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Section 17
Do Other Girls Feel like This?

Question 17 | Test | Table of Contents


Assertiveness Testing
As recovery progresses, the patient has learned how to translate her feelings into words, rather than act out these feelings in self-harming behaviors. She has learned to utilize help from another person to do so, and now has the emotional leverage of this relationship with which to test out her new verbal thinking and talking skills, with others, outside the protective setting of therapy or any other caring relationship with which she has accomplished these achievements.

Her therapist or other helper must now encourage her to express her likes and dislikes to others, both within her family and in social settings. The results of this stage of treatment are reviewed in meetings with the helper or therapist.

Typically, such a patient has a history of not being able to confront others, or even to disagree with others over such routine matters as which movie to see or which restaurant to eat at. She has usually been more comfortable as a secret dissident follower, unhappily acting as if she agreed with other people’s choices. Throughout, she has remained compliant, obedient, passive, and falsely cheerful about decisions that include her and demands made upon her. She has learned not to care about her own needs, or to develop opinions and choices about minor as well as major issues that affect her.

Her “assignment” therefore becomes developing assertiveness, whether it is to initiate a plan with friends or family, or to disagree with a plan initiated by another if it displeases her, i.e., defend her personal rights. She has been most comfortable in the role of one who nurtures, supports, and agrees with others. A more assertive role at first will make her uncomfortable and anxious, fearing that she will be disliked if she is seen as demanding.

This issue has to be discussed at length and weekly reports of appropriate shifts in her behavior toward others should be reviewed. She is not asked to become a troublemaker or manufacture false issues with which to disagree, only to protest decisions that are truly to her disliking.

Coaching and Role-Playing
A therapist or other helper can coach her as to how to handle an anticipated conflict. Role-playing becomes very usefW here. In this exercise, therapist and patient have practice discussions, often exchanging roles, to prepare for possible confrontations. Let’s see how this is in fact done.

Elaine: Role-Playing in Action
Elaine, who had given up both her anorexia, prior to entering college, and her cutting, during the first month of her freshman year, was still unable to be assertive. She joined a sorority. It quickly became apparent to the other girls that she didn’t drink alcohol and that she was not on “intimate” terms with boys yet. She was liked by the other girls but teased as the “virgin goody-goody.” Elaine needed to prepare a response to her sorority sisters, one that could express her real thoughts and feelings without alienating them.

In sessions, we discussed her lack of readiness for romance and her unwillingness to drink alcohol. She could feign drinking by pouring herself club soda with a twist of lemon, so she wouldn’t be teased, or try the alternative- demand that the other girls simply accept that she doesn’t drink. She preferred the latter, so we role-played her statement of her choice, with myself playing the part of her friend.

“Elaine, what’s the big deal about having one drink and loosening up a little? It might even help you be more relaxed about guys.”
“I don’t need to be high to enjoy myself. I don’t need any artificial ‘loosening up’ as you put it, to enjoy a guy. I can do that all by myself, without the help of alcohol?’
“But you are never with a guy except your guy friends. How come?”
“Because there isn’t a guy I met yet that I want to be more than friends with. Maybe I’m just fussier than everyone else. I’m not saying that’s better than anyone else, or worse, for that matter, it’s just who I am. Can you deal with me being that kind of person?”

I felt that this last demand would stop the other person from harassing her on those two issues, so I called an end to the role-playing.
“Elaine, that was very good. It only took us three times for you to get to that level of assertiveness. Do you think that you could say that in the sorority house if you’re teased about those issues again?”
“I don’t know. I was a little surprised at what came out of my mouth just then.”
“Was it sincere?”
“Yes.”
“Then why not try telling others who you really are?”
“What if I get them mad at me?”
“What is the worst scenario you imagine about them getting mad at you? They already tease you. Do they dislike you?”
“No. I think that they like me okay.”
“Then you think that this kind of conversation would make them change the way they feel about you?”
“Probably not. It’s just not me .. . to be disagreeable”
“Would you rather the teasing went on until all the boys involved with the sorority joined the girls and you became ‘defined’ by that phrase you complained about before?”
“So there is no easy way out?”
“I think that when you’re changing your style and posture with others it has to make you tense, but that’s better than putting up with what was happening before?’
“You think I’ll lose progress if I don’t change?”
“What do you believe?”
“I think I’ll want to hurt myself- because I’ll get so mad at them?’

“What you’re saying is that if you don’t get assertive with them, and stop them from treating you like you’re inferior and not grown-up enough, you’ll get inwardly angry at them and take it out on yourself. And that can’t possibly change their behavior toward you or redress your grievance in any realistic way?’
“I guess I hardly ever think that I can change anybody’s behavior toward me?’
“I guess it’s time you gave it a try. Oh, and don’t worry They can’t hear your heart pounding from nervousness?’

Elaine had her confrontation, much along the lines we practiced, and it produced the results she hoped it would. The girls backed down on their teasing and her self-esteem rose.

Elaine could now attend socials at school without fear of being called the “virgin goody-goody.” After a while most of the talk behind her back dropped off.

Elaine felt a sense of victory and was pleased to see that boys who came to the sorority mixers approached her, not having been warned off her by gossip. Within a year of this change, and a few light dates, Elaine became involved with a boy who was as shy and inexperienced as she was. This involvement raised her status among the other girls in the sorority and everyone stopped noticing that she didn’t drink alcohol. Her own self-confidence was growing.

One day she came into my office looking serious. “I have to ask you something important.” I nodded and waited.
“You know how many scars I have. What do I tell Bill about them? How much do I tell him about my problems? I haven’t even told him that I’m in therapy. Should I tell him?”
“What is your greatest fear about telling him about the scars, past problems, and that you are in therapy?”
“That he’ll think I’m crazy, mistrust me, or even break up with me.”
“I imagine that he’s already familiar enough with you physically to have seen many of your scars, is that accurate?”
She blushed a bit and nodded.
“Has he ever asked you about them?”
“No, he’s not the pushy type. I mean, we exchange information about each other, but we know to wait for it to be offered. Neither of us asks for what hasn’t been brought up by the other. We’re both equally private and shy, I guess.”
“Do you know if he’s ever been in therapy?”

“What would you think if he told you that he is, or has been in therapy, and has had problems in the past, and still has unresolved problems that he’s working on?”
“I guess I would wonder what they were and would want to know about them.”
“Why would you want to know about them?”
“I guess I would want to know that he wasn’t a killer, or a pedophile or anything perverted like that.”
“Do you think that your problems fall into the category that you just mentioned?”
“No, I guess not. But I am ashamed that I did those things to myself.”
“Do you think that you’re attractive?”
“I guess I’m okay but nothing great.”
“Do you think that Bill thinks that you’re attractive?”
“He’s always saying that he thinks I’m gorgeous. I think he’s crazy, but I like hearing it?’
“Do you think that you are a harsher judge of yourself than Bill is?”
She nodded in resigned agreement. “So I should tell him?”
“It’s a big secret to keep. I think it will be hard for you to feel secure with him if you feel that he’s in love with a false personality you have created. I don’t recommend that you tell someone about this on your first date, but if you’re seeing each other for months and maybe getting serious about your future together, it might be time to get ready to tell him.”
“But what if he leaves me?”
“I don’t believe that he will leave you, but I can see you’re worried.”

“Do other girls feel like this? You know, ashamed of themselves? Scared about new people in their lives finding out about the cutting?”
“Your fears are understandable, Elaine. But don’t lose sight of what you know- Bill cares about you. And in many ways, we all have scars.”
Elaine decided that we would discuss this in future sessions, until she felt ready to tell Bill.
- Levenkron, Steven; Cutting: Understanding & Overcoming Self-Mutilation; W.W. Norton and Company : New York; 1998

Cutting Contagion in Schools

- Sidhu, Shawn, Cutting Contagion in Schools .University of New Mexico

Personal Reflection Exercise #3
The preceding section contained information about helping a client achieve genuine communication with others. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
"They have more than enough to do than patch up people like me."
Experiences of seeking support for self-harm in lockdown
during the COVID-19 pandemic

- Sass, C., Farley, K., & Brennan, C. (2022). "They have more than enough to do than patch up people like me." Experiences of seeking support for self-harm in lockdown during the COVID-19 pandemic. Journal of psychiatric and mental health nursing, 29(4), 544–554. https://doi.org/10.1111/jpm.12834


Peer-Reviewed Journal Article References:
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. 

James, K., & Stewart, D. (2018). Blurred boundaries—A qualitative study of how acts of self-harm and attempted suicide are defined by mental health practitioners. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(4), 247–254.

Lewis, S. P., Heath, N. L., Hasking, P. A., Hamza, C. A., Bloom, E. L., Lloyd-Richardson, E. E., & Whitlock, J. (2019). Advocacy for improved response to self-injury in schools: A call to action for school psychologists. Psychological Services. Advance online publication.

QUESTION 17
Why was it important for Elaine to confront the girls in her sorority about their teasing? To select and enter your answer go to Test.

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