday card, or any other
greeting card, from her mother, even though she had sent her mother
cards on Mother’s Day, Christmas, Easter, and her birthday
without fail for the past fifteen years.
At our initial session, Mona sat there with a friendly
smile, saying nothing. I was aware that her previous therapist
was comfortable with silences of up to ten minutes, so Mona didn’t
expect me to speak for a while.
“I have been told by Dr. N. that you haven’t
had much experience with having your feelings of warmth reciprocated
by those closest and most important to you.”
She brushed my comment off with a frown and a shake
of the head. “Whatever you grow up with, you think is normal.
You just take it as it comes.”
For the first three weeks, Mona was pleasantly
light in response to questions about her discomfort and
loneliness. She told me stories of punishment, assaults, and not
being let into the house after coming home from school on cold
winter days. She seemed to regard me as sympathetic, which I had
been, and easy for her to talk to. We appeared to have gotten
off to a good start.
Mona came in for her seventh session with a frown
on her face.
“What’s the matter?” I inquired.
“What’s the difference?” she snapped back.
“You look upset. I’m concerned. Maybe if we talk about
it, we can improve the situation or how you feel.”
Her face still maintained its hard look.
“You’re concerned? You get paid. I think that you
get paid for squat!”
“Why are you angry? Nothing has changed. I’ve always
been paid. It never bothered you before.”
“Well, maybe this just isn’t good enough anymore.”
“Are you saying that you don’t want to continue therapy?” “I’m saying that you’re not able to
do anything for me. Look!” She lifted her long
sleeve and pointed to a cut, three inches long, on the inside
of her forearm. It was still bleeding through the gauze and tape
she had covered it with. I walked over to my bookcase, took down
a bottle of peroxide, adhesive tape, and gauze pads, walked back
to Mona, sat down, and removed the bandage. I was surprised by
the size of the cut. I poured the peroxide up and down—it
erupted as a lake of pink foam. After a second and third application,
the foam was white. I made a tight bandage to close the cut as
much as I could. The gauze stayed white. The bleeding had stopped.
“You will have to go next door to my dermatologist
colleague to see if it needs stitches or other treatment after
our session is over. What is this about?”
I looked up from the cut to find a tearful Mona.
“Today’s my birthday.”
“No card?”
“No card.” “Do you understand why you were so angry at me when you came in today?”
She answered me in a tone that suggested I should
have known the answer.
“You are the only person I speak to about my feelings. Should
I have been angry with the grocer?”
“That’s quite a cut,” I remarked. “There will always be cuts,” she
countered in a resigned tone. We both stared at the white bandage.
No bleeding observable. She rolled her sleeve down.
“Is that something you want to change?”
“The cuts? No, I want to be a mass of scars and bleeding
my whole life, or until I accidentally kill myself.”
I allowed for the sarcasm—anger takes a while to dissipate.
“So we have the same goals for you?” I offered.
“Some of the same goals,” she grudgingly accepted.
Mona had come into her session angry, dissatisfied,
acting as if she wanted to end the relationship. She did
not have the relationship skills or the ability to reflect upon
what was really bothering her. At the age of twenty-eight,
she was doing what an early adolescent does: she yells at her
mother or father for a grievance that belongs somewhere else.
Ironically, Mona was snapping at me over a grievance she had with
her own mother. Another birthday passing without hearing from
her mother had been a painful reminder of her mother’s neglect.
Therapy offered Mona a new opportunity to learn
that she could depend on another person. By dressing her wound,
I did what a parent would do. This would deepen her trust and
attachment to me and would provide me with more leverage to help
Mona.
My goal was to develop her verbal expressiveness,
which would in turn give her more insight into her own feelings,
especially her anger and sadness. I knew from her symptoms she
had no healthy outlet for emotional pain. I would continually
push her to clarify the reason behind every self-harming act until
the act itself became unnecessary.
- Levenkron, Steven; Cutting: Understanding & Overcoming Self-Mutilation;
W.W. Norton and Company : New York; 1998
Information Brief Non-Suicidal Self-Injury:
What is it, Why Does it Happen and How Can We Help?
- Ohio Department of Education, What is non-Suicidal Self- injury?, Miami University, Center for School Based Health Programs, 2017
Personal
Reflection Exercise #2
The preceding section contained information about a case
study of a self-injurer. Write three case study examples regarding
how you might use the content of this section in your practice.
Peer-Reviewed Journal Article References:
Andover, M. S., Schatten, H. T., Holman, C. S., & Miller, I. W. (2020). Moderators of treatment response to an intervention for nonsuicidal self-injury in young adults. Journal of Consulting and Clinical Psychology.
Bustamante Madsen, L., Eddleston, M., Schultz Hansen, K., & Konradsen, F. (2018). Quality assessment of economic evaluations of suicide and self-harm interventions: A systematic review. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(2), 82–95.
Dueweke, A. R., Rojas, S. M., Anastasia, E. A., & Bridges, A. J. (2017). Can brief behavioral health interventions reduce suicidal and self-harm ideation in primary care patients?Families, Systems, & Health, 35(3), 376–381.
Evans, C. M., & Simms, L. J. (2019). The latent structure of self-harm. Journal of Abnormal Psychology, 128(1), 12–24.
Online Continuing Education QUESTION
16 What was a goal Mona’s therapist had for her treatment?
Record the letter of the correct answer the CEU Test.
