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Section 16
The Structure of Self-Harm

Question 16 | Test | Table of Contents


Mona was referred to me at the age of twenty-eight. She was living alone, and abusing and harming herself in many ways. She had innumerable cuts, dozens on each limb, as well as on her stomach and chest. She had two burns, both from a teakettle full of boiling water, one on each thigh. She wore only crewneck or turtleneck sweaters, even in summer. Her father paid for all of her living expenses, which gave her extraordinary privacy to neglect and harm herself. She had drifted away from her friends, was unemployed, and could be uninhibited and irresponsible about her appearance. There was no one to ask her about “suspicious” damage that might show up rarely should a sleeve ride past her wrist, or a button on a high-neck cardigan sweater come undone.

Her previous therapist had just retired from analytic practice and referred Mona to me. She warned me that Mona could be a difficult patient and that treatment would proceed slowly, since she was granted a “fortress existence” by her father that supported her resistance to change. The analyst also diplomatically informed me that Mona could be “quite independent at times.”

Mona entered the room with a pleasant smile, shook my hand, then became preoccupied with taking off her backpack, scarf, and coat. She placed them at the end of the couch, turned around to face me, and sat down. Her focus on the rituals involving in folding and placing her clothes and backpack, in blatant disregard of my presence, indicated her comfort with detachment from others. As she sat down, she resumed smiling, as if to say, “Now I have time for you.” It was all very natural and devoid of hostility.

Part of the referral information received from her previous therapist indicated a history of physical (not sexual) abuse and of neglect by her mother (divorced from her father for fifteen years and now remarried). The abuse had begun when Mona was a child and had continued through her young adulthood. Mona never received a birthday card, or any other greeting card, from her mother, even though she had sent her mother cards on Mother’s Day, Christmas, Easter, and her birthday without fail for the past fifteen years.

At our initial session, Mona sat there with a friendly smile, saying nothing. I was aware that her previous therapist was comfortable with silences of up to ten minutes, so Mona didn’t expect me to speak for a while.

“I have been told by Dr. N. that you haven’t had much experience with having your feelings of warmth reciprocated by those closest and most important to you.”

She brushed my comment off with a frown and a shake of the head. “Whatever you grow up with, you think is normal. You just take it as it comes.”

For the first three weeks, Mona was pleasantly light in response to questions about her discomfort and loneliness. She told me stories of punishment, assaults, and not being let into the house after coming home from school on cold winter days. She seemed to regard me as sympathetic, which I had been, and easy for her to talk to. We appeared to have gotten off to a good start.

Mona came in for her seventh session with a frown on her face.
“What’s the matter?” I inquired.
“What’s the difference?” she snapped back.
“You look upset. I’m concerned. Maybe if we talk about it, we can improve the situation or how you feel.”

Her face still maintained its hard look.
“You’re concerned? You get paid. I think that you get paid for squat!”
“Why are you angry? Nothing has changed. I’ve always been paid. It never bothered you before.”
“Well, maybe this just isn’t good enough anymore.”
“Are you saying that you don’t want to continue therapy?”
“I’m saying that you’re not able to do anything for me. Look!” She lifted her long sleeve and pointed to a cut, three inches long, on the inside of her forearm. It was still bleeding through the gauze and tape she had covered it with. I walked over to my bookcase, took down a bottle of peroxide, adhesive tape, and gauze pads, walked back to Mona, sat down, and removed the bandage. I was surprised by the size of the cut. I poured the peroxide up and down—it erupted as a lake of pink foam. After a second and third application, the foam was white. I made a tight bandage to close the cut as much as I could. The gauze stayed white. The bleeding had stopped.

“You will have to go next door to my dermatologist colleague to see if it needs stitches or other treatment after our session is over. What is this about?”
I looked up from the cut to find a tearful Mona.
“Today’s my birthday.”
“No card?”
“No card.”
“Do you understand why you were so angry at me when you came in today?”

She answered me in a tone that suggested I should have known the answer.
“You are the only person I speak to about my feelings. Should I have been angry with the grocer?”
“That’s quite a cut,” I remarked.
“There will always be cuts,” she countered in a resigned tone. We both stared at the white bandage. No bleeding observable. She rolled her sleeve down.
“Is that something you want to change?”
“The cuts? No, I want to be a mass of scars and bleeding my whole life, or until I accidentally kill myself.”
I allowed for the sarcasm—anger takes a while to dissipate.
“So we have the same goals for you?” I offered.
“Some of the same goals,” she grudgingly accepted.

Mona had come into her session angry, dissatisfied, acting as if she wanted to end the relationship. She did not have the relationship skills or the ability to reflect upon what was really bothering her. At the age of twenty-eight, she was doing what an early adolescent does: she yells at her mother or father for a grievance that belongs somewhere else. Ironically, Mona was snapping at me over a grievance she had with her own mother. Another birthday passing without hearing from her mother had been a painful reminder of her mother’s neglect.

Therapy offered Mona a new opportunity to learn that she could depend on another person. By dressing her wound, I did what a parent would do. This would deepen her trust and attachment to me and would provide me with more leverage to help Mona.

My goal was to develop her verbal expressiveness, which would in turn give her more insight into her own feelings, especially her anger and sadness. I knew from her symptoms she had no healthy outlet for emotional pain. I would continually push her to clarify the reason behind every self-harming act until the act itself became unnecessary.
- Levenkron, Steven; Cutting: Understanding & Overcoming Self-Mutilation; W.W. Norton and Company : New York; 1998

Information Brief Non-Suicidal Self-Injury:
What is it, Why Does it Happen and How Can We Help?

- Ohio Department of Education, What is non-Suicidal Self- injury?, Miami University, Center for School Based Health Programs, 2017

Personal Reflection Exercise #2
The preceding section contained information about a case study of a self-injurer. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Examining drivers of self-harm guideline implementation by
general practitioners: A qualitative analysis using the
theoretical domains framework

- Leather, J. Z., Keyworth, C., Kapur, N., Campbell, S. M., & Armitage, C. J. (2022). Examining drivers of self-harm guideline implementation by general practitioners: A qualitative analysis using the theoretical domains framework. British journal of health psychology, 27(4), 1275–1295. https://doi.org/10.1111/bjhp.12598


Peer-Reviewed Journal Article References:
Andover, M. S., Schatten, H. T., Holman, C. S., & Miller, I. W. (2020). Moderators of treatment response to an intervention for nonsuicidal self-injury in young adults. Journal of Consulting and Clinical Psychology.

Bustamante Madsen, L., Eddleston, M., Schultz Hansen, K., & Konradsen, F. (2018). Quality assessment of economic evaluations of suicide and self-harm interventions: A systematic review. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(2), 82–95.

Dueweke, A. R., Rojas, S. M., Anastasia, E. A., & Bridges, A. J. (2017). Can brief behavioral health interventions reduce suicidal and self-harm ideation in primary care patients? Families, Systems, & Health, 35(3), 376–381. 

Evans, C. M., & Simms, L. J. (2019). The latent structure of self-harm. Journal of Abnormal Psychology, 128(1), 12–24.

QUESTION 16
What was a goal Mona's therapist had for her treatment? To select and enter your answer go to Test.

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