Girls who Cut, ♥ psychologia - inne (książki, artykuły), [EN] artykuły, nssi (non-suicidal self injury) + ...
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Girls who Cut: Treatment in an Outpatient
Psychodynamic Psychotherapy Practice
with Adolescent Girls and Young
Adult Women
LOUISE RUBERMAN, M.D.
The observation of deficits in the capacity for mature emotional self-regula-
tion in girls who cut is noted in the literature (Daldin, 1990; Novick &
Novick, 1991; Nock et al., 2008). The acquisition of the ability to respond in
a healthy manner to stress and challenge, either from outside or inside the
self, is one of the most important tasks of early development; girls who cut
have not accomplished this developmental task or are seriously compromised
in their efforts to do so. The connection between this observation, the
psychosexual developmental antecedents of this deficit, and psychodynamic
approaches to treatment are explored in the literature and in case reviews.
K
EYWORDS
:
cutting, non-suicidal self-injury, self-abuse, self-regulation,
skin
REVIEW OF LITERATURE
In adolescence the risk of engaging in nonsuicidal self-injury (NSSI)
ranges from about 13.0% to 23.2% (Jacobson and Gould, 2007), which is
even higher than it is in adults (estimated to be 4% by Briere & Gil, 1998).
Given that the 12-month prevalence of NSSI is as high as 2.5% to 12.5%
(Muehlenkamp & Gutierrez, 2007 as referenced in Miller, 2007, as many
as 2.1 million teens self-abuse (Miller et al., 2007). Deeply disturbing are
the statistics on the relationship of NSSI in teens and suicide attempts; in
a recent study, 70% of teens who had engaged in recent NSSI reported
having made, at a minimum, one suicide attempt. And 55% reported two
or more such attempts (Nock et al., 2007). The average age of onset of
NSSI is usually between ages 12 and 14 years (Muehlenkamp and Guti-
Bronx Children’s Psychiatric Center & Montefiore Medical Center, Department of Psychiatry, NY.
Mailingaddress:
Montefiore Medical Center, Office of Residency Training, Department of Psychiatry,
3331 Bainbridge Avenue, Bronx, NY 10467. E-mail:
lruberma@montefiore.org
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errez, 2004), with an even higher risk for young adults between 18 and 25
(Whitlock et al., 2006), which may reflect the potential for contagion in
“nontreatment” groups, such as college students (Muehlenkamp et al.,
2008). There is literature emerging that reports on behavioral subtypes of
adolescents who cut, and that while most engage in only a few episodes of
cutting (Nock et al, 2006; Whitlock et al., 2006), Whitlock and colleagues
(2008) find that gender, number of episodes, and severity of damage vary
in different subsets, and this may affect assessment strategy and treatment.
Having a psychiatric disorder is associated with nonsuicidal self-injury
in teenagers. A study evaluating adolescent psychiatric inpatients who had
engaged in NSSI during the year prior to admission found higher rates of
internalizing disorders (including major depression and post-traumatic
stress disorder), externalizing disorders (including conduct disorder and
oppositional defiant disorder), and elevated substance abuse compared to
youth that do not self-mutilate (Nock et al., 2006). The association
between self-injury and borderline personality disorder is well known in
both adults and adolescents with NSSI (Shearer, 1988, 1994; Stanley &
Brodsky, 2005; Nock et al., 2006). In a controlled study of a group of
self-destructive teens with NSSI and suicidal behavior, only bipolar disor-
der distinguished adolescents with NSSI from those that were not self-
destructive (Jacobson et al., 2008). A recent study of adults (Foote et. al,
2008) points to the association between dissociative disorder, self-harm
and suicidality, and though the symptom of dissociation is reported (Kisiel
& Lyons, 2001; Miller et al., 2007), the relationship of a dissociative
disorder to NSSI has not been studied in adolescents to date.
The most serious aspect of concern in these cases is co-occurrence with
suicidal behavior and the risk of completed suicide (Miller et al., 2007),
and authors note that patients with
both
NSSI and suicidality represent a
more disturbed, at-risk group (Cloutier et al., 2010). Within a group that
self-injures, the statistics do not differ on whether boys or girls are more
likely to attempt suicide (Jacobson et al., 2008). Miller et al. suggest that
because the motivations of the adolescent who cuts to manage her
dysfunctional emotional state differ from the patient who is suicidal and
wants to die, treatment approaches need to be specific (2007).
Individuals engage in NSSI impulsively, typically without the concur-
rent use of substances or reports of pain (Nock and Prinstein, 2005).
Consistent with the idea of impulsivity as an aspect of the self-injury, a
group of adolescents and young adults were assessed for their ability to
generate solutions to a distressing scenario. The study authors stated that
although the NSSI group had more deficits in problem solving, the real
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Treating girls who self-cut with psychodynamic psychotherapy
issue in the group was that they were impulsive and
did not wait
to select
the most adaptive solution to a problem (Nock & Mendes, 2008). In
addition, adolescents with NSSI have a lower physiological threshold for
stress and greater difficulty in stress management than those who do not
self-injure (Nock and Mendes, 2008); the authors suggest treatment strat-
egies and family education to improve techniques for responding to
stressful situations. They further note that in those with NSSI higher
arousal in response to stress is associated with a subgroup whose self-
destructive thinking is less related to others and more “intrapsychic”
(Nock et al., 2009).
In adult women, many of whom have Borderline Personality Disorder,
motivations for nonsuicidal self-injury include the expression of anger, the
wish to punish oneself, the desire to feel normal and the need to distract
oneself from disturbing emotions (Brown et al., 2002; Gunderson &
Hoffman, 2005). Skin self-mutilation is the most common means of
self-injury (Rodham and Hawton, 2007). Particularly salient is the function
the self-injury provides as a “validation” to the person of how terrible
he/she feels; the cut or scar provides “concrete proof of (his/her) emo-
tional distress” (Linehan, 1993 as reported in Gunderson & Hoffman,
2005, p. 49). The behavior feels like a solution to a problem, particularly
one in the interpersonal realm:
In the face of their emotional and interpersonal difficulties, many of these
individuals report that their behavior is designed to provide an escape from
what, to them, seems like an intolerable and unsolvable life (Linehan, 1993,
p. 15).
In addition to sexual abuse and physical neglect, there has also been
found an association with emotional abuse in childhood; adolescents who
cut may react to stress by engaging in NSSI behaviors in order to
self-punish in a manner that reflects a self-critical mode of thinking
(Glassman et al., 2007). Herman (1992) points to the role self-injury plays
in an effort both to cope with unbearable emotional states in cases where
child abuse is part of the history, thus allowing the victim to survive in her
family without disclosing her pain and disrupting the family. Sarnoff
reports a case in which very early physical abuse by a sadistic father led a
teenage boy to self-cutting, producing orgiastic feelings (Sarnoff, 1988).
Finally, the relationship between self-injury and forms of body deco-
ration or “body art” has not been explored in the peer-reviewed literature.
While our culture accepts (as have many through history) a certain amount
of body piercing or tattooing for the purpose of making a statement or
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AMERICAN JOURNAL OF PSYCHOTHERAPY
beautification of the body, girls who cut themselves or otherwise self-
mutilate do not do so to enhance their appearance. Interestingly enough,
despite not being able to parse out the fine “cuts” between the phenom-
ena, psychoanalytic authors have made reference to the deeper meaning of
“body art”. They propose its meaning as sublimation for an impulse to
smear the skin with feces, which might represent a compensation for the
“deprivation of objects” during periods of developmental stress and
growth and as an “eroticization” of the skin in an attempt to make it
“lovely” (H ´ rnik, 1932, p. 235).
DEVELOPMENTAL THEORY, PSYCHOSEXUAL DEVELOPMENT
AND THE FUNCTION OF “SKIN”
Psychosexual development forms the ground upon which mental
health grows. Knowledge and awareness of one’s gender is a crucial
acquisition accomplished very early in childhood and it forms a significant
component of the development of a sense of self. With her girl child, a
mother has multiple deep and powerful identifications with herself as a
little girl as well as to her own mother who had cared for her (Brazelton &
Cramer, 1990); a mother is reborn in the little warm, fleshy person that is
her daughter. The power of this feeling is such that a mother may fantasize
that she and her baby girl are even inside one skin, a concrete image that
corresponds to Mahler’s idea of symbiosis (Mahler et al., 1975). As infants
grow, they “like to venture and stay just a bit of a distance
away from the
enveloping arms of the mother
[my emphasis]” (Mahler, et al., 1975, p. 55).
Mother’s job is to tolerate her daughter’s psychological birth as she grows
without unduly acting out her own separation anxiety, rage at being left, or
disappointment that the girl self she has brought into the world might
mimic her own self-doubts. When any of these conditions are in the
forefront, however, it presents a risk factor for the girl.
The young girl needs, in particular during the Oedipal period, to
identify positively with and to “idealize” the mother for her to be happy in
her gender and femininity (Ornstein, 1985 as referenced in Sands, 1989).
A healthy, well-developing daughter feels, mirrored in her mother’s gaze,
the sense of satisfaction in that which “envelopes” them (Brazelton &
Cramer, 1990). According to Bick (1968), the skin, which in early life
functions as a “boundary” that holds together the personality, is “intro-
jected” as a containing object (the mother) that is experienced as a “skin.”
This description . . . retains the notion of actual separateness. It also
conjures up the use of wrapping, a membrane, a skin, while simultaneously
evoking images of containment and mothering” (Biven, 1977).
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Treating girls who self-cut with psychodynamic psychotherapy
The very little girl’s relationship with her mother through her skin is
unconsciously tapped into in the adolescent or young adult girl who cuts;
she may respond to future demands, particularly ones that stem from
moments of separation, by symbolically cutting into the “envelope” that
once held them both. It may be that the battle she has in regard to her
impulses is symbolically acted out in the cutting.
In writing about the development of masochism, Novick and Novick
(1991) note a lack of growth in feelings of competence that are typically
found in the normally developing infant-mother pair. This competence is
typically generated from countless hours of experience that provide an
infant with the confidence that not only can she elicit a caring, loving
response from her mother, but also, should there be a rift, the relationship
can be mended (Brazelton & Cramer, 1990; Noshpitz & King, 1991). The
absence of these experiences affects reality-testing and is marked by a lack
of feeling of effectance in the toddler period; not only does the child have
deficits in her self-confidence and sense of joy in the physicality of the
developmental period, but also, her efforts to separate and individuate are
mislabeled and distorted. For the female patient, the experience of disap-
pointment and frustration in early relationships is particularly challenging
when the source of the frustration is the same-gender parent—the moth-
er—with whom she cannot identify positively. She associates her most
intimate relationship with dysphoric feelings (rather than comfort and
pleasure), as lacking empathy, and in desperation, she turns to masochistic
defenses as a way to rage at her mother (Galenson, 1988). In essence, the
above describes one aspect of the development of anxious attachments in
infancy (Bowlby, 1977; Sroufe, 2000; Main, 2006).
There is increasing evidence that borderline patients, particularly those
who have been hospitalized and/or are suicidal and/or chronically self-
injurious (parasuicidal), have failed to integrate or resolve attachment
traumata, particularly sexual and physical abuse by caretakers (Diamond et
al., 1999, p. 839).
Particularly salient to the discussion of self-abuse is the lack of pleasure,
the vulnerability of self-esteem, the blurring of boundaries and omnipotent
fantasies of the child described by authors as a “pathological source of
self-esteem” (Novick & Novick, 1991, p. 322). These are patients for
whom causing pain, and in the cases in question, self-inflicted pain, serves
as a pathological means of self-regulation and as a remedy for the desper-
ation of feeling alone, abandoned, or empty (Linehan, 2003).
Psychoanalytic authors have written on the subject of “early symbiotic
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