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Physical Pain Stops my Pain - Treating Teen Self Mutilation
10 CEUs Physical Pain Stops my Pain - Treating Teen Self Mutilation

Section 28
Selected Readings Bibliography/Authors/Instructors

Answer Booklet | Table of Contents
| Self-Mutilation CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

If you would like additional information on this topic,
below are OPTIONAL books to consider buying for your personal library...

A Bright Red Scream: Self-Mutilation and the Language of Pain, listed above, was suggested by our Lead Nurse Planner Nancy Pavelek. Ms. Pavelek stated, "This book provides valuable insights into the reasons why a client/patient self-mutilates. This is an easy read and you don't want to put it down until you're done with it."

Additional Readings

Cutting and Self-Harm: Warning Signs and Treatment

Parents should watch for symptoms and encourage kids to get help.
By Jeanie Lerche Davis
Reviewed by Michael W. Smith, MD

Cutting. It's a practice that is foreign, frightening, to parents. It is not a suicide attempt, though it may look and seem that way. Cutting is a form of self-injury -- the person is literally making small cuts on his or her body, usually the arms and legs. It's difficult for many people to understand. But for kids, cutting helps them control their emotional pain, psychologists say.
This practice has long existed in secrecy. Cuts can be easily hidden under long sleeves. But in recent years, movies and TV shows have drawn attention to it -- prompting greater numbers of teens and tweens (ages 9 to 14) to try it.
"We can go to any school and ask, 'Do you know anyone who cuts?' Yeah, everybody knows someone," says Karen Conterio, author of the book, Bodily Harm. Twenty years ago, Conterio founded a treatment program for self-injurers called SAFE (Self Abuse Finally Ends) Alternatives at Linden Oak Hospital in Naperville, Ill., outside of Chicago.

Picture of an Unhappy Kid

Her patients are getting younger and younger, Conterio tells WebMD. "Self-harm typically starts at about age 14. But in recent years we've been seeing kids as young as 11 or 12. As more and more kids become aware of it, more kids are trying it." She's also treated plenty of 30-year-olds, Conterio adds. "People keep doing it for years and years, and don't really know how to quit."
The problem is particularly common among girls. But boys do it, too. It is an accepted part of the "Goth" culture, says Wendy Lader, PhD, clinical director for SAFE Alternatives.
Being part of Goth culture may not necessarily mean a kid is unhappy.
Lader says "I think kids in the Goth movement are looking for something, some acceptance in an alternative culture. And self-injury is definitely a coping strategy for unhappy kids."
Very often, kids who self-harm have an eating disorder. "They may have a history of sexual, physical, or verbal abuse," Lader adds. "Many are sensitive, perfectionists, overachievers. The self-injury begins as a defense against what's going on in their family, in their lives. They have failed in one area of their lives, so this is a way to get control."
Self-injury can also be a symptom for psychiatric problems like borderline personality disorder, anxiety disorder, bipolar disorder, schizophrenia, she says.
Yet many kids who self-injure are simply "regular kids" going through the adolescent struggle for self-identity, Lader adds. They're experimenting. "I hate to call it a phase, because I don't want to minimize it. It's kind of like kids who start using drugs, doing dangerous things."

Blunting Emotional Pain

Psychiatrists believe that, for kids with emotional problems, self-injury has an effect similar to cocaine and other drugs that release endorphins to create a feel-good feeling.
"Yet self-harm is different from taking drugs," Conterio explains. "Anybody can take drugs and feel good. With self-injury, if it works for you, that's an indication that an underlying issue needs be dealt with -- possibly significant psychiatric issues. If you're a healthy person, you might try it, but you won't continue."
Self-harm may start with the breakup of a relationship, as an impulsive reaction. It may start simply out of curiosity. For many kids, it's the result of a repressive home environment, where negative emotions are swept under the carpet, where feelings aren't discussed. "A lot of families give the message that you don't express sadness," says Conterio.
It's a myth that this behavior is simply an attention-getter, adds Lader. "There's a [painkiller] effect that these kids get from self-harm. When they are in emotional pain, they literally won't feel that pain as much when they do this to themselves."

What It Looks Like

David Rosen, MD, MPH, is professor of pediatrics at the University of Michigan and director of the Section for Teenage and Young Adult Health at the University of Michigan Health Systems in Ann Arbor.
He offers parents tips on what to watch for:

  • Small, linear cuts. "The most typical cuts are very linear, straight line, often parallel like railroad ties carved into forearm, the upper arm, sometimes the legs," Rosen tells WebMD. "Some people cut words into themselves. If they're having body image issues, they may cut the word 'fat.' If they're having trouble at school, it may be 'stupid,' 'loser,' 'failure,' or a big 'L.' Those are the things we see pretty regularly."
  • Unexplained cuts and scratches, particularly when they appear regularly. "I wish I had a nickel for every time someone says, 'The cat did it,'" says Rosen.
  • Mood changes like depression or anxiety, out-of-control behavior, changes in relationships, communication, and school performance. Kids who are unable to manage day-to-day stresses of life are vulnerable to cutting, says Rosen.

Over time, the cutting typically escalates -- occurring more often, with more and more cuts each time, Rosen tells WebMD. "It takes less provocation for them to cut. It takes more cutting to get the same relief -- much like drug addiction. And, for reasons I can't explain but have heard often enough, the more blood the better. Most of the cutting I see is quite superficial, and looks more like scratches than cuts. It's the sort that when you put pressure on it, it stops the bleeding."

What Parents Should Do

When parents suspect a problem, "they are at a loss of how to approach their child," Conterio says. "We tell parents it's better to err on the side of open communication. The kids may talk when they're ready. It's better to open up the door, let them know you're aware of this, and if they don't come to you, go to someone else ... that you're not going to punish them, that you're just concerned."
Be direct with your child, adds Lader. "Don't act out of anger or let yourself become hysterical -- 'I'm going to watch you every second, you can't go anywhere.' Be direct, express concern. Say, 'We're going to get help for you.'"
Parents often mistake cutting for suicidal behavior. "That's usually when they have finally seen the cuts, and they don't know how to interpret it," explains Rosen. "So the kid gets dragged into the ER. But ER doctors aren't always used to seeing this, and find it difficult to understand whether it's suicidal or self-injurious behavior. Many kids who are not suicidal at all are being evaluated and even hospitalized as suicidal."
Unfortunately, "the attitude in hospital emergency rooms can be very cavalier and harsh about self-injurers," adds Lader. "There's a lot of dislike, because it's a self-made injury, so ER personnel can be very hostile. There are all kinds of stories of girls getting stitched without anesthetic. The thing is, after they've self-injured, the girls are calmer -- so when they're getting stitches, they feel the pain. Yet the doctor is angry, wants to get this over with."
Psychotherapy should be the first step in treatment, Lader adds. The SAFE web site has a list of doctors who have been to her lectures, who want to work with self-injurers. With other therapists, ask if they have any expertise in working with self-injurers. "Some therapists have a fear reaction to it. The therapist needs to be comfortable with it," she advises.
However, the girl or boy must be ready for treatment, says Rosen.
"The ultimate lynch pin is -- the child has to decide they're not going to do this anymore," he tells WebMD. "Any ultimatum, bribery, or putting them in a hospital is not going to do it. They need a good support system. They need treatment for underlying disorders like depression. They need to learn better coping mechanisms."

When An Inpatient Program Is Necessary

When kids just can't break the cycle through therapy, an inpatient program like SAFE Alternatives can help.
In their 30-day program, Lader and Conterio only treat patients who voluntarily request admission. "Anybody who can't perceive that they have a problem will be hard to treat," says Conterio. Those who come to us have recognized that they have a problem, that they need to stop. We tell them in the acceptance letter we send them, 'This is your first step toward empowering yourself.'"
When admitted to SAFE, patients sign a contract that they won't self-injure during that time. "We want to teach them to operate in the real world," says Lader. "That means making choices in response to emotional conflict -- healthier choices, rather than just self-injuring to feel better. We want them to understand why they are angry, show them how to handle their anger."
Although self-harm is not allowed, "we don't take away razors," Conterio adds. "They can shave. We don't take belts or shoe laces. The message we're sending is, 'We believe you're capable of making better choices.'"

Turning Inward to Heal

Many kids haven't thought about it at all -- exactly why they self-injure, says Lader. "It's like any addiction, if I can take a pill or self-medicate in some way, why deal with the problem? We teach people that cutting only works in the short term, and that it will only get worse and worse."
When kids learn to face their problems, they will quit self-harming, she adds. "Our goal is to get them to communicate what's wrong. Babies don't have the capacity for language, so they use behavior. These adolescents regress to that preverbal state when they self-harm."
Individual and group therapy are the hubs of this treatment program. If there is underlying depression or anxiety, antidepressants may be prescribed. The patients also write regularly in their journals -- to learn to explore and express their feelings.
Helping them gain self-respect and self-esteem is a critical treatment goal, Conterio tells WebMD.
"Many kids have difficulty dealing with situations and people that make them angry," Lader adds. "They don't have great role models for that. Saying no, standing up to people -- they don't really believe they're allowed to do that, especially girls. But if you can't do that, it's very difficult to maneuver the world, survive in the world without someone stronger, more capable than you to fight your battles."
Circular negative thinking keeps kids from developing self-esteem. "We help them empower themselves, take risks in confrontation, change how they view themselves," says Conterio. "If you can't set limits on someone else's behavior, stand up to them -- you can't like yourself. Once these girls learn to take care of themselves, stand up for what they want, they will like themselves better."
"We want them to get to the point where they believe, 'I am somebody, I do have a voice, I can make changes, instead of, 'I'm nobody,'" she says.

Staying Safe

One study of the SAFE program showed that, two years after participating, 75% of patients had a decrease in symptoms of self-injury. An ongoing study is indicating a decrease in hospitalizations and emergency room visits.
"I've been doing this for 20 years, and the success rate is far greater than the failure rate," says Conterio. "We truly believe that if people can continue to make healthy choices, they won't go back to self-harm. We get emails that are a blast from the past. Some patients do extremely well. Others regress. Others have finally decided to do the work they learned here. When they apply it, they do well. It all goes back to choice."
The bottom line: "When kids decide they don't want to cut any more - and they get stressed again -- they have to be able to manage stress as it arises," Rosen says. "They can't succumb to cutting. People who can figure out some alternative way to manage stress will eventually quit it."
Parents can help by providing emotional support, helping identify early warning signs, helping kids distract themselves, lowering the child's stress level, and providing supervision at critical times, Rosen says. "But a parent can't do it for them. It takes a certain level of resource to be able to stop cutting, and many kids don't have those resources. They need to stay in therapy until they get to that point."

Self-harm is not a problem that kids simply outgrow, Rosen adds. "Kids who develop this behavior have fewer resources for dealing with stress, fewer coping mechanisms. As they develop better ways of coping, as they get better at self-monitoring, it's easier to eventually give up this behavior. But it's much more complicated than something they will outgrow."

Exploring the inner world of self-mutilating borderline patients: A Rorschach investigation. By: Fowler, J. Christopher; Hilsenroth, Mark J.; Nolan, Eric. Bulletin of the Menninger Clinic, Summer2000, Vol. 64 Issue 3, p365, 21p; (AN 3508726)

Psychiatric patients who engage in self-destructive behavior by cutting, burning, or abrading their skin are currently one of the most difficult-to-treat groups in both inpatient and outpatient settings. The complexities of treating these patients, the risk factors associated with this symptom, and the rise in the prevalence of self-mutilation in America's adolescents and young adults provided the impetus for the current study. This article explores aspects of aggression, dependency, object relations, defensive structure, and psychic boundary integrity that may contribute to the genesis and maintenance of self-mutilation. Rorschach protocols from 90 borderline personality-disordered inpatients (48 self-mutilators and 42 non-self-mutilators) were scored using five psychoanalytic content scales. Results indicate that self-mutilating patients exhibit greater incidence of primary process aggression, severe boundary disturbance, pathological object representations, defensive idealization, devaluation, and splitting than did a matched group of non-self-mutilating borderline patients. Clinical theory and technical recommendations are considered in light of the current empirical findings. (Bulletin of the Menninger Clinic, 64[3], 365-385)
For the past 70 years, analysts have worked to comprehend the unconscious structures that are thought to be responsible for masochistic fantasies and behaviors of humiliation and physical pain (Bollas, 1992; Bonaparte, 1952; Deutsch, 1930; Doctors, 1981; Freud, 1923/1961b,1924/1961a; Kernberg, 1984; Menninger, 1938; Reich, 1940; Smirnoff, 1969; Stolorow & Lachmann, 1980). Masochism, in the form of bodily self-destruction, negativism, and negative therapeutic reactions, has consistently presented a perplexing theoretical problem and a serious challenge to effective treatment of neurotic, borderline, and psychotic disorders (Freud, 1924/1961a; Joseph, 1982; Olinick, 1964; Riviere, 1936). Modern clinicians are faced with similar theoretical complications in comprehending the underlying psychic structures of self-mutilating individuals. These patients frequently become embroiled in negative therapeutic reactions and masochistic transference impasses that destroy the frame of the treatment and can, in the most extreme cases, lead to the suicide of patients.
Self-mutilating patients are predominantly adolescent and young adult females who engage in self-destructive behavior by cutting, burning, or abrading their skin. Like masochists of Freud's era, these patients are currently one of the most challenging and treatment-refractory groups of seriously disturbed patients (Favazza & Conterio, 1988; Favazza & Favazza, 1987; Pao, 1969; Simpson, 1980). The impact of their sadomasochistic attacks on their body and on the frame of the treatment can be deeply disturbing to those who treat them. In short, countertransference fear, repulsion, and rage can interfere with the therapist's ability to consider the intrapsychic meaning of cutting as a defensive reaction, as a transference communication, or as a suicide attempt.
When therapists attempt to manage self-destructive actions without a clear interpretive frame for understanding and communicating their interventions, therapist and patient can fall into a reflexive mode of chronic crisis management (Sacksteder, 1997). The potential for transference enactments to go unanalyzed by the therapist is greatest at such moments because the primary task of treatment can be lost in the midst of crises. This type of disengagement from the interpretive task is a serious impediment to the treatment of a condition that is often erroneously considered simply "manipulative," but that has serious consequences for the patient.
Past research has shed light on the dangers and complexities of this phenomenon by exploring demographic and personal characteristics (Favazza, 1989; Feldman, 1988), the phenomenology of patients (Himber, 1994; Leibenluft, Gardner, & Cowdry, 1987), and clinical observations and treatment approaches (Kernberg, 1987; Stone, 1987; Tantam & Whittaker, 1992). The data on suicide rates for self-mutilating borderline patients are twice that for other borderline patients (Stone, Hurt, & Stone, 1987). Other risk factors include the potential for developing stereotyped and chronic self-mutilation due to increased release of endorphin metenkephelin (Cold, Allolio, & Rees 1983), contagion through modeling (Rosen & Walsh 1989; Walsh & Rosen, 1985), and the development of an identity as a "cutter" (Podvolt, 1969).
While the etiology is complex, self-mutilators frequently report childhood experiences of emotional and physical trauma, including sexual abuse, early traumatic invasive surgery, and neglect (Cross, 1993; Favazza & Conterio, 1988; Feldman 1988). These traumatic events are thought to create severe disturbances in object relations (Berliner, 1958; Chasseguet-Smirgel, 1995; Kernberg, 1984), in the capacity to symbolize experience (Muller, 1996), and in maintaining an ongoing experience of self that is free from derealization and dissociation (Favazza, 1992; Feldman, 1988; Rosenthal, Rinzler, Walsh, & Klausner, 1972; Soloff, Lis, Kelly, Cornelius, & Ulrich, 1994).
The purpose of this study is to investigate psychoanalytic concepts of self-mutilation empirically by exploring object representations, affect, and thought disorder manifest in two similar groups of inpatient Rorschach protocols. Assessing unconscious processes manifest in projective test data allows for an analysis of greater depth and breadth than do self-report data, while maintaining the advantages inherent in large-sample investigations. In order to narrow the range of unconscious processes to be investigated, we reviewed the vast array of psychoanalytic explanations of masochism and self-mutilation.
Modern ego psychology, object relations theory, and self psychology provide insights into the structural deficits and the underlying motivations that maintain self-mutilation. We have therefore drawn from several theorists' work (Doctors, 1981; Kernberg, 1984; Stolorow & Lachmann, 1980) as a springboard for constructing a study of the unconscious correlates of self-mutilation using Rorschach responses from borderline inpatients.
Kernberg (1984) proposed that patients who self-mutilate tend to be infantile, narcissistic, and "as if" personalities, functioning at an overt borderline level. In histrionic and infantile personality disorders, self-mutilation occurs in the context of some real or imagined failure or thwarted wish. The act is considered an unconscious coercive effort to gain control over the environment by inducing guilt in the frustrating other. Kernberg observed a more severe form of self-mutilation in "malignant narcissistic" patients. These patients tend to present as aloof and uninterested in others, rather than clinging. When their grandiose self-image is challenged, they experience intense humiliation, and in an effort to rid the self of unbearable humiliation, these patients physically enact, through self-mutilation, an unconscious triumph over the internal world of objects as they cheat death and pain. These patients flaunt their sense of superiority over their therapists when they discover that the therapist is chagrined or frightened by their self-mutilation. A third category of patient suffering from atypical psychoses is far more rare, and can be identified by the bizarre nature of the self-mutilation and the unusual degree of cruelty and idiosyncratic features. Each distinct subgroup suffers from primitive pathological object relations, primitive defenses, rage, and narcissistic vulnerabilities.
Stolorow and Lachmann (1980) have suggested that masochistic activity often occurs in response to a fear of fragmentation and that it represents an abortive (and sometimes sexualized) attempt to restore the cohesion and stability to a fragmenting self-representation. Building on decades of psychoanalytic exploration of masochism, the authors assert that the most violent and primitive expressions of self-directed aggression are found in individuals who are most vulnerable to narcissistic injury. Relatively minor frustrations such as the loss of control over a relationship and failed mirroring may threaten the structurally deficient narcissistic individual. In such cases, the need for experiences of acute pain, localized on the skin surface, may help buttress or protect against the derealization, sensations of falling apart, and dissociation that is commonly associated with a dissolving self-other boundary.
In a similar analysis, Doctors (1981) concluded that self-mutilating adolescents have not obtained emotional object constancy, exposing them to defensive splitting of good and bad part-objects. Furthermore, the lack of sufficient differentiation between self and objects results in an unstable array of internal representations in which even minor frustration can rapidly develop into intense rage that inundates the object world, and thereby spoils precariously maintained self-representations and object representations. This spoiling of the inner world, combined with a fragmenting ego boundary, further blurs the patient's tenuously held distinction between self and other. The breakdown in the capacity to maintain self-other differentiation has been linked to self-reports of falling to pieces, or feeling empty, unreal, and dead inside. According to this theory, a main unconscious motivation of self-mutilation is the effort to repair and restore a sense of self-cohesion and to expunge bad part-objects in order to restore good object representations.
Significant theoretical and clinical differences exist between ego psychology and self psychology, especially in the understanding of narcissistic and borderline disturbances. Despite these differences, there are fundamental similarities across theoretical orientations that are particularly important to this investigation. All three theories assume that the act of cutting is an unconscious effort to reestablish some degree of narcissistic equilibrium and self-cohesion. For Kernberg (1984), pathological affect and object representations set the stage for self-mutilation, especially when patients feel deprived, abandoned, or insulted by the therapist. The motivation to master and control another object is an effort to restore narcissistic balance, either through a dependent yet coercive object relation or through a coercive insistence on mirroring of the patient's grandiose self-organization. For Stolorow and Lachmann (1980), narcissistic injury produces intense rage in the structurally deficient ego, which can lead to sensations of fragmentation and boundary dissolution. For Doctors (1981), a narcissistic injury may precipitate an affective storm that inundates the patient's object world, transforming precariously maintained positive imagoes into malevolent objects.
These clinical theories find some support in descriptive studies and to a lesser extent in large-scale empirical research. For example, Stolorow and Lachmann's assertion that these patients use acute experiences of pain to bolster crumbling ego boundaries finds support in case descriptions (Cross, 1993; Doctors, 1981; Favazza, 1989; Gardner & Gardner, 1975; Miller & Bashkin, 1974; Pao, 1969; Simpson & Porter 1981). Researchers have found that self-mutilators are significantly more prone to derealization and drug-free hallucinations/delusions than are non-self-mutilating borderline patients (Soloff et al., 1994), and self-mutilators have higher rates of serious identity disturbance than the non-self-mutilators (Simeon et al., 1992). The clinical inference that aggression is a key factor in the act of self-mutilation has equivocal research support. Soloff and colleagues (1994) found that self-mutilating patients scored lower on the Buss-Durkee Hostility Inventory than did clinical controls, and that physical assaults on others were negatively correlated with self-mutilation. By contrast, Simeon and colleagues (1992) reported that self-mutilators produced significantly higher scores on the Minnesota Multiphasic Personality Inventory (MMPI) Psychopathic Deviance Scale (PD), yet did not differ significantly from controls on the Buss-Durkee Hostility Inventory. Finally, Rosenthal and colleagues (1972) noted that most of the 24 female patients reviewed in their study feared their own anger, described an inability to cope with these feelings, experienced derealization, then cut themselves in an effort to reintegrate. These equivocal findings may have more bearing on the patients' willingness or ability to report their subjective affect states than it does on the nature of their affective life. Thus aggression may be related to self-mutilation, but it has been unclear to what extent hostility and aggression are consciously registered, contained, and modulated by the ego.


From the preceding clinical and empirical data, we have formulated the following hypotheses:
  1. Self-mutilation is associated with intense, unmodulated aggressive affects. As a result, self-mutilating borderline patients are expected to manifest more primary process aggression on the Rorschach than the other borderline group.
  2. Clinical reports describe most self-mutilating patients as excessively dependent and clinging; thus the self-mutilating borderline group may produce more oral dependent imagery on the Rorschach than the second group.
  3. The wish to omnipotently control a precariously held self-other distinction through self-mutilation is an unconscious expression of an imbalanced, malevolent inner world; therefore self-mutilating patients may manifest greater imbalanced, omnipotently controlling, and malevolent object representations than the second group.
  4. Defensive devaluation, idealization, splitting, and denial may play a critical role in self-mutilating patients' attempts to manage intense affects and reestablish narcissistic equilibrium. We expect self-mutilating patients to manifest greater degrees of these defenses.
  5. Self-mutilating patients are thought to experience more fragmentation and boundary disturbance and therefore will manifest greater degrees of self-other boundary disturbance than the second group of borderline inpatients.

Method Sampling and group classification

The initial sample consisted of 224 patients admitted to The Austen Riggs Center. Patient records from January 1993 to June 1997 (including identification numbers, diagnostic codes, detailed descriptions of specific behavioral manifestations of self-mutilation, and medical procedures performed in response to the self-destructive activity) were first masked to disguise patient identity, then downloaded from the Center's database. Behavioral records were then classified by Dr. Fowler into self-mutilating and non-self-mutilating groups prior to collecting archival Rorschach records. The data extracted from the medical records can be considered a reliable and relatively accurate representation of the patients' self-destructive activities during hospitalization because the nursing staff was required to record all incidents of self-inflicted lacerations and burns.
The primary diagnosis of borderline personality disorder (BPD) was established in a consensus case conference at the culmination of the initial evaluation and treatment phase 4-6 weeks following admission. Diagnoses were made using available sources of information, including an integration of interview data from the admission consultation, initial contact with the therapist and psychopharmacologist, consultations with outpatient therapists, prior hospital records, and interviews with relatives to clarify family history of psychiatric disorders, life history, and premorbid level of functioning. All patients were assessed by a board-certified and licensed psychologist and psychiatrist. Diagnoses were assigned according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994). This method of diagnostic practice approximates the LEAD (longitudinal expert evaluation using all data) standard of diagnosis (Pilkonis, Heape, Ruddy, & Serrao, 1991; Skodol, Rosnik, Kellman, Oldham, & Hyler, 1988; Spitzer, 1983). The diagnosis of BPD was confirmed in 100% of the cases by an independent rating conducted by either a psychiatrist or psychologist as an ongoing aspect of the hospital's performance improvement policy. It is important to note that in all cases the diagnosis of BPD was determined independently of Rorschach data. Although all patients in this study had multiple Axis I and Axis II disorders, those patients with a comorbid Axis I psychotic disorder were excluded from the study.
Criteria for inclusion into this study required a hospital stay of 6 months or more in order to obtain a representative sample of patient behavior. All patients had completed a battery of projective tests administered during the first 30 days of the index hospitalization. In addition, an act of self-mutilation had to occur within 60 days following administration of the Rorschach to ensure the temporal relevance of the Rorschach data. The final sample of 90 adult inpatients consisted of 2 males and 88 females with a mean age of 30.9 years (SD = 9.1) at admission. The average number of years of education completed by the patients was 14.96 years (SD = 1.9). A total of 54 patients were single, 24 were married, and 9 were divorced or widowed.

Rorschach scales and scoring

Administration and original scoring of the Rorschach followed the procedures articulated by Exner (1993). These protocols were later rescored on the Rorschach content scales by Dr. Fowler, who was blind to patient identity, group inclusion, and diagnosis. For the purpose of interrater reliability (Weiner, 1991), 20 Rorschach protocols were chosen at random and scored independently by Dr. Hilsenroth, who was also blind to all patient data. The two sets of scored protocols were then compared, and percentages of correct agreement and intraclass correlations were calculated. The resulting interrater agreement and intraclass coefficients are presented in Table 1.
Aggressive ideation was assessed using Holt's (1977) method for scoring primary and secondary process manifestations on the Rorschach. Holt's system differentiates two levels of aggressive content. Level I scores are related to primary process forms of primitive aggressive themes, specifically measuring murderous or palpably sadomasochistic aggression. Level 2 aggression scores are related to secondary process ideation and specifically measure indirect forms of hostility or aggression expressed in more socially acceptable ways. The Holt system has demonstrated high levels of test-retest (Gray, 1969) and interrater reliability (Fowler, Hilsenroth, & Handler, 1995), as well as construct validity in a number of studies (Blatt & Berman, 1984; Hilsenroth, Hibbard, Nash, & Handler, 1993).
The Rorschach Oral Dependency scale (ROD; Masling, Rabie, & Blondheim, 1967) was developed as a psychoanalytic content scale to assess oral/dependent imagery. A response is defined as oral dependent if it falls into any of the following categories: food and drinks, food sources, food objects, food providers, passive food receivers, food organs, supplicants, nurturers, gifts and gift givers, good luck symbols, oral activity, passivity and helplessness, pregnancy and reproductive anatomy, and negations of oral percepts (e.g., not pregnant; man with no mouth). The construct validity and interrater reliability regarding this measure have proven to be excellent in more than 90 experimental studies utilizing various populations (Bornstein, 1996).
The Mutuality of Autonomy Scale (MOA; Urist, 1977) assesses the thematic content of relationships (stated or implied) between animal, inanimate, and human representations in Rorschach percepts. The scale was developed to assess the degree of differentiation of object representations, focusing primarily on the developmental progression of separation-individuation from engulfing, fused relations to highly differentiated self-other representations. Scale points 1 and 2 reflect the capacity to construe self- and other representations as structurally differentiated and engaged in mutually interactive or parallel activity (e.g., "two people talking about grocery prices, pushing shopping carts"). Scale points 3 and 4 capture dependent and mirroring object relationships and often reveal an emerging loss of autonomy between figures (e.g., "Siamese twins connected at the waist"). Scale points 5, 6, and 7 reflect not only the loss of the capacity for separateness but also increasing malevolence (e.g., "an evil fog engulfing this frog ... smothering it"). Reliability data are excellent (Tuber, 1989), and the scale has demonstrated a high degree of construct validity with behavioral ratings (Ryan, Avery, & Grolnick, 1985; Urist, 1977; Urist & Schill, 1982), assessment of therapeutic change (Blatt & Ford, 1994), and multimethod assessment of the construct (Fowler, Hilsenroth & Handler, 1995; Urist, 1977). For this study, we chose a composite score of all level 5, 6, and 7 pathological scores (PATH; Berg, Packer, & Nunno, 1993) because it has been found to be a robust and stable measure of pathological object relations.
Defensive structures were assessed using the Lerner Defense Scale (LDS; Lerner & Lerner, 1980). This scale is based on Kernberg's (1975) theoretical conceptualizations and other commentators' clinical observations (Holt, 1977; Mayman, 1967; Peebles, 1975). Primitive defenses of splitting, idealization, devaluation, and denial represented in percepts of human, quasi-human, and human detail (Hd) responses were assessed for this study. The LDS has shown good construct validity and high interrater reliability (Lerner, 1991). To use more stringent parametric statistics in the analysis of those defenses that are ranked on a continuum from high to low order (devaluation, 1-5; idealization, 1-5; and denial, 1-3), defenses were weighted according to rank and then were collapsed into an overall score for that category. For example, if there are three instances of idealization on a subject's protocol, one Level 1 and the other two instances at Level 3, the subject would receive a total idealization score of 7 (1 + 3 + 3 = 7).
The Boundary Disturbance and Thought Disorder Scale (BDS; Blatt & Ritzler, 1974) assesses an individual's capacity to maintain distinctions between objects along cognitive/perceptual and affective dimensions. Blatt and Ritzler drew connections between the degree of thought disorder present on the Rorschach and the concomitant degree of ego boundary dysfunction. Drawing on Rapaport's indices of thought disorder, they proposed the following hypotheses: (1) Mild forms of ego boundary fragmentation or looseness of boundary (boundary laxness) could be measured by fabulized combination. (2) More severe problems of differentiating fantasy from reality (inner/outer boundary disturbance) would be represented in responses containing confabulations. (3) The most severe form of boundary fragmentation and disintegration (self/other boundary disturbance) would be captured in the severely thought-disordered responses known as contaminations. Several studies (Blatt & Ritzler, 1974; Lerner, Sugarman, & Barbour, 1985; Wilson, 1985) have found that borderline patients typically have greater difficulty with boundary laxness and inner/outer boundaries, whereas schizophrenic patients typically have greater difficulty distinguishing between self/other boundaries. The more severe self/other boundary disturbance may correspond to what many have described as the crumbling ego boundaries, dissociation, and drug-flee hallucinations observed in many patients who self-mutilate.

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- Coordinating Author/Instructor: Tracy Appleton, LCSW, MEd

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