In the last section, we discussed 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
As you know, attachment is a vital part of human relationships. Self-mutilators suffer from severe deficits in the ability to form personal attachments.
In this section, we will examine different aspects of a self-mutilator's ability to form a relationship which includes: a lack of a workable medium for relationships; the factor of low self-esteem; keeping friends at a distance; and the result of shame of past abuse.
4 Aspects of a Self-Mutilator's Ability to Form a Relationship
♦ # 1 - Lack of a Workable Medium
Many self-mutilators have no workable medium in which to establish healthy attachments with other people. Unlike most mentally healthy people who form relationships that incorporate trust and distance of varying degrees, self-injurers cannot find this medium and do not have many healthy attachments to others. I asked Barbara, age 18, who she trusted and who she leaned on when she needed help.
Barbara responded, "Myself. It's stupid and weak to depend on others because they always let you down." Barbara's response indicates that some event, circumstance, or personality has thwarted the development of the restorative mechanisms of trust and dependency.
♦ # 2 - Low Self-Esteem
Low self-esteem also has a great effect on whether or not a person will become a self-injurer. A client with low self-esteem is prone to form attachments with persons who are abusive to them or needier than them. Barbara was dating someone much older, Brian age 25, who would verbally and physically abuse her. One reason for this might be that this abusive relationship was reminiscent of her home.
Barbara had come from a very violent childhood. Her father was an alcoholic and beat her regularly. Her mother, apathetic to her daughter's abuse, ignored Barbara's complaints. An explanation of this is that security and pain have become fused. The idea of home, which most people associate with warmth and safety, had never been true for Barbara. Consequently, she had never known what true security meant and sought relationships that closely resembled what she was most familiar with.
♦ # 3 - Keeping Friends at a Distance
Interestingly enough, I have found that many teen self-mutilators who do form friendships do so in a prolific manner. Fifteen year old Jenny was a very charismatic and outgoing young girl. She attracted people to her and had many friends. However, many of these friendships were one-sided. Jenny knew these people intimately, but none of her companions knew anything about her personal struggles or other aspects of her life.
In this way, Jenny was able to feel some nurturing benefits from her relationships, but could keep the others at a distance from herself to guard against any kind of betrayal. Jenny said to me, "I like having a lot of people around me and liking me. I feel loved. But that doesn't mean I have to just throw all of myself out there. That personal stuff is mine to keep." By harboring a nest of admirers, Jenny was able to gain some self-approval, but by not sharing her inner anguish with her friends, these relationships did not benefit her to provide emotional support.
♦ # 4 - Shame of Past Abuse
As you know, a fundamental bond in any healthy relationship is the sharing of personal information with other people. However, self-mutilators who have undergone significant abuse in their childhood have deeply ingrained resistance towards sharing with others, due to the shame involved with their issues. Many times, the nature of the self-injury is so severely embarrassing to a client; it may take months and even a year before they finally acknowledge the harm they are doing to themselves.
Elizabeth, age 18, used to cut herself with the buckle of the same belt her father had used to beat her as a young child at the age of 8. For 7 years, Elizabeth concealed information about her self-injury and her shame only accumulated over that amount of time. This sense of shame spread from the specific act of cutting to a general sense of shame about herself.
The conflict caused her to continually sabotage any chance of success she might have at any job, or in any personal relationship. In Elizabeth's case, she found it extremely difficult to become attached to me, even though she knew that I was no personal threat. The main cause of her distance was in the belief that I would be repulsed by her actions.
♦ Technique: "Person I Want to Be"
As you know, setting goals for giving up self-injury involves adding new behaviors, interests, and gratifications to replace the old symptoms. Elizabeth and Barbara were suffering from very low self-image. Elizabeth herself was unable to see any way out of her perpetual cycle of shame. To help them see that they can change and that they can shape who their identity, I used the "Person I want to be" exercise. The purpose of this exercise was to aid them in identifying positive goals and personality characteristics that they wanted to achieve or enhance.
I asked them to answer the following questions:
1. How do I want my life to be?
2. Identify attitudes, feelings, and behaviors that interfere with making progress toward this goal.
Elizabeth responded, "I want to get rid of my guilt. Whenever I even think of that aspect of myself, I cringe. It's so ugly and because it's a part of me, I'm ugly too, inside and out. I really wish I could change the ugliness into something beautiful or at least cover it up so I can't see it or sense it, but it doesn't work that way. I realize that I have to start recognizing that just because a small piece of me is repulsive, that doesn't mean that all of me is ugly. I need to stop degrading myself."
Through the use of this exercise, Elizabeth could start to pinpoint those behaviors and self-attitudes that drove her to self-mutilate. While addressing her abuse will take extensive time, I feel that by identifying and educating her about her symptoms Elizabeth can reach a more positive self-image and cease her cycle of shame.
In this section, we discussed four aspects of a self-mutilator's ability to form a relationship which includes: a lack of a workable medium of relationship; the factor of low self-esteem; keeping friends at a distance; and the result of shame of past abuse.
In the next section, we will examine the various methods by which self-mutilators avoid discussion in therapy: a blank slate; deflecting; and a false self.
Peer-Reviewed Journal Article References:
Adrian, M., Berk, M. S., Korslund, K., Whitlock, K., McCauley, E., & Linehan, M. (2018). Parental validation and invalidation predict adolescent self-harm. Professional Psychology: Research and Practice, 49(4), 274–281.
Courtemanche, A. B., Piersma, D. E., & Valdovinos, M. G. (2019). Evaluating the relationship between the rate and temporal distribution of self-injurious behavior. Behavior Analysis: Research and Practice, 19(1), 72–80.
Fox, K. R., Harris, J. A., Wang, S. B., Millner, A. J., Deming, C. A., & Nock, M. K. (2020). Self-Injurious Thoughts and Behaviors Interview—Revised: Development, reliability, and validity. Psychological Assessment, 32(7), 677–689.
Turner, B. J., Cobb, R. J., Gratz, K. L., & Chapman, A. L. (2016). The role of interpersonal conflict and perceived social support in nonsuicidal self-injury in daily life. Journal of Abnormal Psychology, 125(4), 588–598.
Whipple, R., & Fowler, J. C. (2011). Affect, relationship schemas, and social cognition: Self-injuring borderline personality disorder inpatients. Psychoanalytic Psychology, 28(2), 183–195.
Williams, G. E., Daros, A. R., Graves, B., McMain, S. F., Links, P. S., & Ruocco, A. C. (2015). Executive functions and social cognition in highly lethal self-injuring patients with borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 6(2), 107–116.
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