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

Section 20
Extremes of Avoidance vs. Clinging

CEU Question 20 | CEU Test | Table of Contents | Self-Mutilation
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

The Need for Control
As you know, patterns of self-harmful activity reflect the need for control. This need often drives the TRS (Trauma Reenactment Syndrome) woman’s daily activities as well. For example, she may clean compulsively. Always striving for control may make her unable to enjoy leisure activities or to function well at work. It is often at the root of her problems with her children, other family members, and friends. It pervades her efforts to seek help from professionals and peers, which she then rejects.

In the struggles around control in relationships, Trauma Reenactment Syndrome creates a generalizable pattern in which the TRS woman alternates between avoiding social contact and then frantically clinging to partners, friends, family members, and sometimes colleagues. The results of this pattern are horribly uncomfortable for her. She feels unhappy and anxious when alone, but then equally unhappy and anxious when with others. She endures seemingly endless cycles of restlessness and discomfort. This pattern is an important part of her inability to establish or maintain intimacy.

Bette Midler, playing the role of Janis Joplin in the movie “The Rose”, pushes everyone away and then cries out in a moment of desperate, lonely intoxication, “Where is everybody?” The TRS victim’s ambivalence about her need for nurturance and her need to control creates a contradictory communication to all those involved with her: “Where is everybody?” and “Why don’t they leave me alone!” This rapid shift between asking for help and then rejecting it exhausts others. Both personal and professional caretakers withdraw in exasperation. The TRS victim may experience this withdrawal as rejection, reinforcing her mistrust of relationships, and so the cycle escalates.

Extreme reactivity marks the TRS woman’s behavior and is often a clue to her history of abuse. Because she has experienced relationships as both unpredictable and unsafe, she is quick to imagine snubs and criticisms. She may question the motives of everyone around her. She is also hypervigilant, a clinical term used to describe anyone who is always on guard, always watchful, quick to perceive any incipient danger, whether real or imagined.

Karen, As A Child
“I always sleep on the floor of my room, not in my bed. I wake up if someone comes in my room. I keep my light on even though I get punished. I need to see if everything is where I put it when I went to sleep. My teddy has to be right next to me, just like this. If I move him, something will happen.

“I know how to make Mommy’s coffee for her just right in the morning. I know if she’s going to be nice or mad by how she takes the cup from me when I bring it to her in bed. I know it’s very important to be neat and clean and brush my hair before I bring her the coffee. I know how much Mommy loves me. That’s why I have to do things right.

“I know if Mommy is mad at Daddy by how she gets ready for him to come home at night. If she waits and has her first drink with him, she’s not mad. If she tells me to make her a drink before he comes home, I know they’ll fight. It’s my fault they fight, but I can’t figure out what I do wrong.

“I am in the first grade. I’m always a very good girl at school. My teacher says I’m trying to be too good. She says, “Go have fun, Karen,” but I don’t know how to do that.”

Going to Extremes
Boundaries are problematic in many different ways for TRS women. The definition of the self in relationships is affected by both the weakness and rigidity of their boundaries. Karen offers a good example of the problem with rigid boundaries:

“My friend at work, Julia, keeps talking to me about her AA meetings. She tells me at lunch all about how she used to get high, how screwed up her life was. She seems so comfortable talking to me about this stuff. Julia even talks about really embarrassing moments like when she was still married and she would be so high she would get into sexual situations with other guys.

“Then there is Alice, another one of the girls I eat lunch with at the hospital. She’ll talk about her period or tell funny stories about birth control and what happened with some guy she’s seeing. I just can’t get over being amazed by what these other nurses talk about so openly. I feel shocked, but sometimes I also envy them.

“They give me a real hard time about what a clam I am. “Hey, Karen,” Julia says, “why are you holding out on us? I know you’re seeing someone, so what’s going on?”

“I feel angry and also really scared when they tease me about this. I know I’m secretive, but I just can’t trust anyone enough to be different.”

When she first began therapy with me, Karen was locked inside of herself, her armor a pleasant and sociable exterior. For example, when I asked standard questions about where she lived, who she lived with, and what her friendships were like, she hesitated before answering. Her answers were very brief and told me little about her.

Karen was also extremely reluctant to share any information with me about her intimate life. I asked her if she was dating, if she was sexually active, and if she had any sexual issues. She finally told me that she was angry because I seemed to feel entitled to such personal information. When I explained that these were questions I often asked when getting to know a new client who presented relationship problems as the reason for entering therapy, she was clearly astonished that anyone would answer such questions.

As I got to know Karen better, I learned that she was such an intensely private person that even her closest friend, Ellen, knew very little about her intimate relationships. Although Karen professed a willingness to try to share more of herself with Ellen, she had a difficult time doing so.

Because of rigid personal boundaries, Karen and other TRS women experience chronic loneliness and a sense of being both different from others and invisible. It is therefore logical that they also feel unloved and unlovable. Some TRS women manifest rigid boundary problems in an extreme avoidance of normal social or physical contact. One of my clients left her house only to go food shopping or to a weekly twelve-step meeting. She could not go to work because she felt unsafe in any situation that involved flexible social contact. She also stopped seeing her friends and would not answer the telephone or the doorbell. Her contact was limited to a noncommunicative relationship with her husband, who worked an afternoon/evening shift, and her eighteen-year-old son, who was at work or with his girlfriend most of the time. The only reason this woman could tolerate her weekly AlAnon meeting was because it was highly structured and therefore predictable. She was not really able to make the program work for her, however, because she could not make use of the essential ongoing social support outside of meetings. She was stuck, refusing to go to additional twelve-step groups because that would mean going to a new place and meeting new people.

This kind of pattern, when it becomes severe enough to render the person dysfunctional, is called “agoraphobia,” or fear of open spaces. Although it is considered a serious disorder in its own right, it is one of many possible symptoms of Trauma Reenactment Syndrome. In extreme cases, an agoraphobic is completely unable to leave her home under any condition. Mental health professionals often treat agoraphobia as an anxiety disorder, using behavioral conditioning and medication. When I encounter it in TRS women, I approach it as part of an understandable response to trauma, and I attend to the client’s need to develop the capacity for relational attachment.

June’s relational patterns represent the other extreme of boundary problems: loose or diffuse boundaries. Her personal boundaries are not only diffuse, but unpredictable. One day she may scream if her daughter comes into the bedroom without asking permission (even though the door is almost always open), and another day she will leave the bathroom door open when she is in the shower and tell her daughter, or even her teenage son, an intimate sexual episode while she dries off, fully visible through the open door.

Nancy manifests inappropriate boundaries in another way. She is careless, in fact indifferent, in regard to divulging personal details about her clients at the travel agency. When one client complained that Nancy had chatted with another about the financial and personal details of his trip, Nancy was genuinely bewildered by his outrage.
- Miller, Dusty; Women who Hurt Themselves: A Book of Hope and Understanding; Basic Books: Massachusetts; 1994

Self-Mutilation and Pharmacotherapy

- Smith, Bryan, Self-Mutilation and Pharmacotherapy, Michigan State University Department of Psychiatry B119 West Fee Hall East Lansing, MI 48824-1316, 2005

Personal Reflection Exercise #6
The preceding section contained information about issues of control and boundaries in self-injurers. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
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.

Evans, C. M., & Simms, L. J. (2019). The latent structure of self-harm. Journal of Abnormal Psychology, 128(1), 12–24.

Hasking, P. A., Bloom, E., Lewis, S. P., & Baetens, I. (2020). Developing a policy, and professional development for school staff, to address and respond to nonsuicidal self-injury in schools. International Perspectives in Psychology: Research, Practice, Consultation, 9(3), 176–179.

Online Continuing Education QUESTION 20
What are the two extremes of boundary issues experienced by women with Trauma Reenactment Syndrome? Record the letter of the correct answer the CEU Test.

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