• Home
• Courses Listed by Topic
• Courses Listed by Hrs
• Courses Listed by Code
• CE Requirements
• Colleague Share
• Large Group Discount
• Instructors | About Us
• Free Training Videos
• Create an Account

Psychiatric patients who engage in self-destructive behavior by cutting, burning, or abrading their skin are currently one of the most difficult-to-treat groups in both inpatient and outpatient settings. The complexities of treating these patients, the risk factors associated with this symptom, and the rise in the prevalence of self-mutilation in America's adolescents and young adults provided the impetus for the current study. This article explores aspects of aggression, dependency, object relations, defensive structure, and psychic boundary integrity that may contribute to the genesis and maintenance of self-mutilation. Rorschach protocols from 90 borderline personality-disordered inpatients (48 self-mutilators and 42 non-self-mutilators) were scored using five psychoanalytic content scales. Results indicate that self-mutilating patients exhibit greater incidence of primary process aggression, severe boundary disturbance, pathological object representations, defensive idealization, devaluation, and splitting than did a matched group of non-self-mutilating borderline patients. Clinical theory and technical recommendations are considered in light of the current empirical findings. (Bulletin of the Menninger Clinic, 64[3], 365-385)
For the past 70 years, analysts have worked to comprehend the unconscious structures that are thought to be responsible for masochistic fantasies and behaviors of humiliation and physical pain (Bollas, 1992; Bonaparte, 1952; Deutsch, 1930; Doctors, 1981; Freud, 1923/1961b,1924/1961a; Kernberg, 1984; Menninger, 1938; Reich, 1940; Smirnoff, 1969; Stolorow & Lachmann, 1980). Masochism, in the form of bodily self-destruction, negativism, and negative therapeutic reactions, has consistently presented a perplexing theoretical problem and a serious challenge to effective treatment of neurotic, borderline, and psychotic disorders (Freud, 1924/1961a; Joseph, 1982; Olinick, 1964; Riviere, 1936). Modern clinicians are faced with similar theoretical complications in comprehending the underlying psychic structures of self-mutilating individuals. These patients frequently become embroiled in negative therapeutic reactions and masochistic transference impasses that destroy the frame of the treatment and can, in the most extreme cases, lead to the suicide of patients.
Self-mutilating patients are predominantly adolescent and young adult females who engage in self-destructive behavior by cutting, burning, or abrading their skin. Like masochists of Freud's era, these patients are currently one of the most challenging and treatment-refractory groups of seriously disturbed patients (Favazza & Conterio, 1988; Favazza & Favazza, 1987; Pao, 1969; Simpson, 1980). The impact of their sadomasochistic attacks on their body and on the frame of the treatment can be deeply disturbing to those who treat them. In short, countertransference fear, repulsion, and rage can interfere with the therapist's ability to consider the intrapsychic meaning of cutting as a defensive reaction, as a transference communication, or as a suicide attempt.
When therapists attempt to manage self-destructive actions without a clear interpretive frame for understanding and communicating their interventions, therapist and patient can fall into a reflexive mode of chronic crisis management (Sacksteder, 1997). The potential for transference enactments to go unanalyzed by the therapist is greatest at such moments because the primary task of treatment can be lost in the midst of crises. This type of disengagement from the interpretive task is a serious impediment to the treatment of a condition that is often erroneously considered simply "manipulative," but that has serious consequences for the patient.
Past research has shed light on the dangers and complexities of this phenomenon by exploring demographic and personal characteristics (Favazza, 1989; Feldman, 1988), the phenomenology of patients (Himber, 1994; Leibenluft, Gardner, & Cowdry, 1987), and clinical observations and treatment approaches (Kernberg, 1987; Stone, 1987; Tantam & Whittaker, 1992). The data on suicide rates for self-mutilating borderline patients are twice that for other borderline patients (Stone, Hurt, & Stone, 1987). Other risk factors include the potential for developing stereotyped and chronic self-mutilation due to increased release of endorphin metenkephelin (Cold, Allolio, & Rees 1983), contagion through modeling (Rosen & Walsh 1989; Walsh & Rosen, 1985), and the development of an identity as a "cutter" (Podvolt, 1969).
While the etiology is complex, self-mutilators frequently report childhood experiences of emotional and physical trauma, including sexual abuse, early traumatic invasive surgery, and neglect (Cross, 1993; Favazza & Conterio, 1988; Feldman 1988). These traumatic events are thought to create severe disturbances in object relations (Berliner, 1958; Chasseguet-Smirgel, 1995; Kernberg, 1984), in the capacity to symbolize experience (Muller, 1996), and in maintaining an ongoing experience of self that is free from derealization and dissociation (Favazza, 1992; Feldman, 1988; Rosenthal, Rinzler, Walsh, & Klausner, 1972; Soloff, Lis, Kelly, Cornelius, & Ulrich, 1994).
The purpose of this study is to investigate psychoanalytic concepts of self-mutilation empirically by exploring object representations, affect, and thought disorder manifest in two similar groups of inpatient Rorschach protocols. Assessing unconscious processes manifest in projective test data allows for an analysis of greater depth and breadth than do self-report data, while maintaining the advantages inherent in large-sample investigations. In order to narrow the range of unconscious processes to be investigated, we reviewed the vast array of psychoanalytic explanations of masochism and self-mutilation.
Modern ego psychology, object relations theory, and self psychology provide insights into the structural deficits and the underlying motivations that maintain self-mutilation. We have therefore drawn from several theorists' work (Doctors, 1981; Kernberg, 1984; Stolorow & Lachmann, 1980) as a springboard for constructing a study of the unconscious correlates of self-mutilation using Rorschach responses from borderline inpatients.
Kernberg (1984) proposed that patients who self-mutilate tend to be infantile, narcissistic, and "as if" personalities, functioning at an overt borderline level. In histrionic and infantile personality disorders, self-mutilation occurs in the context of some real or imagined failure or thwarted wish. The act is considered an unconscious coercive effort to gain control over the environment by inducing guilt in the frustrating other. Kernberg observed a more severe form of self-mutilation in "malignant narcissistic" patients. These patients tend to present as aloof and uninterested in others, rather than clinging. When their grandiose self-image is challenged, they experience intense humiliation, and in an effort to rid the self of unbearable humiliation, these patients physically enact, through self-mutilation, an unconscious triumph over the internal world of objects as they cheat death and pain. These patients flaunt their sense of superiority over their therapists when they discover that the therapist is chagrined or frightened by their self-mutilation. A third category of patient suffering from atypical psychoses is far more rare, and can be identified by the bizarre nature of the self-mutilation and the unusual degree of cruelty and idiosyncratic features. Each distinct subgroup suffers from primitive pathological object relations, primitive defenses, rage, and narcissistic vulnerabilities.
Stolorow and Lachmann (1980) have suggested that masochistic activity often occurs in response to a fear of fragmentation and that it represents an abortive (and sometimes sexualized) attempt to restore the cohesion and stability to a fragmenting self-representation. Building on decades of psychoanalytic exploration of masochism, the authors assert that the most violent and primitive expressions of self-directed aggression are found in individuals who are most vulnerable to narcissistic injury. Relatively minor frustrations such as the loss of control over a relationship and failed mirroring may threaten the structurally deficient narcissistic individual. In such cases, the need for experiences of acute pain, localized on the skin surface, may help buttress or protect against the derealization, sensations of falling apart, and dissociation that is commonly associated with a dissolving self-other boundary.
In a similar analysis, Doctors (1981) concluded that self-mutilating adolescents have not obtained emotional object constancy, exposing them to defensive splitting of good and bad part-objects. Furthermore, the lack of sufficient differentiation between self and objects results in an unstable array of internal representations in which even minor frustration can rapidly develop into intense rage that inundates the object world, and thereby spoils precariously maintained self-representations and object representations. This spoiling of the inner world, combined with a fragmenting ego boundary, further blurs the patient's tenuously held distinction between self and other. The breakdown in the capacity to maintain self-other differentiation has been linked to self-reports of falling to pieces, or feeling empty, unreal, and dead inside. According to this theory, a main unconscious motivation of self-mutilation is the effort to repair and restore a sense of self-cohesion and to expunge bad part-objects in order to restore good object representations.
Significant theoretical and clinical differences exist between ego psychology and self psychology, especially in the understanding of narcissistic and borderline disturbances. Despite these differences, there are fundamental similarities across theoretical orientations that are particularly important to this investigation. All three theories assume that the act of cutting is an unconscious effort to reestablish some degree of narcissistic equilibrium and self-cohesion. For Kernberg (1984), pathological affect and object representations set the stage for self-mutilation, especially when patients feel deprived, abandoned, or insulted by the therapist. The motivation to master and control another object is an effort to restore narcissistic balance, either through a dependent yet coercive object relation or through a coercive insistence on mirroring of the patient's grandiose self-organization. For Stolorow and Lachmann (1980), narcissistic injury produces intense rage in the structurally deficient ego, which can lead to sensations of fragmentation and boundary dissolution. For Doctors (1981), a narcissistic injury may precipitate an affective storm that inundates the patient's object world, transforming precariously maintained positive imagoes into malevolent objects.
These clinical theories find some support in descriptive studies and to a lesser extent in large-scale empirical research. For example, Stolorow and Lachmann's assertion that these patients use acute experiences of pain to bolster crumbling ego boundaries finds support in case descriptions (Cross, 1993; Doctors, 1981; Favazza, 1989; Gardner & Gardner, 1975; Miller & Bashkin, 1974; Pao, 1969; Simpson & Porter 1981). Researchers have found that self-mutilators are significantly more prone to derealization and drug-free hallucinations/delusions than are non-self-mutilating borderline patients (Soloff et al., 1994), and self-mutilators have higher rates of serious identity disturbance than the non-self-mutilators (Simeon et al., 1992). The clinical inference that aggression is a key factor in the act of self-mutilation has equivocal research support. Soloff and colleagues (1994) found that self-mutilating patients scored lower on the Buss-Durkee Hostility Inventory than did clinical controls, and that physical assaults on others were negatively correlated with self-mutilation. By contrast, Simeon and colleagues (1992) reported that self-mutilators produced significantly higher scores on the Minnesota Multiphasic Personality Inventory (MMPI) Psychopathic Deviance Scale (PD), yet did not differ significantly from controls on the Buss-Durkee Hostility Inventory. Finally, Rosenthal and colleagues (1972) noted that most of the 24 female patients reviewed in their study feared their own anger, described an inability to cope with these feelings, experienced derealization, then cut themselves in an effort to reintegrate. These equivocal findings may have more bearing on the patients' willingness or ability to report their subjective affect states than it does on the nature of their affective life. Thus aggression may be related to self-mutilation, but it has been unclear to what extent hostility and aggression are consciously registered, contained, and modulated by the ego.

1. Self-mutilation is associated with intense, unmodulated aggressive affects. As a result, self-mutilating borderline patients are expected to manifest more primary process aggression on the Rorschach than the other borderline group.
2. Clinical reports describe most self-mutilating patients as excessively dependent and clinging; thus the self-mutilating borderline group may produce more oral dependent imagery on the Rorschach than the second group.
3. The wish to omnipotently control a precariously held self-other distinction through self-mutilation is an unconscious expression of an imbalanced, malevolent inner world; therefore self-mutilating patients may manifest greater imbalanced, omnipotently controlling, and malevolent object representations than the second group.
4. Defensive devaluation, idealization, splitting, and denial may play a critical role in self-mutilating patients' attempts to manage intense affects and reestablish narcissistic equilibrium. We expect self-mutilating patients to manifest greater degrees of these defenses.
5. Self-mutilating patients are thought to experience more fragmentation and boundary disturbance and therefore will manifest greater degrees of self-other boundary disturbance than the second group of borderline inpatients.

Fifteen adolescent French girls with a recent history of self-mutilation and 18 adolescent girls without such a history participated in a study of the relationship between alexithymia, depression, and self-mutilation. Results of correlational analyses showed that depression and alexithymia -particularly its "difficulty in identifying feelings and differentiating them from bodily sensations" factor- were significantly related to self-mutilation. Sequential logistic regression analysis showed that depression and the alexithymia factor as a set reliably distinguished between those who self-mutilated and those who did not. Of the two independent variables, depression was identified as the better predictor of self-mutilating behavior. Although the "difficulty in identifying feelings and differentiating them from bodily sensations" factor of alxithymia did have an effect independent of depression, much of the relationship between this factor and self-mutilation appeared to be the result of mediation by depression.
Self-mutilation may be defined as "a volitional act to harm one's own body without intention to cause death" (Yaryura-Tobias, Neziroglu, & Kaplan, 1995, p. 33). This deliberate, physically violent but non-suicidal act done to oneself by oneself (Alderman, 1997) may take many forms. Some of these are culturally sanctioned (e.g., tattooing, body piercing) whereas others are pathological in nature (Favazza, 1996). Pathological self-mutilation may be categorized into major, stereotypic, and superficial/ moderate self-mutilation (Favazza, 1998; Favazza, & Rosenthal, 1993). Major self-mutilation involves acts which result in significant tissue damage (e.g., castration) and are usually associated with psychosis and intoxication. Stereotypic self-mutilation consists of stereotypic, rhythmic acts such as head banging and self-biting, commonly seen in conditions such as severe mental retardation and Tourette's syndrome. Superficial/moderate self-mutilation consists of superficial behavior such as skin cutting, burning, and scratching. The present study concerned itself with this last category. More specifically, it focused on adolescent girls showing self-cutting behavior.
Self-mutilation usually begins in late childhood or early adolescence and can continue for up to 20 years (Favazza & Rosenthal, 1993); the rates are highest among adolescents. Although the behavior has been observed in boys (Ross & Heath, 2004), the typical self-mutilator is a single, adolescent or young adult female (Favazza & Conterio, 1989; Pattison & Kahan, 1983; Raine, 1982; Suyemoto & MacDonald, 1995). Self-mutilation is repetitive in nature and distinct from suicidal behavior. Self-mutilators usually cut more than once (Bach-y-Rita, 1974; Himber, 1994; Simpson, 1980) but have no intention to cause death (Graff & Mallin, 1967). They distinguish between self-mutilative acts and suicidal ones (Herpertz, Steinmeyer, Marx, Oidtmann, & Sass, 1995), and, unlike suicide attempters, generally experience a feeling of relief following the act (Alderman, 1997; Favazza, 1996; Pattison & Kahan, 1983). Solomon and Farrand (1996) suggested that self-mutilation may be an adaptive alternative to suicide; however, those who cut themselves can have suicidal ideation which can lead to suicidal behavior. In fact, Stanley, Gameroff, Michalson, and Mann (2001) reported that between 55% and 85% of self-mutilators have made at least one suicide attempt.
Although there has been a growing interest in early trauma as a factor in the development of self-mutilative behavior (e.g., Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Low, Jones, MacLeod, Power, & Dugan, 2000; Van der Kolk, Perry, & Herman, 1991), relatively little is known about what motivates self-mutilators and many professionals are at a loss to understand the behavior (MacAniff Zila & Kiselica, 2001). Because tension relief is a correlate of self-mutilation, it has been speculated that the act is a specific method of coping with emotional distress that leads to an immediate reduction in tension. (Alderman, 1997; Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Van der Kolk, Perry, & Herman, 1991; Winnicott, 1989; Yaryura-Tobias et al., 1995). Van der Kolk et al. (1991) suggested that this is a way for individuals who lack more adaptive coping techniques to achieve psychological equilibrium. Self-mutilators generally are unable to verbally describe their intolerable affect (Zlotnick, Shea, Pearlstein, Simpson, Costello, & Begin, 1996), and the act of self-mutilation itself becomes an expression of these unspoken feelings of despair.
Individuals who cannot verbally express negative affects may be described by the term "alexithymia." The latter concept derived from clinical observations that psychosomatic patients were unimaginative and limited in their ability to verbally and symbolically express emotions (Ruesch, 1948). They were constricted in emotional functioning, had a barren fantasy life, found it difficult to differentiate feelings from bodily sensations, and had trouble talking about their emotions (Sifneos, 1972, 1973, 2000). Alexithymia therefore has been defined as a personality construct characterized by a difficulty in identifying and communicating feelings; a problem in distinguishing between feelings and bodily sensations; a relative lack of fantasy and imaginative activity; and a preference for focusing on external events over internal experiences (Taylor, Doddy, & Newman, 1981). Longitudinal studies suggest that it is a stable trait rather than a state effect of psychological or medical distress (Taylor, Bagby, & Luminet, 2000).
Alexithymia is highly predictive of a broad range of physical and mental problems. Associations have been found with hypertension (Todarello, Taylor, Parker, & Fanalli, 1995), inflammatory bowel disease (Porcelli, Zaka, Leoci, Centonze, Taylor, & Parker, 1995), chronic pain disorder (Lumley, Asselin, & Norman, 1997), somatoform disorders (Cox, Kuch, Parker, Shulman, & Evans, 1994), eating disorders (De Groot, Rodin, & Olmstead, 1995), depression (Grabe, Spitzer, & Freyberger, 2004; Honkalampi, Hintikka, Laukkanen, Lehtonen, & Viinamaki, 2001; Wise, Mann, & Hill, 1990), dissociation (Grabe, Rainermann, Spitzer, Gänsicke, & Freyberger, 2000), panic disorder (Zeitlin & McNally, 1993), anxiety, phobia, obsessionality, interpersonal sensitivity, aggression, paranoia, and psychoticism (Grabe et al., 2004).
Because alexithymia has proven to be such a strong predictor of a broad range of pathology, a relationship with self-mutilation might be expected. The inability to differentiate and verbally express emotions that characterize alexithymics is also a characteristic of self-mutilators (MacAniff Zila & Kiselica, 2001). It is therefore not surprising that, compared to non-mutilators, self-mutilators have been found to report a greater degree of alexithymia (Zlotnick, et al., 1996).
Many studies of the relationship between alexithymia and other forms of pathology have not integrated in their analyses an assessment of depression. It has been reported that alexithymia is moderately to strongly related to depression (Grabe, et al., 2004; Hintikka, Honkalampi, Lehtonen, & Viinamäki, 2001; Honkalampi, et al. 2001; Honkalampi, Hintikka, Tanskanen, Lehtonen, & Viinamäki, 2000; Speranza, Corcos, Guilbaud, Loas & Jeammet, 2005; Wise et al., 1990) and that the latter variable acts as a powerful mediator between alexithymic features (particularly the "difficulty in identifying feelings and differentiating them from bodily sensations" factor) and psychopathology (Honkalampi et al., 2000; Speranza, Corcos, Stéphan, Loas, Pérez-Diaz, Lang, Venisse, Bizouard, Flament, Halfon, & Jeammet, 2004). For this reason, the present investigation analyzed the relationship between alexithymia and self-mutilation while taking into consideration the possible mediating effect of depression in order to ascertain whether or not alexithymia makes an independent contribution to self-mutilation separate from depression.

This article examines the syndrome of self-mutilation with specific attention given to self-mutilation in female adolescents and young adults. Causes, symptoms, types, definitions, and treatments are discussed. Included is an explanation of the lexical and conceptual confusion that accompanies self-mutilation. Implications and recommendations for counselors are addressed.
Acts of self-mutilation by female adolescents and young adults have received increased attention in the popular literature (Pedersen, 1996; Pipher, 1994; Schappell, 1995; Steinem, 1993; Todd, 1996), yet understanding and effective treatment of self-mutilation remain elusive. Self-mutilation is a phenomenon often associated with autistic children, schizophrenics, and those diagnosed with multiple personality disorder, but rarely addressed in discussions of female adolescents and young adults. The paucity of information available is apparent when trying to identify recent works on the topic. This lack of general knowledge and specific research regarding self-mutilation is detrimental to those who exhibit self-mutilating behaviors and those counseling professionals who may encounter self-mutilation in their clients.
In 1985, self-mutilation was discussed on a national television show (Favazza & Conterio, 1989). Viewers were supplied with an address to which they could write for more information. Over 1,000 letters were received. Favazza and Conterio used this group for a study on self-mutilation. Of the 254 people who responded positively to their request to participate in the study, 240 were female and reported 14 years to be the average age of their first self-injurious act. It is interesting that 91% had neither known nor read about self-mutilation before viewing the program, illustrating the need for more attention to the subject.
The extreme cases of self-mutilation that result in the need for immediate medical attention are usually the most familiar, yet these instances are far from typical. Many authors describe the typical self-mutilator as female, adolescent or young adult, single, usually from a middle- to upper- middleclass family, and intelligent (Favazza & Conterio, 1989; Pattison & Kahan, 1983; Raine, 1982; Suyemoto & MacDonald, 1995).
The purpose of this article is to educate the counselor on the many aspects of self-mutilation in female adolescents and young adults. Specific attention is given to its definitions, causes, symptoms, types, and treatment. There is also an attempt to address the semantic and conceptual confusion that accompanies self-mutilation.
Although self-mutilation does occur among certain populations of boys (e.g., among sexually abused boys; see Cabe, 1999), we have focused this article on self-mutilation in girls for two reasons. First, our review of the literature indicated that even less is known about self-mutilation in boys than is known about self-mutilation in girls. Second, we have counseled considerably more girls than boys who self-mutilate and have drawn from these clinical experiences in writing this article. Although the purpose of this article is to convey what we have learned about self-mutilation in girls, we hope that this article will assist other counselors in their efforts to study, understand, and help troubled boys who are also tortured by the distressing problem of self-mutilation.

Hypotheses regarding the motivations for self-mutilation are as varied as the acts themselves. An early report of self-mutilation by Offer and Barglow (1960) proposed several explanations but emphasized the major dynamic as aggression turned against the self to retaliate against a "bad mother" (p. 109). It is interesting that this theory came at a time when communication patterns (particularly those between children and mothers) in families with children who have schizophrenia were being reported that tended to "blame" the mother for schizophrenia in her child (Goldenberg & Goldenberg, 1996). This form of linear thinking (i.e., mother "causes" child's behavior) may have influenced Offer and Barglow's cause-effect explanation. Although ultimately too simplistic to explain self-mutilation, this explanation provided a start for other researchers.
Ross and McKay (1979) provided an extensive list of possible causes of self-mutilation including ritual and symbolism, sex, regression, existential statement, manipulation, risk taking, attention seeking, retaliation, frustration, depression, tension relief, inappropriate communication, self-punishment, and low self-esteem. The most commonly supported of these theories are ritual and symbolism and tension relief.
Ross and McKay (1979) explained ritual and symbolism in descriptions of self-mutilation that are laden with religious overtones and symbolism. Favazza and Conterio (1989) concurred with this theory, citing frequent references to the need to atone for sins by those who self-mutilate. Himber (1994) found a common theme of self-purification among these individuals. Influence of the Bible, identification with Christ, sinfulness, heavenly commands, demonic influences, and religious commands were reasons offered by Favazza (1996) for more extreme cases of self-mutilation.
Many support the theory of tension relief as at least a partial explanation for self-mutilation (Alderman, 1997; Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Winnicott, 1989; Yaryura-Tobias et al., 1995). This idea postulates that an act of self-mutilation brings an immediate diminution of tension that results in a relaxed state. Ross and McKay (1979) and van der Kolk et al. (1991) believed that this is a way for those who lack more adaptive means to achieve psychological homeostasis. Himber (1994) saw this as a type of affect modulation in which self-mutilation is used to modulate intolerable emotions.

Sexual identity in the context of a discussion of self-mutilation must address several points: sexual experience or abuse, attitude toward one's gender, body image, and self-mutilation as a form of masturbation. The common theme throughout these separate but integrated issues is sexual confusion.
Graft and Mallin (1967) reported sexual confusion among nearly all of their study's participants. Although some had extensive sexual experience, including same-sex and incestuous activity, others were inordinately prudish. Pao (as cited in M. Simpson, 1980) emphasized the repugnance his group of self-mutilators exhibited toward their female sexuality as well as their uncertainty about sexual identity. In referring to his group composed of individuals who self-mutilated, Pao (as cited in M. Simpson, 1980) emphasized the group members' repugnance exhibited toward their female sexuality as well as their uncertainty about sexual identity. More than half of the participants in Favazza and Conterio's (1989) study reported the presence of troublesome sexual feelings: 34% hated their breasts, 56% strongly hated having a pelvic exam, and 10% indicated they would be better off without a vagina.
The onset of menstruation often correlates with adjustment problems for female adolescents and young adults. For the self-mutilator, this time is frightening and often even repugnant. Rosenthal et al. (as cited in M. Simpson, 1980) reported 65% of participants in their study had negative, unhappy, or disgusted reactions to menarche. Almost half of this group had irregular menstrual periods and frequent amenorrhea. Favazza and Conterio (1989) reported that 58% of their participants hated their periods. Those with more abnormal menstrual patterns more frequently exhibited self-mutilating behaviors. Yaryura-Tobias et al. (1995) reported a correlation between the onset of self-mutilation and the return of the menstrual cycle.
Just as the onset of menstruation often precipitates confusion for the girl who self-mutilates, so does the associated issue of emerging sexuality. Self-mutilation is often associated with the inability to deal with one's sexuality due to earlier or ongoing sexual abuse, or rape. C.A. Simpson and Porter (1981) hypothesized that these experiences somehow change normal physical and emotional responses to both sex and pain. Greenspan and Samuel (1989) studied three young women whose self-mutilation began shortly after they were raped. The backgrounds of the first two individuals were void of any previous abnormal sexual experiences, but the third had a history of incest. In their study of 19 self-mutilating young women, Yaryura-Tobias et al. (1995) noted that 70% of them reported childhood sexual abuse.
In a longitudinal study of 74 clients, van der Kolk et al. (1991) examined how histories of childhood trauma contribute to self-destructive behaviors such as self-mutilation. The authors found a strong correlation between a history of childhood physical and sexual abuse with self-mutilation. They recommended that therapists working with clients who self-mutilate should be prepared to deal with past issues of childhood trauma as well as the effects of such experiences on current relationships.
Daldin (1988) proposed that the sexual component of self-mutilation is primarily masturbatory. Self-mutilation is seen as representing a self-stimulating activity that combines sexual gratification with punishment for the impulse to self-stimulate. Again, the idea of a distorted sense of pain and pleasure is addressed as is that of a distorted body image. C. A. Simpson and Porter (1981) agreed that self-mutilation might be a form of body stimulation.

The body image aspect of sexual identity extends to the subject of what these young women will go through to control their bodies. This issue of control often takes the form of an eating disorder. M. Simpson (1980) noted the connection between self-mutilation and anorexia nervosa, citing similar origins for both behaviors. Disturbance of body image, self-directed aggression, and indirect self-destructive behavior were the key correlates. Favazza and Conterio (1989) reported that 61% of participants in their study admitted to having or having had an eating disorder, with the average age of onset being 16 years. Of study participants who engaged in self-mutilation, C. A. Simpson and Porter (1981) found only 1 of 20 to be within the normal range for weight-height ratio.
M. Simpson (1980) also found that substantial symptoms of dysorexia (a bad or depraved appetite) may be quite common among those young women who exhibit self-mutilation and that acts of self-mutilation are frequently associated in time with binge eating or its associated vomiting. According to Yaryura-Tobias et al. (1995), within 2 years after improvement of anorexia and elimination of amenorrhea, study participants manifested a compulsion for self-mutilation. At times, self-mutilation and eating disorders coexist, whereas at other times, one seems to replace the other.
Alderman (1997) suggested that patterns associated with both self-mutilation and eating disorders are connected by the commonalties of trauma and disassociation. The relationship between self-mutilation and eating disorders is not cause and effect; self-mutilation and eating disorders are separate choices for coping with similar situations.

Some researchers have investigated the relationship between self-mutilation and substance abuse. There is some disagreement about the nature of the relationship between substance abuse and self-mutilation. Pattison and Kahan (1983) and Graft and Mallin (1967) believed that drug and alcohol abuse are major predisposing factors for self-mutilation. However, Ross and McKay (1979) proposed that the ingestion of drugs and alcohol is itself an act of self-mutilation and that a drug-induced state may actually trigger self-mutilation because of impaired judgment, reduced pain perception, and fantasy stimulation.
Regardless of which hypothesis is correct, it is important to be aware of the frequency of reported substance abuse among those who self-mutilate. Although 59% of Favazza and Conterio's (1989) study participants reported that no self-mutilation occurred while they were under the influence of alcohol or drugs, 28% were concerned with their drinking, 18% considered themselves alcoholics, and 30% had abused nonprescription drugs. M. Simpson (1980) reported that amphetamines were popular among those who self-mutilate because of the drug's ability to amplify sensation and-stimulate body awareness. Similarly, C.A. Simpson and Porter (1981) found that a majority of their study participants abused alcohol, nonprescription drugs, or both, and they gave comparable reasons for this and for their acts of self-mutilation, "to feel good ... to make the bad feeling go away" (p. 432).

The absence of appropriate attachment and nurturing during childhood may contribute to the onset of self-mutilation. Favazza and Conterio (1989) found that more than half of their study participants selected the adjective "miserable" to describe their childhood, and 62% noted childhood abuse. Kafka (1969) reported clients recalling early experiences of abandonment and a lack of maternal handling during the very early stages of childhood. Lack of social support, isolation, and family disruption were present in almost half of Pattison and Kahan's (1983) sample. How does this information apply to a study of self-mutilation?
Himber (1994) postulated that growing up abused, neglected, or both makes accepting comfort and help from others difficult. Consequently, individuals who self-mutilate learn to rely on their own resources. C. A. Simpson and Porter (198 l) found that many of those individuals did not know how to maintain meaningful interpersonal relationships. Many of their study participants frantically looked for important attachments, yet refused to form them. Rosen, Walsh, and Rode (1990) regarded lack of attachment in early life due to the loss of a significant other, particularly a parent, as hindering the development of a stable capacity for love. New losses are seen as recapitulating the original loss and its accompanying emotions.
Alderman (1997) viewed self-mutilation as a way to keep others at a distance, both physically and emotionally. Emotional distance results from the shame and secrecy that accompany self-mutilation. Individuals who self-mutilate do not discuss their behavior with others, which can lead to a feeling of emotional isolation. The sensation of physical disassociation with oneself that often accompanies self-mutilation can extend itself to a lack of attachment to others. Physical distancing from others can also occur as a way to avoid exposing wounds and scars. This may result in the self-mutilator refraining from sexual or intimate contact with others.
Another theory, supported by Ross and McKay (1979), was offered by Graft and Mallin (1967):
As the child matures and can distinguish verbal from nonverbal communication, it still demands both when it is injured. Only with greater maturity can it subsist on verbal messages of comfort in lieu of physical messages. We view the behavior of the cutter as a manifestation of a breakdown in this developmental system. (p. 40)

The main issue for young women who self-mutilate is usually a combination of difficulty with verbalization and functioning from a false self (Pipher, 1994; Winnicott, 1989). Verbalizing emotions often seems impossible to the self-mutilator: "I just cry and get hysterical when I try to talk" (Offer & Barglow, 1960, p. 104). Himber (1994) found that individuals who self-mutilate function developmentally at a preverbal level. Therefore, the initial goal of counseling should be to provide a relationship that is "sustaining enough to help contain the flood of overwhelming affect" (p. 627).
Graff and Mallin (1967) stressed that the aim of counseling should initially be to assist the patient's maturity process to the point where she can use words rather than destructive gestures as a sign of emotion. Others (Rosen et al., 1990; M. Simpson, 1980) reported that an improved facility in verbal emotional expression was associated with clinical improvements and cessation of self-mutilation. Roeback et al. (as cited in Ross & McKay, 1979) found that reinforcement of social responses of these individuals combined with a multifaceted counseling approach was a key to eliminating self-mutilation.
Pipher's (1994) notion of the false self is an important concept related to addressing the expressive difficulties of individuals who self-mutilate. According to Pipher, the false self emerges when girls fail to acknowledge their own feelings. Winnicott (1989) theorized that the emergence of a false self results in a psychological state characterized by a lack of spontaneity and blunted affective experience. Among those who self-mutilate, the denial of the true self, the emergence of the false self, and the concurrent masochistic patterns of behavior may be triggered by early childhood trauma, such as sexual abuse (van der Kolk et al., 1991). Consequently, a critical goal of counseling is to promote the reemergence of the true self by talking about these patterns of behavior, gently and patiently exploring any early traumas, and encouraging the genuine expression of previously denied feelings. Throughout this process, the counselor must assist the individual who self-mutilates to stay connected to her feelings and slowly work through any turbulent, psychological changes that may be prompted by the counseling (Pipher, 1994).

The limited information regarding self-mutilation frequently hinders its proper treatment. Many counselors, psychologists, marriage and family therapists, and medical professionals who encounter individuals who self-mutilate are often at a loss to understand their behavior. These professionals may feel frightened, repulsed, frustrated, and find it difficult to ask in sufficient detail about the self-mutilation (Favazza, 1996; Himber, 1994). Offer and Barglow (1960) even observed how confusion and frustration regarding self-mutilation among staff members of an inpatient facility led to staff arguments, fragmented and inconsistent treatment, and resulted in an environment for the young women that was not therapeutic. M. Simpson (1980) attributed this type of response on the part of professionals to the strong sense of bewilderment that surrounds self-mutilation.
Individuals who self-mutilate are aware of the reactions their behaviors elicit. Favazza (1996) encountered many such individuals who, because of previous harsh and unsympathetic treatment, falsely admitted to suicide attempts in order to be treated with more humanity. Conversely, Himber (1994) told of a woman who had a long-standing relationship with her physician who set regular appointments with her to examine and treat her wounds, which she felt was a contributing component of her eventual recovery.
Even for those professionals who attempt to properly care for self-mutilation, problems often arise. When counseling strategies aimed at getting the client to stop self-mutilation fail, the client frequently experiences a sense of being misunderstood, and the counselor frequently perceives himself or herself as being ineffective and overwhelmed (Himber, 1994). Ross and McKay (1979) found that only after conceding that they did not understand self-mutilation were counselors then able to suspend clinical judgment and allow the young women to explain their behavior. This process worked for two reasons: The young women felt empowered by becoming part of their own recovery, and the insight gained by the counselors allowed for more appropriate techniques.

The array of unsuccessful attempts at controlling self-mutilation may seem disheartening. However, if counselors are aware of strategies that have been tried and have failed, they will not disappoint their clients or themselves by trying them again. Cited examples of ineffective treatments are physical restraint, hypnosis, chemotherapy, no-cutting contracts, faith healing, group psychotherapy, relaxation therapy, electroconvulsive therapy, family therapy, educational therapy, and even chiropractic care (Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Ross & McKay, 1979).

Cognitive therapy shows clients the connection between their thoughts and their self-mutilation. This approach addresses both the difficulty these young women have with verbalization and their choice to revert to a false self Walsh and Rosen (as cited in Favazza, 1996) established four categories of thought that lead to self-mutilation and need to be addressed in cognitive therapy: self-mutilation is acceptable, one's body and self are disgusting and deserving of punishment, action is needed to reduce unpleasant feelings, and overt action is necessary to communicate feelings to others. Pipher (1994) also stressed the need for these young women to think about how to proceed and alter their thought processes so they do not need to harm themselves.
Pipher (1994) illustrated a successful example of cognitive therapy. He described the case of Gail, a 15-year-old artist and musician who became overwhelmed by "world issues" such as homelessness and AIDS as well as more personal issues like not fitting in and being ridiculed by her peers. She eventually resorted to burning herself with cigarettes.
To address her feelings of hopelessness and helplessness, Pipher (1994) encouraged Gail to work directly with the homeless at a soup kitchen. This was a tangible way for her to address some of the issues that were consuming her. In addition, when feeling overwhelmed, Gail wrote down what was disturbing her until the desire to burn herself subsided. Instead of reverting to destructive thoughts, she addressed exactly what and how she was feeling. These strategies, in combination with talking extensively in therapy about her pain and learning how to ask her parents and counselor for comfort, assisted her efforts to stop self-mutilating.

Various attempts have been made to use behavior modification techniques in counseling those involved in self-mutilation. It is interesting that methods used to treat obsessive-compulsive disorder (OCD) were tried by both Gardner and Gardner (as cited in Raine, 1982) and Yaryura-Tobias et al. (1995), the latter with greater success. Gardner and Gardner found it difficult to find an alternative form of tension relief for their clients due to the overwhelming attainment of this through self-mutilation. Alderman (1997) suggested alternative behaviors that mimic the effects of self-mutilation without the accompanying physical harm, such as submersion of the arm (or other body part) in ice water. Yaryura-Tobias et al., on the other hand, reported decreased intensity and frequency of self-mutilation after 8 weeks of intense behavior therapy consisting of exposure and response prevention, which is also effective with clients who exhibit OCD.
Ross and McKay (1979) applied Training Alternative Behaviors (TAB), which essentially involves attending to and reinforcing appropriate, desired behavior and generally ignoring the self-mutilation. A major obstacle to TAB is that it is not possible to control the behavior of other persons, including parents, who may interfere with the treatment. If the reinforcement regimen is not followed consistently, it fails. Yaryura-Tobias et al. (1995) warned that caution must be taken when using any form of reward/punishment techniques because of issues of side effects, adaptation, and ethics.

Other effective measures in treating self-mutilation in young women have been reported. Wexler (1991) practiced Alternative Hypothesis Therapy (A-H) to assist his clients in reframing frustrating situations and conflicts. Instead of resorting to self-mutilation as a means of coping with their stresses, individuals are encouraged to become aware of when the need to self-mutilate occurs and then to identify alternative behaviors that will allow them to productively deal with the given source of stress. For one young woman, this included charting her ability to accept others' behavior. When she reached her "bottom line" (p. 180), or limit of tolerance, she had to act to maintain her self-respect. This helped to broaden the range of behaviors she could deal with and gave her a way to stay in control. She was so excited by her success that she went on to teach the method to others who self-mutilate.
Ross and McKay's (1979) research analyzed the efficacy of many singular counseling techniques and found that there were limited benefits to clients when counselors adhered to one approach. More effective, they concluded, was a multifaceted approach consisting of modeling, assertiveness training, and teaching and reinforcing socially acceptable ways of expressing negative feelings. Similarly, in a survey of 500 mental health professionals, Suyemoto and MacDonald (1995) found that a majority of therapists favored such multifaceted approaches. The models most often reported as useful in understanding and treating self-mutilation included those that addressed the client's need to express or control what they perceived as overwhelming affect. Also reported as useful is understanding self-mutilation as a way to create boundaries between self and others and to protect against depersonalization or the fear of loss of identity.
Due to the variety of causes recorded for self-mutilation it is not surprising that there is little agreement on how to treat it. There are, however, suggestions on how to identify underlying issues. Himber (1994) recommended asking about details of the acts of self-mutilation. This not only establishes that the counselor is able to hear and really wants to know what is happening, but may offer openings for understanding each individual case and its roots. Yaryura-Tobias et al. (1995) suggested screening the self-mutilator for symptoms of OCD and eating disorders. Greenspan and Samuel (1989) believed that sensitive questioning about rape and incest should be a part of the initial evaluation.