Polly
Polly began to cut herself following the death of a relative, who, during Polly’s early years, had been a surrogate mother while mother worked. During her early years with this relative, Polly was given nurturance and unconditional acceptance, which had been all but impossible in Polly’s relationship with her mother. When Polly began to have more contact with her mother, the already ambivalent relationship between the two became inflamed.
Polly’s depressive feelings and feelings of depersonalization began; she would fantasize that she heard a voice hypnogognically at night, she had frightening dreams, and she started self-cutting. She said the cutting behavior reminded her of losses (so she would not forget), was a response to feeling “nothing” (at times she craved and wanted to “disappear”), and counteracted a desperate and urgent sense of guilt. The worst times for Polly typically followed feelings of abandonment by one boyfriend or another—in these tortured relationships bouts of cutting and occasional suicidality followed feelings of abandonment. When a rejection or some form of abandonment (even slight) occurred, Polly was prone to feeling that she did not know who she was. She had difficulty when she looked in the mirror, questioning if it was really herself she was looking at; when she imagined herself, she really did not know what she looked like. At times she felt as if there were two personas within her; at times she felt there was NOTHING in her, that she was a sack of skin. Although attractive, she did not feel beautiful at all and wanted to cover herself in loosely fitting garments that covered her (as well as her scars); she felt that various body parts, including her skin, were ugly. She felt truly “uncomfortable” in her own skin. Polly’s dysphoric feelings tended to range between constant anxiety and feelings of paranoia—she felt easily judged and “looked at”; drug use allowed her to numb these feelings and to function as best as she could. In addition to drug use, she developed a restrictive eating disorder that occasionally bordered on anorexia. The cutting, drug use, and eating disorder were used to manage her turbulent inner life. She was convinced that she would never grow up and have a normal life, family, or happiness.
Treatment
Treatment of self-destructive patients is extremely challenging to patients, therapists and families alike. Because adolescents are focused on the here and now, interesting them in the past—in particular, on their relationships with their parents during their younger years and how their character was formed around those relationships—is a challenge that not every adolescent (or every therapist) is ready to meet. As in any therapy, even in manualized cognitive therapies, the personality and skill of the therapist is paramount. In psychodynamic therapies described in this and other papers (Ruberman, 2009), it is particularly important that the therapist’s personality, experiences, and point of view fit well with those same factors in the patient. In fact, the relationship between the patient and therapist is likely the mutative factor in any psychotherapy. Marsha Linehan, who writes about dialectical behavioral therapy (DBT) in suicidal or parasuicidal patients suggests that
the relationship with the therapist is at times what keeps her alive when all else fails … similar to many schools of psychotherapy, DBT works on the premise that the experience of being accepted and cared for and about is of value in its own right, apart from any changes that the patient makes as a result of therapy (Linehan, 2003, p. 9).
Treatment of these two young women has been complicated and immensely rewarding. Neither was raised in psychologically sophisticated families—initially, family members were hesitant to have their daughters engage in a treatment that seemed foreign to them. Neither was self-referred or referred by a mental health practitioner; Polly was referred by her pediatrician and Heather, by her school. In the experience of this writer, referrals that come in this manner can tend to be challenging, the families less knowledgeable about inner psychological processes. But frequently, if the young women can be engaged in a patient, meaningful psychotherapy, these treatments sometimes are rewarding in a way that “more experienced patients” are not and families feel that, for the first time, their eyes are opened to the meaning of their children’s behavior. The beginning of treatment becomes a shared educational experience of learning to understand inner cues and beginning to recognize the impact of the unconscious in daily life, choices and psychopathology. The beginning of treatment is a time when a therapist can educate a family if one is patient and goes at the speed the family can manage so that they can integrate both a new presence in their lives (the therapist) and the idea that their daughter has an emotional life of which they may have been unaware.
Treatment of both Polly and Heather involved periodic contact with family members, especially in the beginning of treatment and at moments of acting-out. Therapeutic contracts with both young women included their right to privacy unless their health was at great risk. When they self-mutilated, they were encouraged to tell their parents rather than having the therapist call to relay the information. It was explained to both girls that if their parents felt listened to, this would lead to trust of the treatment and to even more privacy and trust in them by their parents. (See Ruberman, 2009 for a discussion of treatment of parents).
In the treatment of both of these girls, the transference was a maternal one. Among this writer’s experiences of treatment of girls who engage in NSSI, the transference here stood out as particularly fragile and vulnerable to feelings of being intruded upon or misunderstood. The therapist had to be careful not to be drawn into the protective, at times paranoid, features of the transference to either a hostile/rejecting mother or to an all-knowing and accepting mother. Polly was more vulnerable, raw at times and self-condemnatory. The therapeutic relationship faltered at moments of severe stress, when she felt misunderstood; her impulsivity at these moments seemed designed to rectify the world’s mistreatment of her. She raged at her mother for caring only for herself. A (seemingly) unempathic comment by the therapist could also produce enormous rage that would have to be tolerated and understood.
Fonagy (2000) described the interplay of anticipation of care and the reality of an inadequate caregiver response to distress in an infant with disorganized attachment.
It is as if the infant’s emotional expression triggered a temporary failure on the part of the caregiver to perceive the child as an intentional person. The child comes to experience his own arousal as a danger signal for abandonment (
Fonagy, 2000, p. 1136).
In the case of Polly, one could see, in retrospect, the difficulty a high-strung small child must have placed on HER mother, the role another caregiver played to relieve the stress of the mother-child relationship, and the despair that it must have caused Polly to feel not only grief but also unprotected by her mother from this and other intense feelings.
Novick and Novick (1991) capture this “intense helpless rage” stemming from difficult early relationships that lead to the “omnipotent solution” of the masochistic attack.
When Polly cut, there was a dual identification, as she felt that she was both punishing her mother and being punished by the mother within her. In marking herself she would avoid ever making a particular mistake again (often related to failed relationships).
Heather was superficially more resilient; dreams and associations pointed to the rage she had at family members for not caring about her. In her mind, only her mother cared about her; she cut at herself in a solipsistic gesture that may have attempted to cut her mother away from the “envelope” that enclosed them, but this only served to keep her mother enthralled, worried, and engaged. She remembered feeling depressed and “left out” as a young child, which resembles masochistic patients described by Novick and Novick:
[they have] no cushion of self-esteem … these children remained exclusively and anxiously tied to their mothers, with the feeling that safety and survival depended solely on their mothers (1991, p. 314).
With Polly there was less despair of being capable of a relationship, but her relationships were shallow. She was always her mother’s girl.
These girls shared an ambivalence about their femininity. Neither had developed the sense of comfort in her own “skin” as an emerging, fully competent female adult, at ease with her sexuality. For Heather, the pleasure she felt was in being in control; there was no age-appropriate relationship to afford her this level of pleasure. For Polly, restrictive eating was a conscious result of wanting to keep herself from being girlishly curvy (see Daldin, 1990, p. 4 for a description of a girl with NSSI and anorexia in which the latter was “understood as an identification with the mother as well as an attempt to starve her developing sexual body”). For Heather, bulimia was a way to maintain the interest of a boy in the only part of her that she believed might be appealing to him—her figure. She did not feel that someone might be attracted to the whole of her.
Chen et. al. (2009) noted the co-occurrence of bulimia with suicidal behavior and anorexia with self-injurious behavior. They feel that eating disorders in the borderline population convey additional risk for suicidal and parasuicidal behavior.
Claes (2003) found that self-injury in the eating-disordered population was a marker for more disturbances in the clinical picture.
Muehlenkamp et al. (2009) explored the function of self-injurious behavior in patients with bulimia, finding a similar emotion-regulatory function of NSSI to that of bulimia; the authors noted the increased severity in patients with co-occurrence, and cautioned that one behavior may substitute for the other if aspects of treatment did not include skill sets to increase tolerance of distress. The eating-disordered adolescent can be seen as turning to the ritual of the eating to help with “problems with tension regulation” in an attempt to replace the mother or “idealized selfobject” with food: “Patients often describe what sounds like a passionate love affair with their favorite foods.” (
Sands, 1989, p. 87). Thus, both behavior patterns (cutting and eating disorders) respond to deficits and disappointments in the early relationship with mother; it may be that the specific responses are dictated by the characteristics of the mother-infant pair. For both of the cases reviewed, mature object relationships were not possible, and whether the relationship with mother was gratifying or not, it was the only one that mattered.
For both of these patients, the treatment represented an oasis of caring and acceptance; in both, the therapist was exquisitely aware of boundaries and counter-transference reactions involving wanting to “mother” these girls and help them grow, unscathed, to maturity. It was important to accept them for who they were, but vest both their difficulties and their willingness to get help within
them, not within the therapist. Ultimately the choice to be helped is the patient’s.
Bromfield (2005) writes, “Only by withholding our judgment and permitting our wonder can we convince the adolescent child to do the same, maybe enabling her to come out from the dark” (p. 47). Notably, both families became extremely cooperative and supportive of treatment of their daughters. Both young ladies began to reconsider their roles in how the story of their lives had unfolded. With time, they even began to develop, in the case of Polly, some empathy for a mother with whom it had been tremendously challenging to co-exist. Heather began to convey in sessions that there were probably other sides to the story she had told about her life. Both young women needed to learn, as pointed out in the work of
Nock and Mendes (2008), how better to respond to the stresses in their lives, though no doubt this will continue as a challenge, particularly at moments of greater developmental demands.
In the literature, the gold standard of treatment of girls (and boys) who demonstrate pathology such as outlined above is DBT (
Miller et al., 2009). When available, and with interested young women (and their families), psychodynamic psychotherapy allows for growth and development of their mature female selves. Given the inherent risks of suicidality posed by cases such as these, being able to acquire pleasure from themselves as mature females is a critical goal that will—it is hoped—serve as a protective envelope.