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Section 2
Self-Injury and The Role of Dissociation

Question 2 | Test | Table of Contents

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In the last section, we discussed the five reasons clients initiate self-injury. Those reasons were to relieve anger; to indirectly retaliate; to test loyalty; to maintain control; and to induce caring responses from others. We also saw how the "Fantasy" technique can help self-injurers express their emotions.

As you may know, those clients who inflict injury upon themselves are under the influence of dissociation. This occurs when the client either totally removes themselves from the pain or perhaps does not feel the pain keenly.

In this section, we will discuss different ways clients who are self-injurers can experience dissociation: such as a numb or empty feeling; they dissociate by viewing the pain as a penance for perceived wrongdoing; also they can dissociate form the pain to validate their existence.

2 Ways Clients Experience Dissociation

♦ # 1 - Numb, Empty Feeling
Let's look at the first group of dissociated clients, those who feel numb during their self-infliction. They have completely separated themselves from their body. Elizabeth, age 19, stated, "When I'm self-injuring, I don't feel anything. The pain kicks in sometimes a few days later, sometimes not until it starts to heal and itch. Most other times, I don't feel it at all."

In Elizabeth's case, her mind had completely alienated itself from her body and began to function as a separate entity. When this happened, it left Elizabeth feeling alone and surreal. Because her body was no longer participating in her life, she felt that she could use it to express her inner turmoil. Elizabeth saw her body as a painter would a canvas: merely a means by which she might make a connection between bodily violence and artistic voice so to speak.

In a more extreme case of numbing, I found that those clients who suffer from severe bodily alienation use pain to assure themselves that they are still living. The blood they draw in cutting proves to them that they are still human and a part of the world around them. Elizabeth, felt a renewal of consciousness after cutting herself.

She stated, "Prior to my episodes of self-injury, I feel numb and detached, as if my body wasn't mine. After an episode of self-injury, I feel immensely relieved and also a bit embarrassed by my actions because I know other people will judge me harshly." Elizabeth's feelings of detachment and then relief resulted from her pain that she used to express her inner anguish.

♦ "Before, During, and After" Technique, 2 Steps
In treating clients like Elizabeth that suffer from severe dissociation, I find it beneficial to use the "Before, During, and After" exercise to help them better understand why they injure themselves.
Step 1: In this exercise, I had Elizabeth make three columns on a piece of paper and label at the top of each "Before" "During" and "After."
Step 2: Then, I had Elizabeth write three emotions she felt before she would cut herself, during the actual act of cutting, and after she finished.

Under the heading "Before," Elizabeth wrote "panicked, lonely, and exhausted" which reflected her overwhelming feelings that led to her dissociation. Under "During", she wrote, "Intense, miserable, hysterical" and under "After," she wrote, "ashamed, guilty, and relieved." This indicated that while she would cut herself, she gained no feelings of renewal. It was not until after she had completely finished the act that she gained that feeling of relief she had been striving for.

♦ # 2 - View Pain as a Penance
Thoseclients who self-mutilate in an attempt for penance or self-enhancement feel the pain, but as a means to an end. Missy, age 19, who would dance on broken toes during ballet rehearsal, said, "You would think that it would hurt, but it actually feels kind of like a natural high, like a runner's high." Clients like Missy use pain as part of their discipline in an effort to improve themselves through extraordinary means.

Likewise, Jennifer, age 22, poured acid on her arm when she was fired from a job. She stated, "The pain made me feel like I had been purged, that my unemployment was reconciled. I felt like I had suffered enough, and now I could move on." Jennifer, like Missy, used pain to force away their feelings of inadequacy. Jennifer felt recompensed for her job loss, and Missy felt that she had improved her dancing skills through her pain.

♦ "Self-Mirror" Technique, 4 Steps
In addition to the "Before During and After" technique, I also find the "Self-Mirror" exercise to help in reuniting Elizabeth with the sense of self she had lost as a result of her dissociation.
Step 1: I had Elizabeth again divide a piece of paper into three columns.
Step 2: At the head of each column were the labels, "Approving" and "Disapproving".
Step 3: Under Approving, I had Elizabeth write statements that she would say about herself that gave her a feeling of positive self-esteem.
Step 4: Under "Disapproving", Elizabeth would write statements about herself from the past that were negative in nature.

For the "Approving" column, Elizabeth wrote, "I'm attractive;" "I feel young and vibrant;" and "I can do anything I try." For the "Disapproving" column, she wrote, "I can't do anything right;" "Nobody can stand me;" and "I hate who I am." I then asked Elizabeth which statements she used the most about herself. She responded, "Before I felt so overwhelmed, I used to like myself. Right before I started cutting, though, my self-esteem plummeted and I guess that's when the more negative statements came in."

Through this exercise, Elizabeth identified that her feelings of worthlessness only increased the pressure in her life. She could now see that her dissociation stemmed from these negative self-assertions. Should she have had a more positive outlook on herself; she might have avoided her dissociation.

In this section, we discussed several examples of clients suffering from dissociation: those who feel numb; those who use pain to reassure themselves of their own existence; and those who view the pain as a penance for wrongdoing. Also we talked about two techniques that can be used to help clients better cope with their dissociation: the "Before, During, and After" technique and the "Self-Mirror" method.

In the next section, we will examine the consequences of badly executed hospitalization such as: a feeling of isolation; a discharge without being truly cured of the dilemma; and belittling the self-injurer.
Reviewed 2023

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.

Buda, B. (2012). Review of Nonsuicidal self-injury [Review of the book Nonsuicidal self-Injury, by E. D. Klonsky, J. J. Muehlenkamp, S. P. Lewis & B. Walsh]. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 33(3), 182.

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.
Briere, J., & Eadie, E. M. (2016). Compensatory self-injury: Posttraumatic stress, depression, and the role of dissociation. Psychological Trauma: Theory, Research, Practice, and Policy, 8(5), 618–625.

Hooley, J. M., Ho, D. T., Slater, J., & Lockshin, A. (2010). Pain perception and nonsuicidal self-injury: A laboratory investigation. Personality Disorders: Theory, Research, and Treatment, 1(3), 170–179.

QUESTION 2
What are three types of dissociation teens who self-mutilate can experience? To select and enter your answer go to Test.

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