Self-Injury 1
Self-Injury: A Study of Shame
______________________________
Fulfillment of the
Partial Requirements for
The Degree of Master of Arts in
Adlerian Counseling and Psychotherapy
________________________________
by:
Janice E. Winnes
October 2008
Self-Injury 2
Psychological activity is a complex of aggressive and defensive mechanisms whose final
purpose is to guarantee the continued existence of the organism and to enable it to develop
in safety.
Alfred Adler, Understanding Human Nature
The truth about childhood is stored up in our body
and lives in the depth of our soul.
Our intellect can be deceived,
our feelings can be numbed and manipulated,
our perception shamed and confused,
our bodies tricked with medication.
But our soul never forgets.
And because we are one,
one whole soul in one body,
someday our body will present its bill.
Alice Miller, Prisoners of Childhood
Self-Injury 3
Table of Contents
I.
Abstract
5
II.
Introduction
6
III.
A Literature Review of Self-Injury
A.
Definitions
7
B.
Cultural and historical perspective
8
C.
Diagnosis or what?
11
D.
Reasons behind self-injury
13
E.
Reactions from others
14
F.
Profile of the self-injurer
17
G.
Family dynamics
22
1.
Parental neglect and emotional abuse
23
2.
Childhood sexual and physical abuse
27
H.
The act of self-injury
30
I.
Dissociation
33
IV.
Therapists working with self-injury
35
V.
Self-help tools: Books and self-injury focused web sites
42
VI.
Theoretical treatments for self-injury
A.
Pharmacological
45
B.
Psychoanalysis
46
C.
Trauma resolution
48
D.
Cognitive-behavioral
51
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VII.
VIII.
Internalized shame: Foundation of self-injury
53
A.
Shame theory
55
B.
Internalized shame
57
C.
Formation of a shame-based identity
60
1.
Identification images
63
2.
Development of affect-shame, drive-shame and need-shame binds 66
3.
Defending strategies
73
4.
Disowning and splitting of self
76
Discussion
A.
How Adlerian assumptions relate to self-injury
77
B.
Is shame the foundation of inferiority?
83
IX
Conclusion
86
X.
Toward Further Study
87
Self-Injury 5
Abstract
Self injury is a phenomenon that is complex in its causes, its manifestations, its
purposes, and treatment. Variants of this behavior can be traced throughout centuries and
cultures, but has been regarded by Western cultures as taboo and responded with fear and
disgust. Only within the past twenty years have researchers and the medical community
begun to see self-inflicted injury as a response to extreme emotional distress which is
reaching contagion proportions. Aside from psychotic cases, the self-injurer is usually a
woman who is well educated and friendly, but has an extremely difficult time articulating
thoughts and feelings, and suffers from low self-esteem and often self-hatred. Self-injury is
an attempt to regulate overwhelming emotions, and is not a suicidal attempt. It is a selfpreservation mechanism. She usually comes from a family environment that was
neglectful or abusive with a cold, rejecting mother and distant and hypercritical father.
Shame is closely connected with self-injury through secondary shame concerning negative
reaction of others, scarring, and the compulsive, uncontrollable need to self-inflict. It is the
hypothesis of this paper to show that primary shame, which has become internalized
through the formation of a shame-based identity, is the underlying reason that drives the
symptoms and behavior. How Adlerian assumptions relate to self-injury is discussed,
along with how internalized shame could be the foundation and substance of the inferiority
complex.
Self-Injury 6
Introduction
The body's skin is its largest organ, a protective barrier that serves several
functions. Physiologically it regulates body temperature, protects against infection, and
provides sensations of both pain and pleasure. To the one who self-injures, the skin is
symbolic and the palette for expression of emotional pain and pleasure; for the skin, sliced
open, provides relief. It becomes a regulator to provide equilibrium to explosive emotions
and emotional distress. It protects against fear and anxiety that threaten the unconscious
self. The act of self-injury becomes the blood-letting of poisons of self-hatred and rage that
seem to invade the psyche of the sufferer. Thus, the skin provides powerful symbolism for
emotional regulation, protection against chaotic emotional poisons, and physical sensation
for release of emotional paralysis.
The skin also defines and shapes the body's boundary. When this boundary is
violated through abuse, the skin can symbolically take on a diffused means of dealing with
emotional and relational boundary issues. Powerless as a child victim, the self-injurer finds
power by dictating the beginning, middle and end of physical manipulation. For those who
struggle with interpersonal boundary issues, breaking the skin becomes a symbolic way to
forcibly establish a line between the injurer and someone to whom she feels dangerously
joined (Conterio & Lader, 1998, p.65). Thus, self-injury is the remedy that connects the
physical self to the emotional self.
Self-Injury 7
Literature Review of Self-Injury
Definition
The self-injury syndrome has been given many names: parasuicide, self-attack, selfmutilation, symbolic wounding, self-affliction, deliberate self-harm (Pattison & Kahan,
1983, p.867). Each of these specialized names can indicate a peculiar set of behaviors,
symptoms, and diagnosis. The behaviors that accompany these definitions can range from
delicate to course cutting, meticulous skin carving, biting, head banging, burning, stabbing,
and body mutilation or amputation. These more bizarre behaviors are more often associated
with other diagnoses such as mental retardation, borderline personality disorder, or
dissociation. This paper will focus on the more contagion behavior of skin cutting.
Armando R. Favazza (1996), foremost authority and researcher on self-injury, defines it
as the deliberate, direct, non-suicidal destruction or alteration of one’s body tissue. He
goes on to further classify the behavior into major, stereotypic, and superficial/moderate.
Major classification refers to extreme, infrequent acts such as amputation and castration
most often connected with major features of psychosis, acute alcoholism and drug
intoxications, and transsexualism. Stereotypic types of behavior include head-banging,
hitting, self-biting and most commonly occurs with moderate to severely retardation as well
as autism and Tourette’s syndrome. The superficial/moderate type is the most common
found throughout the world in all social classes, and is the type that this paper will address.
It usually begins in early adolescence and includes skin cutting, carving, burning, needlesticking, bone-breaking, and interfering with wound healing. When these behaviors become
an overwhelming preoccupation, they assume a life of their own and become what Favazza
Self-Injury 8
refers to as the repetitive self-mutilation syndrome. He states that persons with this
syndrome adopt an identity as a “cutter” and describe themselves as addicted to their selfharm (Strong, 1998, p. xii).
Cultural and historical perspective
The act of cutting one’s own skin or of body alteration is not a new phenomenon but
has been done throughout the ages and throughout the world’s cultures. Skin has been,
across cultures and ages, a means to communicate identity, status, and a sense of
belonging, such as through tribal face painting and piercing, tattooing, circumcision, or the
red dot on the forehead of Hindu women. The Biblical account of the demon-possessed
man “cutting himself with stones” (Mark 5:5) and medieval Christian flagellations and selfdeprecations, as well as other cultural rites and spiritual rituals, have provided examples of
self-injurious behaviors throughout religious history.
While self-injury has occurred publicly or in secret throughout history, there is a recent
contagion of self-injury among youth. A study by White Kress et al. (2006) found that
nearly 13% of American youth surveyed reported personally engaging in self-injurious
behaviors. The United Kingdom has one of the highest rates of self-injury in Europe. A
reported 140,000 cases in 1996 were reported by accident and emergency departments, and
those numbers have increased significantly over the past decade (Tillotson, 2008, p. 29).
However, the true rate is much higher due to the number of individuals who do not report
their injuries.
There are several cultural forces within Western society today that contribute to this
contagion. One factor is our culture’s emphasis on a quick fix, and immediate gratification.
Addictions are becoming an easy solution for many who want to find relief and escape
Self-Injury 9
from a society that seems out of control. Another social factor that has validated the
popularity of self injury is the influence of rock groups and pop singers, such as the Indigo
Girls, Richey Edwards, Jessicka Fodera, Courtney Love, Marilyn Manson, and Sid Vicious
(aka John Simon Ritchie). They have validated self-injury through their lyrics and while
actively slashing themselves during performances, modeling self-injury to adoring fans.
Two girls attended a Marilyn Manson concert, who had carved his name on their chests, the
blood from their wounds dripping down their tank tops (Gabrielle, 1999). Other celebrities
like Johnny Depp, Colin Farrell, and Kelly Holmes have disclosed problems with selfinjury. The disclosure of Princess Diana’s struggle with self-injury cast an almost elite,
although tragic, focus on this coping behavior.
Another major force in this contagion is the increasing breakdown of the family,
resulting in family life that is chaotic, abusive and/or negligent. Children grow up isolated
from parental attention as they are left to themselves with video games and computers.
Also, parents are increasingly making unrealistic demands of their children for athletic,
artistic, or academic achievement to satisfy their own egos, which often starts during preschool years.
Today’s Western culture sees the evidence of tattooing and body rings as a means of
identification and individuation. While this can be seen as a means of self-infliction it is
differentiated from self-injury as it is related to both purpose and means. If the purpose is to
self- inflict pain for the purpose of coping with overwhelming negative effect, then it would
be considered self-injury. If the purpose is to endure the pain for the purpose of altering
appearance through tattoos, body rings, or surgery by another, then it would not be
considered self-injury (Alderman, 1997, p.12).
Self-Injury 10
Despite the centuries of self-mutilating behaviors that have occurred throughout
cultures, the medical community has only recently taken a serious look into self-injury. In
the 1960s, a new round of professional interest was generated by what seemed to be a
sudden influx of cases of cutters. Harold Graff and Richard Mallin (1967), authors of one
of the best early studies on cutters while working at the Philadelphia Psychiatric Hospital,
began seeing so many “wrist-slashers” that they dubbed these “the new chronic patients in
mental hospitals, replacing the schizophrenics.” They were perceptive to recognize that
this chronic cutting was very different than the suicidal wrist slashing they had seen in
suicide attempts. Favazza (1996) describes the events that initially interested him in the
study of self-mutilation:
“In 1980, a resident psychiatrist at my medical school asked me to discuss a case
at a teaching conference. The patient was a young woman who had repeatedly
slashed her body with razor blades since early adolescence. Back then, conventional
wisdom held that self-mutilation was some sort of muted suicidal behavior.
However, upon discovering that the patient was quite intelligent, I wondered why
she hadn’t committed suicide since she surely knew how to do so. Something
wasn’t right.
“By chance I came across an intriguing book about a group of mystical Islamic
healers in Morocco. These healers work themselves into a ritual frenzy and slash
open their heads. Sick persons attending the ceremony dip bits of bread and sugar
cubes in the healer’s blood and eat them. For this group, the blood of the healer is
potent medicine. I had always associated self-mutilation with pathology, yet here
was a situation in which self-mutilation was a positive act performed to promote
Self-Injury 11
recovery from illness. Was it possible that the young woman who cut herself was,
like the Moroccans, trying to heal herself? It got me thinking about self-mutilation.
The more I thought about it the greater my curiosity grew until I finally became
determined to make sense of the seemingly senseless behavior known as selfmutilation.” (Strong, 1998, p. ix).
Diagnosis or what?
This syndrome can last for decades, although the normal course is ten to fifteen years.
Other impulsive, coping behaviors such as eating disorders, alcohol and substance abuse,
and kleptomania can be co-morbid or interspersed with self-injury. However, experts
cannot agree on whether self-injury itself is a symptom, or feature of a diagnosis, or a
diagnosis in its own right. The DSM IV TR does not list self-injury as a recognized
disorder, which has provided much discussion and debate among those treating this
problem. Levenkron (1998) says that “the failure of the Diagnostic and Statistical Manual
to consider a severe, physically endangering, and sometimes life-threatening psychological
behavior as a disorder means that clinical efforts to understand the problem are in danger of
remaining on the back burner.” (p.25)
Self-injury is cited in the DSM IV TR as a secondary feature of a primary disorder
such as borderline personality disorder, anorexia nervosa and bulimia nervosa, extreme
anxiety coupled with depression, and episodes of psychotic behaviors. In this feature stage
within a primary diagnosis, the self-injury is one means of dealing with emotional pain and
psychological confusion. If treatment starts at this feature level, self-injury can more easily
be stopped. However, when a self-injuring behavior begins as one of many symptoms and
becomes promoted to most often used, to the point where all other symptoms are used less,
Self-Injury 12
or with less intensity, then that person has developed a full blown diagnosis of selfmutilation (Levenkron, 1998, p.73).
At the feature stage, the patient uses self-injury in conjunction with other
personality defense mechanisms such as rage, frequent dissociation, amnesia, and intense
feelings of self-hatred, or fear of personality disintegration. During this stage, self-injury
reinforces relief through tactile and visual stimulus experience; the shock of pain through
cutting, scraping or burning the skin, and the sight of their own blood flowing. From that
stage when self-injury relieves overwhelming emotions, the progression slips downward to
where the individual will self-injure when she only anticipates or suspects dreaded feelings
will arise. As this continues, the spiral ends in compulsive self-injury and by- passes the
previous thought processes. This progression from feature to a diagnosis is gradual and the
severity of the problem depends on the duration that the individual has used his/her
maladaptive behaviors. The more time that was entrenched in self-injury, the greater the
dependence on it.
When an individual has learned adaptive or maladaptive behaviors, the process
becomes automatic and that skill is then usually challenged to try more difficult forms of it.
In a maladaptive form which has been developed into a disorder, that individual is more
likely to push the self-destructive behavior further. This increased damage is translated to
the brain as normal or usual as it occurs slowly over a period of time. For the self-injurer,
the mind will apply a set of rationales to deepen the disordered behavior, such as: How
much pain can I take? How much disfigurement of my skin can I tolerate? How much
bleeding can I stand? The rational is that more is better. The mind adjusts to the existing
Self-Injury 13
level of behavior and seeks to increase intensity to maintain the satisfaction of relief that
was once new.
According to a study by Marchetto (2006), self-injury treated in emergency rooms were
given a primary diagnosis of Borderline Personality Disorder most of the time. Marchetto
explains that “a clearly discernable diagnostic criterion as skin-cutting might significantly
influence decisions by clinicians to assign the BPD diagnosis without necessarily satisfying
the minimum required number of DSM criteria.” (p. 454).
Reasons behind self-injury
Regardless, of the pathos and suspicion that surrounds self-injury, it is agreed that it is a
strangely effective coping mechanism for dealing with emotional pain. For most persons,
the question of why a person would inflict injury to himself on purpose is puzzling. It was
this very puzzlement that led Favazza (1996) to spend his career researching the issue:
“The short answer to the question ’why do patients deliberately harm themselves’
is that it provides temporary relief from a host of painful symptoms such as anxiety,
depersonalization, and desperation. The long answer is that it also touches upon the
very profound human experiences of salvation, healing, and orderliness. Selfmutilation is a morbid form of self-help. In the hands of special individuals who are
able to control the behavior, it provides some benefits. However, the training,
discipline, and courage needed to attain such positive results are not my cup of tea nor
would it appeal to most people. Self-mutilation is nothing to trifle with. For
individuals who cannot control the behavior, it provides short-term relief but at a great
cost.” (p. xix).
Self-Injury 14
Marilee Strong (1998) answers the question by saying that “for cutters, it is a strangely
effective coping method for dealing with an inner pain so overwhelming it must be brought
to the surface. If they are comforted by pain, it is generally because it is all they have
known.” ( p. xvii). Levenkron (1998) answers by explaining that by injuring herself, the
cutter attempts to redress the pain she felt as a child, but in so doing, she never
accomplishes a closure to the feelings of hurt or neglect ( p. 44). Scott Lines, chief
psychologist for the Psychological Trauma Center in San Francisco, believes that cutting is
as much about binding as it is about rending. “We all feel good when a wound heals, but
cutters need that feeling. It gives them the illusion that they are healing, that their skin and
psyche can hold themselves.” (Strong, 1998, p. 37).
Reactions from others
Reactions from others toward self-injury usually provide no comfort to the
injured one. That an individual could, with foresight and intent, repeatedly cause
damage to his/her body is unimaginable to everyone but the self-injurer. This
creates a reaction from others that range from fear and anger to horror and disgust,
and the questions that linger in the silent shame of this behavior are, for the most
part, unasked. The puzzled observer is fearful of the answer and assumes that
suicide is the reason. However, the dynamics of this bizarre act of self-injury is in
itself a coping mechanism that is reacting to a will to live, not a will to die. This
reaction of revulsion and disgust from others drives a deeper wedge into the
shame of the self-injurer so that secrecy shrouds the subject for both the selfinjurer and observer, a subject too taboo to broach, and the last secret a person is
Self-Injury 15
willing to disclose. Therefore, clients can be in therapy for years before their selfinjury is acknowledged.
This is due, in part, to unwillingness or ignorance of therapists toward selfinjury. One woman who injured herself through scratching and picking
mentioned these behaviors to her therapist, who then dismissed it as nothing. This
was an easy evasion because her therapist was reluctant to hear about self
scratching and blood. It was only when the woman lost over four units of blood,
and alarmed the doctors who thought she must be bleeding internally, did the
therapist realize that picking and scratching were major issues (Hyman, 1999, p.
25-26).
Levenkron (1998) treated severe anorexics in the 1970s and compares that to self-injury
today:
“I discovered that the staff was very angry at them…The anorexics were
deliberately causing themselves harm and wasting valuable hospital beds that
people with serious and involuntary medical problems could be
using…Professionals in mental health, patients’ families, and the general
public all harbor a very similar attitude toward the self-mutilator as their
counterparts had to the emaciated anorexic about twenty years ago…In the
case of the eating disorders, anorexia and bulimia, a younger group of mental
health professionals emerged, determined to understand the illness, their
causes, and the specifics of the behaviors involved. This population of
clinicians learned how to desensitize themselves to the unusual and
unattractive behaviors of their patients, and to equally unattractive physical
Self-Injury 16
results of these behaviors. Twenty years later, we are at that same sort of
pivotal point in clinical history, where the same changes must happen in the
mental health field for the self-mutilating patient.” (p. 60)
Judith Reece (2008), a senior nursing lecturer at the University of Derby, said that
many self-injuring patients feel they are seen as timewasters or attention seekers when
treated by nursing staff. She was shocked by patient testimonies obtained for her study on
self-injury. She reported that patients felt that nurses were only interested in treating the
wounds without going deeper into why the patient had self-injured (p.11). Another study
conducted by Fish and Duperouzel (2008) revealed that some nursing staff used guilt as
pressure on patients not to self-injure, telling them their job was on the line if they
continued to cut (p. 14).
While some staff may doubt that they can help people who self-injure, their actions
can have an enormous impact. Palmer (2008) addresses healthcare staff members who treat
self-injuring patients: “People who self-harm consistently say that, although the quality of
the clinical treatment they receive is important, staff attitudes to them are crucial.
Dismissive or judgmental responses…can deepen their trauma, reinforce their sense of
guilt or lower their self-esteem; non-judgmental responses, on the other hand, can aid them
in their recovery processes.” (p. 17).
Relatives of self-abusers often struggle with guilt of responsibility that their past
actions or relationship would have caused this frightening behavior. This sometimes
benefits the troubled family relationships as they work together through treatment to
identify and correct damaging family dynamics. Other families reject the problem and
blame the cutter or an isolated family member for causing the problem and the emotions
Self-Injury 17
that led to it. Families feel frustration, confusion, and worry that, from now on, every word
or action could prompt another cutting episode, or they are too worried about how the selfinjurer’s problem will reflect on them. Many fear that it could lead to suicide. Levenkron
(1998) summarizes by saying that for healing to take place, it is critical that the reactions of
family, friends, clinicians, and the general public see the self-injurer for what she is—a
person in desperate need of help and human contact (p. 61).
Profile of the self-injurer
The question could be asked if there are any characteristics that could profile this
client population. Conterio and Lader, directors of S.A.F.E. (Self Abuse Finally Ends)
Alternatives, the only program in the country that specializes exclusively in the treatment
of self abuse, have treated more self-injurers than anyone else in the country. In their book,
Bodily Harm (1998), the authors state that although self-injury knows no geographic,
cultural, or class boundaries, the majority of those they treat form a composite of the
typical self-injurer.
“The ‘typical’ self injurer would be a white, middle-class woman of above average
intelligence who began cutting herself in adolescence. She has low self-esteem and
may suffer from bouts of depression. She has trouble relating to people and
forming intimate relationships. Despite her smarts and education, she has an
extremely hard time articulating her thoughts and feelings and a seemingly
insatiable need for love and acceptance, she experiences difficulties in various areas
of impulse control, and tend toward rigid, dichotomous thinking, including
perfectionism. Because she did not internalize positive nurturing skills from her
Self-Injury 18
parents, she does not take very good care of herself and feels she is too bad a person
to ‘deserve’ comforts or luxuries.” (Conterio & Lader, 1998, p. 138-140).
Other features are noted by a study done by Favazza and Conterio in which they
conclude that more than half of their subjects were troubled by sexual feelings and a large
number hated part of their anatomy. Seventy-one percent considered their own selfmutilating behavior to be an addiction. (Favazza, A. R., & Conterio, K., 1988, p. 26).
Levenkron (1998) describes the self-injurer as someone who experiences herself as
powerless. She can be quite outgoing, but no matter how confident she may seem in public,
she nevertheless feels alone and different, an outsider. She often is plagued by a fear of
punishment, usually from a parent, for being deficient and a disappointment in a way that
was either specifically defined for her, or one that was unspoken but understood. She feels
she has no one to depend upon or to trust with her emotions, which produces fearfulness
most of the time. She is often apologetic even when she has done nothing to apologize for.
He states that he consistently encountered two characteristics in all self-injurers: a feeling
of mental disintegration, or inability to think, and a rage that cannot be expressed or even
consciously perceived toward a powerful figure in their life, usually a parent (p. 44).
As one looks at the common features that represent the self-injurer, questions arise.
Why are women the most typical self-abuser? Conterio and Lader state that in the thirteen
years of treating self-abusers through their S.A.F.E. program they have seen only about
twenty males compared to thousands of women. Because of the prevalence of women
typifying self-abuse, virtually all references to the self-abuser in books, articles, and other
references use the feminine pronoun.
Self-Injury 19
They claim that women are more likely to seek out treatment; men are more likely
to turn their emotions outward in aggressive behaviors toward others, ending up in prison
rather than psychiatric hospitals. Women tend to turn their anger inward resulting in
depression and self-blame; men are more likely to use drugs and alcohol to cope with
unwanted thoughts and emotions (Conterio & Lader, 1998, p. 23). However, when violent
men are prevented from violence because of being confined in hospitals or prison, they
become depressed, self-injurious, and suicidal. In other words, they tend to feel and
behave like abused women (Hyman, 1999, p. 62).
Why is the self-abuser usually Caucasian? It would be safe to say that women of
non-European origin also self-abuse themselves, but Jane Wegscheider Hyman (1999)
conducted a research project in which she says that only Caucasian Americans of European
descent responded to her search. It must be noted here that the Caucasian description fits
the typical profile, but is certainly not inclusive to that race. Such factors could just as well
play into the fact that the typical self-abuser comes from middle class, is educated, and a
high achiever. It is probably more from that population that treatment in expensive
programs, hospitals, and therapists would be a normal means of turning for help.
However, more recent studies are revealing a high rate of self-injury among Asian
women. Richardson (2004) reports that Asian women are believed to be six times more
likely to engage in self-injury than other female groups. A recent literature review by
Husain et al (2006) on Asian women who self-injure reveal problems with racial
stereotyping and discrimination, isolation, marital and family problems, domestic abuse,
hard-to-meet expectations and the concept of “izzat”, or family honor. Another study by
Muralidharan (2005) shows that some Asian women may regard self-injury as an
Self-Injury 20
acceptable way to deal with distress because it allows them to express their anguish and to
keep problems within the family.
Why would the onset of cutting start in adolescence? Adolescence is a time of
change and of transition. It is hard enough for even a well-adjusted teenager, but for the
one who has lived already a life full of alienation and shame these years can become
unbearable. It is a stage of life when most come to terms with their changing body and
sexuality and to transition into the demands and responsibilities of adulthood. There is a
sense of loss of control over the body and its functions as menstruation and other physical
changes of puberty take over. Childhood illnesses or sexual abuse can create hatred toward
the body.
Conterio and Lader (1998) cites a study by Barent W. Walsh and Paul M. Rosen on
self-abuse during adolescence which finds that the single most important predicator of
future self-abusive behavior was what they termed “body alienation”. This is the
experience of feeling hatred, revulsion, and disgust for the body, often times accompanied
by a desire to be “cut off” from the bodily and sexual experience. Their study goes on to
say that chronically ill and abused children often view their bodies as damaged, defective,
dirty and disgusting—traitorous and beyond their control (p. 101). For those who have
experienced sexual abuse, the development of primary and secondary sex characteristics
may intensify feelings of shame, guilt, and sexual abhorrence.
Strong (1998) quotes Mark Schwartz as he further defines this dilemma. “There is
something about that developmental phase, the biochemical changes that are occurring, that
starts to activate all the structural damage in the brain that came from earlier trauma. It is
at this age that abused children start exhibiting a number of acting out and acting in
Self-Injury 21
behaviors from cutting to eating disorders to outward aggression.” (p. 54). He attributes
the rise in impulsive behaviors during this stage as not only hormonal, but a combination of
a complex interaction with brain chemistry, hormones, and the social environment.
And navigating the social environment, itself, is a challenge for any adolescent who
is beginning to leave the security (if it was, indeed, secure) of the nuclear family and find
one’s own place in “the group” of peers. For the cutter, this only intensifies the already
isolation, rejection, and loneliness that is deep-seated within the self-concept.
School can be a possible contributing factor to self-injury through the pressures of
exams, and bullying by peers. For both male and female adolescence, having an awareness
of peers who had engaged in self-injury was a significant factor associated with
encouraging their own self-injury (Rodham et al., 2005, p. 38). Davies (2008) reported a
study of secondary school students who said that communication, such as talking, listening
and advice-giving, was a way to prevent self-injury. Adolescences were three times more
likely to suggest using social networks such as family and friends in self-injury prevention
than in going to professionals. Thousands of websites on self-injury now guide and help
young people.
Strong quotes the results of Walsh and Rosen’s study that found that the adolescents
they studied chose self-mutilation because it addressed all their psychological needs. “It
discharged tension in a concrete, abrupt, dramatic, impulsive fashion. It was directed
against their bodies in a deliberate, self-defacing, self-disfiguring way, derived from their
sense of bodily alienation…the act expressed their cumulative despair and rage at having
experienced profound losses in the past and at experiencing additional painful losses in the
Self-Injury 22
present…In fact, a more striking way of communicating inner discomfort is difficult to
imagine.” (Strong, 1998, p. 63)
Family dynamics
Those who self-abuse themselves experienced abuse during their childhood, usually
at the hands of their parents or other authority figure they looked to for security and
protection. Pain was therefore confused with love, or at least perverted attention. Strong
(1998) quotes Psychologist David Frankel who summarizes the family situation of the
abused child: “Usually kids internalize a sense of a parent they can call up from inside
themselves for comfort in times of distress. These kids don’t have that—or what they call
up is a mom who wishes they were dead and a dad who wants to sleep with them.” (p. 42).
Specific features in the family of origin that are common among those that self-injure have
been compiled by experts working in the field of self-injury: Often there is a history of
childhood illness or severe illness or disability in a family member, taking on too much
responsibility for what happens in relationships (excessive self-blame) or adopting a
caretaking role even when it is unhealthy for them to do so. They suffered great instability
during their childhood and in family relationships, which often included sexual and
physical abuse, and placement outside the home. In most cases, the fathers were sexually
seductive toward their daughters, were distant and hypercritical, and usually had other
problems such as alcoholism. The mothers were most often cold, rejecting, punitive, and
judgmental. The vast majority said they grew up in families full of anger and double
messages in which they were told to always be strong and prevented from expressing their
feelings. (Graff & Mallin,1967, pp. 36-42;Grunebaum & Klerman, American Journal of
Psychiatry, 1967/ Strong, 1998, p.32-33; Levenkron, 1998, p.44; Conterio & Lader, 1998,
Self-Injury 23
p.140; Briere & Gil, 1998, p. 610; Favazza, & Conterio, 1988. Community Mental Health
Journal 24: 22-30/Strong, 1998, p. 26)
Parental neglect and emotional abuse
.
Conterio and Lader (1998) have worked with thousands of adolescents struggling
with self-abuse, and recognize that a major contributing factor is the effect of parental
abuse. They explain the damage that under-parenting and over-parenting can have, and its
contribution toward self-abusive behaviors in children. They explain that during
adolescence the under-parented child often comes across as pseudo-mature, wise beyond
her years because of the inappropriate duties foisted on her. Deprived of parental attention
and energy, she learned early to fend for herself, not to expect care or concern from adults.
They develop the persona of the strong one in the family, believing that they are not
allowed to express any need or vulnerability. Underneath the surface are all the unmet
longings for nurturing and parenting, along with sorrow and rage. This teen may harbor a
lot of resentment for the loss of her childhood and cannot celebrate adult roles and
responsibilities as achievements because they remind her of her inconsolable losses.
Instead she fights to keep her memories and feelings at bay, often in self destructive ways.
The over-parented child struggles with too little separation and too few boundaries between
herself and the adults who care for her. Parents would not let them separate. They were
rigidly perfectionist and controlling. Children of smothering parents may find in
adolescence that their growing urges for autonomy seem dangerous and destructive to the
people they love. They must establish clandestine boundaries around their thoughts,
feelings, and experiences, and sometimes the guilt they feel leads them to carry out secret
agendas involving self-punishment. (Conterio & Lader, 1998, p. 99-100)
Self-Injury 24
While cutters are not generally diagnosed with narcissistic personality disorder,
most would be found within a family system labeled by researchers and therapists from
Rhode Island Psychological Center as “narcissistic family”. Authors Stephanie DonaldsonPressman and Robert Pressman in their book, The Narcissistic Family: Diagnosis and
Treatment, observe that within this population were found common behavioral traits: a
chronic need to please; an inability to identify feelings, wants, and needs; and a need for
constant validation. This group who grew up in narcissistic families, felt that the bad
things that happened to them were well deserved, while the good things that happened were
probably mistakes or accidents. They had difficulty being assertive, privately feeling a
perverse sense of rage that they feared might surface. Their study compared children from
alcoholic and abusive homes with those children without those experiences in their parents.
They concluded that “regardless of the presence or absence of identifiable abuse, we found
one pervasive trait present in all of these families: the needs of the parent system took
precedence over the needs of the children.” (Pressman & Pressman, 1994, p. 3-4). It is
clear to see that these traits run parallel to those we have observed in self-injurers. Tillotson
(2008) reiterates this when she points out that self-harm may highlight a need for care, or
provide an opportunity to offer self-care in an environment where care needs are not met.
(p. 30).
The narcissistic family model follows the relationship of Narcissus and Echo. In
the tale, Echo has lost the ability to form her own words and can only repeat the words of
others. She falls in love with Narcissus and follows him, hoping that he will say some kind
or loving word to her so that she can repeat it back to him. When Narcissus says “I love
you” to his own reflection, she is finally free to say it to him; however, he is so engrossed
Self-Injury 25
in himself, that he is unable to hear it. In the end, they both die, each with their own love
and needs unattended.
Narcissus represents the parent system which is primarily set in getting its own
needs met. Echo is the child, trying to gain approval by becoming a reactive reflection of
her parents’ needs and therefore never developing the ability to find her own “voice” to be
able to recognize her own wants and needs. Within this family system, the locus for
meeting emotional needs become reversed. A healthy family system provides for the
emotional needs and development of the children; however, in a narcissistic family system,
it becomes the responsibility of the children to meet the emotional needs of the parents.
When the mirror reflects the inability to meet the parents’ needs, this reflection almost
always is interpreted by the child as inadequacy and failure on her part. The focus is
skewed, and the child grows up feeling defective, wrong, and to blame.
Many, if not most, of those that self-injure come from overtly narcissistic families
where the parent system is so overwhelmingly self-involved that it may have difficulty
meeting even lower-level needs such as food, clothing, shelter, and safety. In therapy,
adults raised in overtly narcissistic families may have very few childhood memories, is
filled with unacknowledged anger, feels hollow, inadequate and defective, and suffers from
periodic anxiety and depression. These are all common characteristics found in those that
self-injure.
This emotional chaos occurs when there is no parental accessibility to their
children’s emotional needs such as a loss o have conversations about feelings, and when
the display of any emotion by the child is not tolerated by the parent and any show of anger
from the child (not the parent) is forbidden. The child, then, learns to mask and hide her
Self-Injury 26
own feelings and instead to pretend to feel things she does not feel, and finds ways, like
self-injury, to keep from experiencing her real feelings.
Strong (1998) reflects this dilemma, also, when she observes that cutters from
homes where parents enforced strict and rigid codes of morality or behavior felt that they
were not allowed to find a place for their feelings, since they were never permitted to feel
sad, angry, vulnerable, or otherwise childlike. They were expected to be adult in thought
and behavior, amid threats and absence of empathy. A lot of self-injurers tell of their
parents giving the message, “Stop crying or I’ll give you something to cry about.” (p. 77).
This is illustrated in the life of Liz, who began cutting herself when she was thirteen
following an argument with her mother: “I would get so mad, and I wasn’t allowed to
express it. The pressure inside me would build up, and in order to release it, I would cut
my wrist and forearm…and I would get an immediate release.” (Strong, 1998, p. 82)
Research bears this point out. A research study conducted by Carroll, Schaffer,
Spensley and Abramowitz (1980) reported that 13 (out of 14) of the self-mutilating subjects
and 2 (out of 14) of the control group stated that expressions of anger were not allowed in
their families. More self-mutilating patients than control members reported strong
restriction of anger in their families (p<.005). These researchers theorized in their
conclusion that parental hostility fosters development of a punitive superego that, under
stress, overwhelms ego defenses and triggers self-mutilation.
These covert, damaging styles of parenting (under-parenting, over-parenting, and
narcissistic) can often be seen in families that appear normal with successful, high
achieving parents. These parents often have good intentions, and are not aware of the
Self-Injury 27
emotional damage that is occurring in the child. However, the second family atmosphere
that is most often seen in self-injurers is overt physical and sexual abuse.
Childhood sexual and physical abuse
Research has defined some of the major factors in what propels self-injuring
behaviors, and one significant variable was childhood sexual abuse. A paper published by
Zlotnick, Shea, Pearlstein, Simpson, Costello, and Begin (1996) concluded that several
studies have found that the rate of sexual abuse is significantly higher among selfmutilators versus non-mutilators. ( p.13). Another study that confirms this was done
comparing childhood histories of both physical and sexual abuse, as well as repeated
surgery drawn from much clinical literature about self-injurious behavior. The study
concluded that of the three types of trauma, sexual abuse was most strongly related to all
forms of self-destructive behavior. (van der Kolk, B.A., Perry, & Herman 1991, pp.1665,
1667)
Within this environment, maternal abuse is cited in many families of those that selfabuse and indicates a serious failure of nurturing. Pettigrew and Burcham (1997) found
that maternal abuse indicated the worst family environment, and in every case, maternal
abuse occurred where all extremes of abuse were present. Despite the fact that many were
victims of sexual abuse by fathers or male relatives, abused children often identify with the
aggressive parent because in their minds it’s better than identifying with the weak and
powerless mother who did nothing to protect them, who either tacitly encouraged the abuse
or failed to recognize and stop it (Strong, 1998, p.71). Hyman gives an example of this in
her interview with Mary whose father repeatedly raped her and, for several years starting at
age 5, would sell her to a friend for use in a lucrative child pornography and prostitution
Self-Injury 28
business. Mary was subjected to unspeakable sexual acts and physical torture before a
camera. As an adult, she asked her mother if she hadn’t thought it strange that Mary would
be gone for weeks at a time and all summer long during her childhood. Her mother replied,
“I figured it was better not to ask.” (p. 15).
Conterio and Lader (1998) say that patients whose families intruded on their bodies,
through physical abuse or smothering, often describe self-injury as a way of differentiating
themselves from others. Most often the person from whom they seek to separate is their
mother. The message is: “I can do something you can’t—I’m stronger, tougher, and can
tolerate more pain than you.” (p. 78)
When abuse is detected by the un-participating parent, there can be reactions of
denial or minimizing what has occurred, or even anger and punitive retaliation. The abuser
may be removed from the family or sent to prison. Sometimes there is resentment toward
the child for breaking up the family, and/or for stealing the affections of the partner. This
adds to the child’s sense of guilt, shame and responsibility. Even when a parent steps in to
comfort and protect the child after the abuse is discovered, the family system is irrevocably
disrupted.
Sexual abuse shatters a child’s capacity for trust and skews intimacy. She has no
frame of reference in forming healthy relationships since the very ones who should have
made her feel secure and protected, violated that trust. This creates an internalized sense of
utter powerlessness and helplessness. The only way to survive an ongoing state of
helplessness is to achieve some illusion of power and control through self-blame, selfinjury and psychic defenses (Strong, 1998, pp. 67-68).
Self-Injury 29
Abused children learn at a very young age that they exist only to give pleasure to others.
Again a narcissistic family system is recognized as these children are not respected as
individuals, but simply tools of some other more powerful person’s needs. Strong (1998)
says:
“Recurrent sexual trauma, especially at the hands of a parent or other trusted
loved one, is emotional terrorism. The overwhelming fear, pain, and excitement it
engenders can cause serious and lasting damage to the child’s emotional,
neurological, and physiological development. So they shut down their own
emotions, needs, and desires. They bury their feelings so deeply that to even
imagine letting them out feels completely overwhelming, sometimes frightening as
the inner rage feels like it could kill. The child’s immature brain and central nervous
system simply cannot process such repeated over stimulation, so the body’s whole
emotional-response system gets thrown out of whack—which leads to problems with
impulse control and self-mutilation.” (p. 65).
What family factors help determine whether a victim of child abuse will eventually turn
to self-injury? A study by researchers (Romans et al., 1995) was conducted on 22 subjects
who had experienced sexual abuse as children. Their conclusion was that those most likely
to later self-injure had experienced sexual abuse by a father or step-father involving
penetration more than 10 times and with use of force (p. 1340).
One of the most tragic legacies of child abuse is how some learn to equate pain with
love. As bad as the abuse was, it provided the only contact and attention the child received.
Some incest survivors will do anything to maintain a connection, however false, with the
abusing parent. Pain and self-punishment, comforting in its familiarity, maintains the
Self-Injury 30
psychic relationship. Through cutting they can recreate the childhood “attachment”, but
control it by meting it out in safe, measured doses. In that way, they can play the parts of
both abuser and victim and then assume the loving, protective caretaker by bandaging their
wounds and watching them heal. They find comfort in knowing that no one can hurt them
as much as they can hurt themselves. (Strong, 1998, p 71).
The act of self-injury
According to research, the emotional state and sequence of events are uniform for
almost all cutters prior to and after the episode. Cutting bouts are generally precipitated by
a real or perceived experience of loss or abandonment. Feelings provoked by this sense of
loss or abandonment—tension, anger, rage, fear, anxiety, panic—build to an overpowering
crescendo. In response to emotional overload, many self –injurers slip into a dissociated
state. Despite the extreme level of anxiety and agitation, and to the degree that
consciousness and memory are splintered at that moment of cutting, the extent of injury is
often strictly controlled and carefully executed. Either the pain of cutting or the sight and
sensation of flowing blood then snaps her back into normal consciousness and she
experiences a heighten state of feeling “alive”. After cutting, she feels calm, reintegrated,
and “real again”, and will often fall into restful sleep. (Strong, 1998, p.55)
Conterio & Lader describe it this way:
“Having acquired no truly adaptive, internal abilities to soothe herself or control
distress, the self-injurer comes to rely on action—not thoughts, fantasies, or
words—to gain relief from any uncomfortable feelings or thoughts…her emotions
reach a fever pitch; she feels she is going to explode if she does not release
tension; she barely feels her body is connected to herself. The razor pierces the
Self-Injury 31
skin and the blood flows out, carrying with it all the poison, rage, and self-loathing
that the sufferer feels inside. The sight of the gash and the numb sensation that
surrounds it bring comfort and relief; she feels whole again, grounded in reality.”
(Conterio & Lader, 1998, p. 20).
Fiona, who cut herself daily from ages eighteen to twenty-three described it like a
pot boiling on the stove, a slow simmer of anger building to a bubbling-hot rage. “By that
time I’d be pacing, pissed off, walking in circles, or writing furiously. Then when I
couldn’t stand it anymore, I’d just grab a razor and cut. A lot of times I would do four or
five slashes in a split second because I was so angry. Afterwards there was just sheer
relief, like being held under water for a long time and then finally able to breathe.”
(Strong, 1998, p. 133)
Hyman records the thoughts and emotions of Edith, a 51 year old physical therapist
with a postgraduate degree. She has been scratching and picking at herself since she was a
toddler, about the same time her father started to sexually abuse her, and her mother started
punishing her for the abuse. When anxiety or other emotions set off the picking and
scratching, the intensity of her self-injury rises. She can hear herself inside saying, “I don’t
care what anybody thinks, I’m going to do this; I need to do this; I have to do this.” When
Hyman asked her to describe the anxiety she said, “Are you afraid of anything? Snakes,
spiders, anything? I mean, just imagine yourself confronted with your worst fear. And
that’s what it feels like. But it doesn’t have a name. [I can’t say] ‘I’m anxious about this,
I’m anxious about that.’ It’s just anxiety, unattached to anything specific. It feels like a
balloon blowing up inside of me, and it pushes, and pushes, and pushes, and pushes—until
it becomes almost unbearable.” Edith speaks of blood loss as taking care of anxiety, and
Self-Injury 32
high anxiety can require more blood than usual. So great is her need for emotional release
that Edith sometimes keeps the same wound open for a year or longer and has to use
sanitary pads to soak up the blood (Hyman, 1999, pp. 24-25).
A single cutting episode can last half a minute or half a day of intermittent cutting.
A woman can cut to return to her body and to leave her body; she can cut when she is
angry and when she feels nothing; she can cut to punish herself and to avoid suicide; she
can begin cutting herself around puberty, stop at eighteen, and start again at forty-five; she
can cut for thirty years, then stop in her forties or fifties. (Hyman, 1999, p. 40)
But regardless of the variance, the one commonality is blood. The sight and feel of
blood flowing gives a release, no matter what the initial emotion or trigger. It provides a
vehicle that represents blood letting, a release of internal poisons, of exploding emotions,
and often provides a sense of reality. One cutter said, “I enjoy watching my blood
flow…Sometimes I would get worried that it wasn’t real because you don’t expect blood to
be sticky. I would play around with it and then start to worry that it wasn’t real, that I
wasn’t real again. Then I would have to cut more to make sure that it was actually
blood…that it wasn’t fake or it wasn’t just red-colored water. I worried that maybe I
wasn’t real, so I decided to use whatever methods I had to make sure that I was real.”
(Hyman, 1998, p. 162)
Some cutters need to see their blood flow out of their body in a sense of purging,
and self-punishment. One cutter states, “It isn’t the cut necessarily that is important to
me, it is seeing my blood…I guess [bleeding] is like purging to me, it’s very cleansing in
some sort of way…I think part of it is a self-punishment thing, and if I’m bleeding, and
Self-Injury 33
bleeding a lot, then the injury was severe enough so it means that I punished myself.”
(Hyman, 1998, p. 68).
Favazza (1996) notes that blood customs are among the oldest recorded in
formation of brotherhoods, religious significance, and in the healing process and has
awesome symbolic and physiologic powers. (p. 7). He says that self-cutters may feel relief
because they have eliminated some “bad blood”, thus symbolically decreasing the tension
arising from impaired relationships (pp. 272-273). Kafka (1969) describes a patient who
“unzips her skin” through cutting so she can feel the flow of blood like a warm bath. He
referred to this as a mother blanket because the flow of blood symbolized a potential
security blanket capable of giving warmth and comforting envelopment linked to an
internalized mother (pp. 207-12).
Dissociation.
Many, if not most, of those that self-injure will not experience dissociation during
their afflicting episodes; however, some knowledge of dissociation is important in
understanding some aspects of self-injury. As mentioned above, the cruel incidences of
sexual abuse can result in a patient spacing out with dissociation. As Hyman explains,
“Faced with unbearable events and emotions, a small child rarely kills herself. Instead, she
has to find other means of escaping situations in which she is helpless and overwhelmed.
Because of her youth and dependency, she cannot flee, and nothing that she can do will
alter her circumstances. When there is no other exit, the child’s consciousness can protect
itself by leaving her body, a process called dissociation.” (Hyman, 1999, p. 16).
Most of us experience some mild function of dissociation when we daydream or
while we perform some routine task, such as driving a familiar route. Hypnosis is an
Self-Injury 34
induced state of dissociation often used therapeutically for the purpose of relieving some
unresolved emotional or physical problem. But to those who have experienced abuse or
trauma, they will speak of dissociation as a sensation of floating above and looking down
on their bodies during the traumatic event. Especially for abused children who experience
overwhelming danger from which there is no physical escape, it is an ingenious bit of
mental gymnastics—mind and body separate and pain is anesthetized. If the abused child
cannot escape from danger, she can escape emotionally. It is a psychological defense
mechanism that keeps traumatic memories, sensations and feelings out of conscious
awareness (Strong, 1998, p. 38).
Mild dissociation can feel strange but is not unbearable. A severe form, though, is
painful with the person feeling physically and emotionally numb, empty, or dead.
One
feels unreal or “gone”, and is unable to distinguish oneself from other objects, and is
unaware of the existence of her body. Although this numbness serves to protect the person
from insufferable emotions, the feeling of separateness and deadness is terrifying, and
makes one feel that she is disintegrating internally. Hyman interviewed many cutters who
told her that the act of cutting never hurt at first, suggesting that they were severely
dissociating at the time. When they do feel pain, there is relief, as if the pain were a
reassurance that they are in their bodies and therefore real and alive (Hyman, 1998, pp. 1718).
When abuse is chronic and severe, the dissociative state can be prolonged until it
splits into a different identity, protecting the primary personality from the experiences and
memories that could not have survived psychologically. This condition is known as
Self-Injury 35
dissociative identity disorder, formerly known as multiple personality disorder. The most
severe cutting is most often associated with a child identity.
But dissociation, while once useful to escape the actual traumatic experience, exacts
a high psychological price when it becomes an automatic response to even minor stressors
reminiscent of past trauma, or painful or forbidden emotions such as anger. Chronically
dissociative people grow to feel inhuman, and cannot discern what is reality. They may
observe their actions without any sense of control over what they are observing, and,
sometimes, experience the feeling that their minds are slipping into freefall, shattering into
bits and pieces (Strong, 1998, pp. 39-40).
Scott Lines states that most people experience brief episodes of dissociation during
their lives but we are reasonably sure that we can hold ourselves together physically and
psychologically. “What makes cutters different,” he states, “is that they are people who
feel like they are falling apart when a series of events or triggers occur that threaten their
very being. Then they turn to the most effective thing they have discovered to avoid a
complete psychotic break, and pull the pieces back together again.” (Strong, 1998, p. 37)
Therapists Working with Self-Injury
The therapist who chooses to work with self-abusers will need to be willing to face
several challenges. Levenkron (1998) says that it is necessary to “become desensitized not
only to the results of the physical acts committed against the body, but to the fact that this
damage is self inflicted…it is this aspect that is the hardest for us to deal with.” (p.11). A
therapist needs to be desensitized toward the trauma of the self-injury act and resulting
injury, but not toward the self-injurer. A careful respect needs to be realized by the
therapist toward the client and an appreciation of the emotional trauma experienced by the
Self-Injury 36
client. A lack of this therapeutic quality by one which should care, can only deepen the
rejection of the client.
Steven Levenkron has specialized in working with anorexic and self-mutilating
clients for decades, and has written several books on these subjects. In his book, Cutting
(1998), he recounts, “Recently, a young woman of 24 was referred to me. At the initial
interview she reported, ‘The first two therapists I saw told me they couldn’t help me
because they were not familiar with self-mutilation’. ‘How did that make you feel about
yourself?’ I asked. ‘Like I was a freak—beyond their comprehension to understand—or
that maybe they were afraid of what was wrong with me. It also made me feel that I was
hopeless.’” (p. 61).
The characteristics for a therapist interested in working with this challenging and
fragile clientele have been suggested by therapists specializing in working with selfinjuring clients and by self-injurers themselves. These necessary attributes are a calm and
serene demeanor, not easily alarmed, and able to manage well in times of crisis,
empathetic, nurturing, open-minded, non-judgmental, confident, competent, and must have
a reasonable degree of availability. The most crucial ability necessary is the ability to
develop an enduring safe and trusting relationship with the client (Conterio & Lader, 1998;
Hyman, 1999; Levenkron, 1998; Strong, 1998, pp. 164).
Another important quality in a therapist is the capacity to genuinely care and to
persist patiently. Meredith, a cutter who cuts all over her body including her face,
describes this attribute in her therapist: “And I put her through so much—not on a
conscious level—but I constantly tested her to make sure she was safe, it took me about
two years before I could say I trusted her. And we just very recently began talking about
Self-Injury 37
the sexual abuse and my past…It’s taken me three years to get to the point where I feel
okay enough with her to be able to talk to her about some things. So, it’s been a long,
grueling process for the both of us.” (Hyman, 1999, p. 156)
Both Strong and Levenkron emphasize the need for the therapist to reparent the
client, to provide a secure attachment in a relationship which was not provided during
childhood. Strong (1998) reports of a self-abusing woman who, after nine years of work
with her therapist, made peace with her past through reparenting. “I had to be reparented
by my therapist.” she said, “I had to go through the pain all over again.” But this time,
Strong noted, she was not alone, but had a safe and dependable relationship to help guide
and support her through that journey and to process the emotions as they surfaced. By
internalizing the therapist’s ability to care for her, Strong adds, she learned to care for
herself (pp. 159).
Levenkron’s style of being direct and authoritative in a re-parenting stance, he
admits, sometimes puts him bordering on the overconfident. He justifies this by explaining
that it is better to make this error than to be so prudent and careful that (the therapist) looks
hesitant, and shaky. Since the typical self-injurer approaches therapy fearful and anxious,
without any ability to express herself with words, Levenkron finds that at the beginning,
the therapist must do much of the talking. He feels that if he asks too many questions, the
client will infer that he is needy and not knowledgeable, adding to the self-injurers
insecurities. He offers an example of his style in which he is very active in providing
answers rather than asking questions.
“You seem to have made quite a cut on your foot.”
She shrugs, looking embarrassed.
Self-Injury 38
“I’m going to tell you why you cut yourself.”
She looks surprised and relieved.
“When no one can reach you, even though you can reach and affect others,
you feel empty and unreal. Life feels unreal, hopeless, devoid of fun. You get
unhappy, and after a while, depressed, flat, blah, no ups, no downs, everything
starts to matter less and less. You begin to say to yourself, ‘Why bother?’”
“How could you know that about me? I never told anyone about my
feelings.”
“That’s not all I know about you,” I continue. “I know that when you feel
despairing and the ‘why bother’ takes over, that’s when you are ready to cut or
otherwise hurt yourself. At different times you may ‘choose’ to feel the pain or go
into a trance, become numb and ‘watch the cutting happen’—even though you’re
doing it, you feel like a spectator. It is at the moment that the ‘why bother’ goes
away.”
She shakes her head. “Everybody who comes in here asks me questions
that I don’t know the answers to. So I make them up. I make up some pretty good
ones, too….”
She is gesturing wildly with her hands to emphasize her point. I smile at
this emotionally lost thirteen-year-old.
“I guess there’s a lot about yourself that you don’t know. I think that you
are going to need someone to help you learn those things, and help you grow up.”
“Nobody can do that for someone else!”
“Oh yes they can. I can.”
Self-Injury 39
She looks worried. “But I’m the one who does that for other people. It
would be too much for you to try to do that for me!”
“Apparently, you are too much for yourself to fix or help. But that doesn’t
make you too much for me. I don’t even think that helping you will get me the
least bit tired.”
“I get everyone tired. And you’ll get tired of me, too.”
“I know you’re not used to leaning on anyone. But I think that a small part
of you is beginning to believe me—that maybe I have an answer to your secret
wish.”
Making a mock frown at me; “What secret wish?”
“The secret wish that someone could take care of you. That they would
take such complete care of you that it would be as if you were a baby to them, and
they would always be there to protect you and calm you down when you needed
it.”
Her eyes become watery but she flexes her face muscles to prevent the
tears from falling. I lean toward her and gently tell her to let her face muscles
relax. The tears begin to fall.
“I think that those tears mean you’re beginning to trust me.”
I take a tissue and wipe her face. “I’m going to keep these tears in this
tissue. They are precious tears; they mean that you can like yourself, and even
hope for the future.”
“Well, I don’t know about that,” she protests mildly.
“Well, I do.” . (Levenkron, 1998, pp. 177-178)
Self-Injury 40
In this example, we see the nurturance of a re-parenting relationship: a sense of
understanding, unconditional acceptance, a place of safety, protection, your tears (you) are
precious and worth keeping, I will not abandon you, I will be here for you, I can carry your
burden, I will support you, I have hope for you and confidence in your future, in your
ability to get through this. Though other therapists might not agree with this direct
approach, and regardless of the dialogue used, these comforting messages are important to
give continuously, in order to replace the destructive and hopeless messages the client has
ingrained.
In contrast to this method, Hyman (1999) found that self-injurers
emphasized the desire for a therapist to leave the client in control of therapy.
They defined this as meaning that the therapist invites the client to set the pace of
therapy; listens, observes, keeps track, and asks pertinent questions, but does not
presume to know answers. The therapist does not threaten to hospitalize a client
against her will because of self-injury, and they want the therapist to help
intervene in the client’s own self-injury process (when she is ready) by helping her
explore the origins and functions of her self-injury with possible alternatives.
Such control in therapy may help a client regain a sense of control over her actions
and her life. (pp. 152)
Levonkron (1998) insists that therapists need to become comfortable
talking in detail about cutting and burning, about self-inflicted injuries. They will
have to get used to demanding that their patients show them their injuries, inspect
them and determine whether they require medical attention. He realizes that many
therapists are reluctant to assume this sort of responsibility, but dismisses this by
Self-Injury 41
claiming that it requires, in most cases, knowledge equivalent to the medical
information found in the Boy Scout Manual. He insists that making the client
show new injuries during the session forces the client to internalize the therapist as
an internal image watching the cutting episode, releasing the secrecy of the act. In
this way, Levenkron states that therapists will have to feel as comfortable with
their client’s bodies, as with their minds. (pp. 10-11).
Hyman stresses that the attitude of the therapist toward self-injury can
“cause a woman to feel worse about herself...Some women have been yelled at
because of an injury; humiliated by having a caregiver ask others, in the women’s
presence, how she can do this to herself, and threatened with hospitalization if she
self-injures. These reactions can reinforce a woman’s belief that she is ‘bad’ and
can confirm childhood experiences of having caregivers confine her against her
will, shame her, or abandon her.” (1999, pp. 148-49)
One client emphasized the need for understanding from her therapist: “Cutting is
not attention seeking. It’s not manipulative. It’s a coping mechanism—a punitive,
unpleasant, potentially dangerous one—but it works. It helps me cope with strong
emotions that I don’t know how to deal with. Don’t tell me I’m sick, don’t tell me to stop.
Don’t try to make me feel guilty, that’s how I feel already. Listen to me, support me, help
me.” (Strong, 1998, p. 2)
Self-Help Tools: Books and Self-Injury Focused Web Sites
With the rise in the prevalence of self-abusive behaviors, there has been an increase
in studies and information available to the public and professionals working with selfinjury. There are books that describe self-injurious behavior and provide guidance in
Self-Injury 42
different techniques to provide information and support (Alderman, 1997; Conterio &
Lader, 1998; Favazza, 1996; Hyman, 1999; Levenkron, 1998; Strong, 1998). However, the
most resourced medium for obtaining self-help for teens today is through self-injury
discussion boards and Web sites. These internet sites have grown considerably between
1998 and 2000, and have continued to grow steadily over the past decade. A Google
search in October, 2008 returned 822,000 sites for “self-mutilation” and 1,100,000 sites for
“self-injury”. However, with this enormous amount of information available, it can be a
valuable asset or a dangerous entity depending on how it is used. Online authors have the
freedom to publish materials without passing through traditional methods that safeguard
readers and ensure quality information.
The majority of adolescents today spend their online time communicating with
both friends and strangers. Social networking sites have become increasingly popular, and
teenagers will use the internet to seek out relational connections with peers and others
when they are troubled. For those that self-injure, this is an especially inviting means of
obtaining support interaction because it is available at any time of the day and can be easily
accessed from private locations.
Moyer et al. (2008) published a report as a resource for school counselors who work
with self-injurers. Their purpose was to help school counselors analyze Web sites that
would provide reliable support for their students, and to help them avoid those sites that
could provide harmful “triggers” to self-injury. They cited a report by Wolak et al. (2003)
that stated that as adolescents search for online social support they may encounter a variety
of Web sites and individuals online, and these troubled teenagers may be vulnerable to
online exploitation.
Self-Injury 43
By following online information appraisal strategies, their report judged Web sites
to be helpful SIB (self-inflicting behavior) resources when they (a) were written by a
credible or credentialed author, (b) were free of commercial and other biases, (c) logically
followed the goals and purpose of the Web site, (d) were updated frequently, (e) provided
references to resources, (e) were easy to navigate with information readily accessible, and
(f) provided users confidentiality and privacy. They excluded interactive sites from their
study because of having the potential to deliver harmful and unpredictable messages about
SIB. They were careful to catalog Web sites that included triggering materials. They
defined a trigger as “online material that causes viewers to experience emotions and
perceptions that typically precede and trigger cutter behavior.” (Moyer et al, 2008, p. 278).
Moyer et al. encouraged school counselors to review a Web site in its entirety
before suggesting it as a support tool. “A simple review of the site can provide an idea of
whether the material is age-appropriate and provides the depth of information that will be
useful to the user.” (p. 279). They provided a number of Web sites under the categories of
(a) informational and factual; this category typically offered definitions and discussion
about the characteristics of SIB, (b) supportive self-help; this category included user’s
stories of struggle and healing with themes stressing the importance of connecting with
others and seeking help while attempting to understand and recover from SIB, (c) procutting—sites to be avoided; these Web-site designs and material seemed to glorify selfinjurious behaviors and used terminology to encourage SIB.
Informational and Factual Web Sites: (limited list)
SAFE Alternatives: www.selfinjury.com/
Self-Injury 44
College of Education, Northern Illinois University:
www.cedu.niu.edu/%26sim;shumow/iit/Self%20Mutilation.pdf
Helpguide.org: www.helpguide.org/mental/self%5finjury.htm
Supportive Self-Help Web Sites: (limited list)
Secret Shame: www.palace.net/%26sim;11ama/psych/injury.html
LifeSigns: www.selfharm.org/what/index/html
Men Who Self-Injure: www.formen10.tripod.com/index.html
Self-Injury: A Struggle: www.self-injury.net/
Pro-Cutting Web Sites—To Be Avoided: (full list)
The Onion: www.theonion.com/content/node/44466
43 Things: www.43things.com/things/view/73042
Watch Me as I Cut Myself Wide Open: www.bmezine.com/ritual/A40901/ritwatch.html
Cutters (Zanne & Razor’s personal Web site): www.vinland.org/scamp/institute/dsh.html
Self-Injury: What Makes You Cut: www.facetheissue.com/selfinjury.htm
Theoretical Treatments Used for Self-Injury
There is no single therapeutic approach that works with all self-injurers since the
roots of the primary disorder vary, and therapists each have their own model of preference.
Acute symptoms need to be brought under control as quickly as possible, which is
generally done through medication or behavioral modification. This is combined with
exploring deeper issues through psychotherapy to supplant destructive defenses with
Self-Injury 45
healthier coping skills. Talking out feelings in individual, group, and family therapy
sessions explore issues that helped cause and maintain a need to self-injure. A critical goal
of therapy is to learn to soothe and care for oneself in a healthy manner by internalizing the
therapist’s care and concern. Therefore, a connection of trust and commitment on part of
both patient and therapist to each other and to the progress of the treatment is necessary for
success.
Pharmacological treatment
Medication can be an important adjunct to treatment and in stabilizing the
emotional condition of patients, but is not in itself sufficient to modify the full spectrum of
destructive thoughts and behaviors that contribute to self-injury.
Prozac, an antidepressant that increases the activity of serotonin in the brain, has
been amazingly successful in reducing and sometimes completely stopping chronic,
repetitive cutting, probably by alleviating the impulsivity and compulsivity that underlie
the behavior (Strong, 1998, p. 163). Naltrexone has been effective in some trials in
controlling cutting by blocking the release of the body’s natural opiates, thus, removing the
euphoric high. Antidepressants known as MAOIs, (monoamine oxidase inhibitors),
antianxiety medications, and mood stabilizers have been useful in treating related comorbid symptoms, such as depression, anxiety, mood swings, and racing thoughts.
A study was conducted at the National Institute of Mental Health of four
medications to treat self-injury and other problems of impulse control in patients with
borderline personality disorder. Each patient took, in succession, an antipsychotic drug, an
antianxiety medication, one of the older generation antidepressants, and an anticonvulsant.
The most significant improvement occurred while the patients were taking the antiseizure
Self-Injury 46
medication, carbamazepine, known by the brand name Tegretol. No serious acts of selfinjury occurred during the Tegretol trial. In comparison, cutting and other aggressive
outbursts increased while patients took Xanax, an anti-anxiety drug—even among those
who had never cut before (Strong, 1998, p. 164).
Psychoanalysis
The biggest hurdle and the biggest benefit to psychotherapy or psychoanalysis with
cutters is the development of a safe and trusting relationship between therapist and client. It
is critical that the therapist develop a connection with the client that nurtures a relationship
of trust, dependency and attachment. Once the client experiences this therapeutic
attachment and learns to trust and connect through treatment, he can begin to build positive
attachments with others. Levenkron calls this aspect of therapy “re-parenting”, and
reverses the experiences in childhood of an abusive or neglecting parent. Working to create
this therapeutic attachment is often challenged by the client who constantly fights the
attachment she wants but is fearful that the trust developed would require her to reorganize
and perhaps give up her defenses. And sometimes more than that is the fear of rejection by
the therapist as she reveals her secrets. Her own self-hatred and low self-esteem assumes
that the therapist would reinforce her own beliefs.
An understanding of attachment theory is basic in understanding some of the
underpinnings of self-injury, for in almost every case, those who self-injure have no
healthy attachment to anyone. Paradoxically, while the self-injurer cannot form
attachments to others, she often has an excellent ability to encourage others to form
attachments to her. She can be an excellent listener and nurturer to others, but the
relationship is one-sided. The self-injurer has a powerful instinct to reject emotional
Self-Injury 47
closeness from others since there is a fear that closeness will result in rejection and harm.
In most cases, these beliefs were experienced and reinforced as children by the very ones
that they depended on for support and trust—their parents.
Low self-esteem is a result of childhood physical and verbal abuse, and has a direct
impact on interrelation attachments. Low self-esteem and self-hatred will be attracted to
relationships that are abusive. This develops to the belief that she deserves this abuse, and
unconsciously, invites it because this is what she is familiar with and consistent with
childhood experiences as normal. In this way, she attaches security with pain.
This fusion of security and pain allows her to deal with her feelings of fear of
abandonment, insecurity, and loneliness with self inflicted pain. In this way, the selfinjurer trusts only her pain because she connects it to home. When she is older and in
emotional trouble, she does not turn to another person to express her grief. Instead she
turns to her pain, because she can count on its presence. It is the most reliable relationship
in her life, and the most familiar (Levenkron, 1998, p. 101).
Over time, patients trace the problems in their present-day functioning back to their
roots in the past and uncover the core of their self-loathing and self-destructiveness. When
they realize that they are not, as they had believed, intrinsically bad or evil but a victim or
circumstances beyond their control—that the loss and betrayal and abuse they suffered as
helpless children was not their fault—they often experience tremendous relief and healing
(Strong, 1998, p. 165).
A set-back can occur during treatment when cutting episodes can get worse rather
than better. This happens because painful experiences of the past begin to surface and will
overwhelm the patient again.
Self-Injury 48
Group therapy is useful to break down barriers of shame, isolation, secrecy, and
form a connection with others. Family therapy can provide new outlets of communication,
and bring focus to dysfunctional family patterns that are played out through cutting. Parents
and partners can learn more appropriate ways to express emotions and respond to crisis.
Trauma resolution
A trauma based-approach to therapy teaches cutters to regain control over their
emotional responses. They learn to view their traumatic experiences as an unfortunate part
of their past but not an ongoing threat to which they must respond. This means attaching
words to the speechless terror of their memories and integrating them with that which has
been split off from consciousness through dissociation.
One of the first tasks is to take control of dissociative episodes. This is done
through teaching “grounding” techniques to differentiate past from present and to bring the
patient back to reality. These techniques can include looking around the room, putting
their feet on the floor, and becoming aware of their body and surroundings. Patients are
taught to identify feelings and body sensations as signals in order to react appropriately to
stimuli, not just with fight-or-flight reactions.
The patient learns how to handle anxiety while being exposed to traumatic
memories in a safe and controlled setting. Relaxation training and stress management are
taught to help control emotional states that overwhelm them which produce the need to cut.
EMDR (eye movement desensitization and reprocessing)is a recent technique developed to
defuse the emotional impact of traumatic memories through systematic exposure to
imagined scenarios while in a relaxed state.
Self-Injury 49
EMDR works like this: The patient invokes the memory and feelings of a particular
traumatic experience while tracking the therapist’s finger moving rapidly back and forth
before the eyes. The sequence is repeated until the patient feels no more anxiety, then the
process is repeated with the patient thinking positive thoughts while following the moving
finger. This technique has had favorable results to reduce anxiety in as little as one session,
and has been successful at reducing the frequency and intensity of intrusive thoughts,
flashbacks and nightmares. The best benefit of this technique is that it produces rapid
results without the need to recall and verbalize all traumatic memories.
EMDR developer, Francine Shapiro, hypothesizes that the technique stimulates the
brain to process and metabolize memories that had been stuck, unprocessed, in the nervous
system, and thus had been relived continuously through flashbacks, nightmares and
intrusive thoughts (Strong, 1998, P.167).
Other helpful methods of working with traumatized patients are to boost their
physical sense of safety through exercise or martial arts, or to help them express themselves
through art, writing, or drama. Another crucial step is to develop a social support system
which gives them the capacity to derive comfort from another and is the single biggest
predicator of whether traumatized patients are able to give up their self-destructive habits.
Substitution strategies have been used by Mark Schwartz, clinical co-director of the
Masters and Johnson treatment programs for trauma and dissociative disorders in St. Louis,
New Orleans, and Kansas City. He had one client with trichotillomania, who had been
sexually abused when she was five years old, paste a gold star in a book for every day she
was able to go without pulling out her hair. “The five-year-old part of her really needed
Self-Injury 50
that attention,” says Schwartz. “The fact that she was giving it a star began to give her an
internal relationship with herself.” (Strong, 1998, p. 168).
What had been viewed as a bizarre symptom in other treatment programs made
perfect sense in his trauma-based model. Ultimately the client was able to resolve the
trauma, and when Schwartz followed-up with her two years later, she had not continued to
harm herself. “Eventually you hope to eradicate the need for the symptom at all, “
Schwartz says. “But in the meantime you ask yourself ‘What can you do in the moment
that would be less destructive?’ If you need to be held, can you ask to be held? If you
need to see blood, can you use a red Magic Marker instead of a blade? If you need to feel
alive can you go out and run or sit in the sun or turn up your stereo headphones? When
there’s enough internal cohesion and an integrated sense of self, the persona can deal with
distress the same way the rest of us do, through effort and accomplishment.” (Strong,
1998, p.168-169).
Whether patients should be required to give up their self-injury as a condition of
therapy is controversial among therapists. Some therapists will refuse to treat a client while
they are actively harming themselves. Others believe that asking a client to give up such a
crucial coping mechanism too soon could be dangerous, even deadly. Still others believe
that to demand that a client stop cutting may not be dangerous but futile. Levenkron states
“It may result in more cutting as the patient says, ‘I’m the one in control and I’m going to
make you feel as helpless as I feel.” Levenkron does not require his clients to stop cutting
until they no longer need it, but he does encourage substitute outlets, such as writing in a
journal or calling him if they feel like cutting. He also helps his clients create a vocabulary
of emotions because, he says, “once they say it, you can handle it” (Strong, 1998, p. 172).
Self-Injury 51
Cognitive-behavioral treatment
From a cognitive-behavioral point of view, cutting is learned behavior, driven by
self-destructive thoughts and beliefs and maintained by both positive reinforcement
(attention, nurturance) and negative reinforcement (relief from distress). This treatment
model maintains that the behavior can be “unlearned” by changing negative thought
patterns, teaching patients healthier coping skills, withdrawing rewards, and in some cases,
through counter conditioning.
The focus is on the patient’s current life to identify what events, thoughts,
behaviors, and emotions trigger self-injury and to develop strategies to prevent giving in to
the behavior. Negative thoughts about self and body that lead to self-injury are challenged
and replaced with positive statements that self-affirm.
Patients learn how to resist thinking about self-injury by thought-stopping, that is,
consciously pushing the urge to cut out of the mind and to discharge feelings through
words rather than actions. A coping plan is developed for dealing with high-risk emotions,
feelings, and situations. Patients might be expected to sign a contract agreeing not to injure
themselves without first trying alternative behaviors, such as talking out their feelings with
a friend, taking a hot bath, engaging in physical exercise, or changing their surroundings.
(Strong, 1998, p. 173)
A cognitive-behavioral approach that has been very successful in treating selfinjury is dialectical behavior therapy, or DBT, developed at the University of Washington
by psychologist Marsha Linehan. It is a manualized outpatient program that consists of one
hour per week of individual therapy and two and a half hours of group therapy for one year.
DBT targets problem behaviors and teaches more adaptive solutions. Patients examine in
Self-Injury 52
detail the chain of events that leads up to their act of self-injury, and then find alternative
means to avoid the need to self-injure. They learn behavioral skills to help regulate their
emotions and tolerate distress. They learn interpersonal skills to better communicate their
needs and feelings. They learn how to build healthy relationships. They learn to take care
of their body. They are encouraged to exercise, eat balanced meals, get enough sleep, take
their medications responsibly, and avoid drugs and alcohol. They learn how to sooth
themselves and relieve distress, such as, taking a bath by candlelight, or getting a massage.
DBT was designed to treat patients with borderline personality disorder who
engage in chronic parasuicidal behavior, which Linehan defines as both self-mutilation
without suicidal intent, and true suicidal acts. She says that borderline patients, due to
painful childhoods and possible biological factors, respond abnormally to emotional
stimulation. Their level of arousal escalates more quickly than the average person, peaks at
a higher level, and takes more time to return to normal. She views self-injury as the result
of a lack of coping and problem-solving skills for dealing with such intense surges of
emotion. (Strong, 1998, p.173)
DBT is often favored as a treatment model for self-injury because it combines the
benefits of both cognitive-behavioral and psychotherapy. While patients undergo
individual psychotherapy, they also learn to target and prioritize problem behaviors with
practical skills. Rex Cowdry from the National Institute of Mental Health says if you can
set a goal to stop the behavior and deal with it on a symptomatic level, then you don’t have
to necessarily resolve the original trauma, “but you do have to provide tools and
alternatives…so even when they are in a state of terrible distress they can somehow recall a
Self-Injury 53
positive outcome: ‘I’ve been here before, I know I can get through this.’” (Strong, 1998, p.
175).
Internalized Shame: Foundation of Self-Injury
Self-injury is a complex syndrome; it is driven by a variety of causes, to varying
degrees of disorder. However, there is a strong common denominator which under girths
self-injury and that is emotional pain. Every expert in this field describing each self-injury
case mentions emotional pain: repressed emotions, explosive emotions, conflicting
emotions, runaway emotions, etc. Hyman says of the fifteen women she interviewed for
her book, Women Living With Self-Injury, “All women who participated in this project
said that they injured themselves, sometimes or always, in response to a variety of
emotions.” (Hyman, 1999, p. 52).
Therapy has involved, often, a cognitive stance in
which to reorder these feelings, but self-injury continues to be an emotional battle. Strong
describes what happens during a cutting sequence: “Strong feelings simply can’t be dealt
with on a mental level but seem instead to demand action.” (p.55). It is evident that a
study into the dynamics of self-abuse requires a good look into the emotional dimension of
this behavior.
I see a missing, major component in the discussion of self-injury by experts who
talk a lot about shame—shame connected with the need to cut, with the addictive
powerlessness of the compulsion, shame to confess, shame about the scars, shame of
childhood abuse---but shame itself, as a major issue, has not been addressed. Only Tracy
Alderman (1997), in her self-help guide to understanding and ending self-inflicted
violence, addresses shame directly. She says that “secrecy, isolation, alienation,
depression, and self-hatred are all consequences of shame, and that many of these
Self-Injury 54
consequences will increase the desire to hurt oneself, thus playing a major role in the cycle
of self-injury.” (p. 61). She identifies shame as one of the most common factors associated
with self-inflicted violence. She says that shame is a powerful emotion, able to alter
thoughts, feelings, and even behaviors. But rather than explaining how shame becomes a
powerful source of altering thoughts, feelings and behaviors, she details areas where shame
“are common products of self-inflicted violence” (p. 60). She then offers two main ways of
reducing shame. The “most obvious” is to discontinue the activities that produce these
feelings, however, since SIV (self-inflicted violence) is still an important function of
coping, she concludes that “while ending the activity has a high rate of success in terms of
reducing shame, it may not yet be a practical approach.” (p. 61). Her second way to
eliminate or decrease feelings of shame is to change the way one views the activity—how
you think about it. She says that if “you begin to view self-inflicted violence as a method
of coping, surviving, and caring for yourself, you are likely to decrease (and hopefully
eliminate) shame and increase feelings of pride.” (p. 61). In other words, deal behaviorally
and cognitively, but not directly with the emotional component. Hopefully, by rearranging
the behavior and cognition, the emotions will follow suit.
But how do strong emotions, and shame in particular, so deeply affect the self so as
to find expression through bodily damage? My hypothesis is that internalized shame is a
powerful, independent component affecting the psyche in self-injury, and needs a more
thorough understanding in order to treat this behavior effectively. I propose to provide
some answers to this question as we examine internalized shame, and recognize within it
familiar features of self-injury. In an Adlerian context, I propose to suggest that shame is
the driving minus of inferiority.
Self-Injury 55
Shame Theory
Gershen Kaufman, clinical psychologist and professor in the Counseling Center at
Michigan State University, lays the groundwork for this concept of a shame theory in his
book, Shame: The Power of Caring. In his introduction he says, “If we are to understand
the self…and self-hatred, and the evolving process of identity, then we must begin with
shame. Shame is a wound made from the inside, dividing us both from ourselves and from
one another. Shame is the affect which is the source of many complex and disturbing inner
states: depression, alienation, self-doubt, isolating loneliness, paranoid and schizoid
phenomena, compulsive disorders, perfectionism, a deep sense of inferiority, inadequacy or
failure…these are all rooted in shame.” (1985 ed., p. xix)
Kaufman became convinced of the influence of affect upon identity formation while
studying Silvan Tomkins’ affect systems theory. He developed a more centralized shame
theory when he identified how specific and powerful this affect was to the development of
identity. Within this theory, Kaufman embraces affect systems theory (Tomkins),
interpersonal theory (Sullivan and Kell), and object-relations theory (Fairbairn). Kaufman
notes that Tomkins’ affect theory is a direct challenge to both classical psychoanalysis and
cognitive-behaviorism which makes affect in general and shame in particular a derivation
of cognition, and in other theories a derivation of something else. Kaufman explains:
“The particular categories of thought that we use inevitably shape
the perception of all other related phenomena. When the construct of
drive is conceived to be primary, all other observables are necessarily
viewed from that perspective; then affect becomes simply a derivative
of the drives. But affect becomes a derivative of cognition when that is
Self-Injury 56
the foremost organizing principle of the self. In neither case is affect
conceived to be independent in its functioning.
“Shame, therefore, is not the same as, nor the product of negative cognition
self-appraisals. Affect is innate. It exists prior to and is primary over drives,
cognition or language.” (Kaufman, 1992 ed., p. ix)
This consideration of the primacy of affect and shame is fundamental to the
understanding of self-inflicted behaviors for everything that surrounds self-injury is shame
based. But what is most critical is how shame invades the identity of the one who selfinjures. Kaufman points out that our identity is that vital sense of who we are as
individuals, embracing our worth, our adequacy, and our very dignity as human beings and
all these can be obliterated through protracted shame, leaving one feeling naked, defeated
as a person and intolerably alone. He says that contained in the experience of shame is “the
piercing awareness of ourselves as fundamentally deficient in some vital way as a human
being.” (p. 8). We have seen exactly this dilemma within the description of self-abusers
and it is this internalization of shame that marks the inner life of the self-abuser. We will
look at how shame impacts the developing self so that the identity captures and internalizes
the painful affect of shame into itself.
Internalized shame
Internalization of shame means that the feeling of shame is no longer merely one
affect or feeling among many which become activated at various times and then pass on.
Rather, internalized shame is now experienced as a deep abiding sense of being defective,
never quite good enough as a person. It forms the foundation around which other feelings
Self-Injury 57
about the self will be experienced and now lies at the core of the self and gradually recedes
from consciousness. In this way, shame becomes basic to the sense of identity.
Internalization also means that the self can now autonomously activate and
experience shame in isolation. Conscious awareness of limitations, failures, or simply
awareness of not achieving a prescribed goal can activate shame. There need no longer be
any interpersonal shame-inducing event. For example, a person might feel ambivalent
about ending his/her marriage but could experience acute shame when asking a clerk for a
divorce application, irrespective of the clerk’s courtesy.
The consequences which stem from shame internalization are three fold and can be
seen in the life of self-abusers: the varieties and depth of shame, a shameful identity in the
form of an underlying defectiveness, and thirdly, autonomous shame activation. There is a
fourth consequence which Kaufman has termed “internal shame spiral” which ensures that
the former three continue to reinforce one another so that shame becomes ever more
solidified within the emerging identity (Kaufman, 1992, p. 74). Kaufman explains this
process which can be recognized in the self-injury cycle:
“An internal shame spiral happens when a triggering event occurs, either a
shame inducing breaking of the interpersonal bridge, or an event which
autonomously activates shame wholly from within. Whichever, when a person
suddenly is enmeshed in shame, the eyes turn inward and the experience becomes
totally internal, frequently with visual imagery present. The same feelings and
thoughts flow in a circle, endlessly triggering each other. The precipitating event is
relived internally over and over, causing the sense of shame to deepen, to absorb other
neutral experiences that happened before as well as those that may come later, until
Self-Injury 58
finally the self is engulfed. In this way, shame becomes paralyzing.
This internal
shame spiral is experienced phenomenological either as “tail-
spinning” or
“snowballing.” Each occurrence of the same spiral can go on to
include a reliving of
previous shame precipitating events which thereby solidifies
shame further within
the personality and spreads shame to many different people,
situations, behaviors,
and parts of the self (Kaufman, 1992, p. 74-75).
Another compelling reason to see internalized shame as crucial in self-injury is the
biochemical consequences of chronic magnification of any affect. Affect and its
suppression result in distinct endocrine changes. Since rage, and more often suppressed
rage, and stress and anxiety are centrally acknowledged problems with self-abusers, the
question we must ask is: Could affect produce permanent changes in brain chemistry?
Kaufman explains the powerful results of backed up affect on brain chemistry:
“Research evidence demonstrating distinctive patterns of autonomic correlates
accompanying the activation of different affects is now accumulating, as Tomkins
had originally hypothesized. Affect magnification can feed equally well on the
expression or suppression of affect. One important consequence of rapidly
magnified affect and its suppression is backed-up affect. Endocrine changes are a
further consequence of backed-up affect. In response to chronic affect
suppression, the resulting endocrine changes may become permanent. This cycle is
an important one. When affect is systematically suppressed, the inevitable result is
backed-up affect. It is the experience of backed-up affect along with its resulting
endocrine changes, like the elevation of blood pressure in suppressed rage that
actually produces the effects typically and ambiguously referred to as “stress”.
Self-Injury 59
Therefore, psychosomatic illness is a direct consequence of backed-up affect and
stress itself is mediated by affect.” (Kaufman, 1992, p. xvii).
During the self-injury cycle, shame intensifies. Kaufman describes affect
magnification as it relates to bulimics in their effort to purge themselves. He says,
“Vomiting is frequently resorted to by bulimics to purge themselves of the shameful food
they so shamelessly devoured…Why such an intense form of purging? There is a kind of
emotional cleansing that occurs if one literally bathes in shame.” (p. 186). Since self-injury
is so often correlated with emotional cleansing, it is interesting to consider this aspect of
affect magnification, a masochistic strategy of reduction through magnification. While
Kaufman (1992) relates this process to bulimia, it could as well be describing self-injury by
cutting:
“While bingeing gradually accelerates shame, purging [cutting] quickly
magnifies it, bringing it to peak intensity through self-disgust. When the same
peaks, there is a ‘bursting effect,’ and one feels purged, cleansed, even purified.
Self-purging through vomiting [cutting] continues until defeat and humiliation are
complete. The bulimic [cutter] behaves so as to guarantee complete humiliation,
acting to magnify and accelerate humiliation because these feelings have become
intolerable. They can be reduced only by first magnifying them until they reach
their peak intensity. By magnifying feelings of humiliation in intensity and
duration, they are finally spent, their fire burned out. This is what creates the sense
of cleansing.” (p. 186).
This, in part, could explain the emotional calm after a cutting episode and the
ability to fall into a restful sleep (Strong, 1998, p. 55). It becomes very probable, then, that
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the explosive, sudden urges to self-injure could be due to backed-up affect being released
and the sudden slip into an internal shame spiral.
Formation of a shame- based identity
An infant and young child can experience shame as it longs to connect with the
caregiver but experiences only neglect or rejection. Language is one of the most potent
communicators of shame and so for the preverbal child the only means to realize a
reparative mend to a parent’s anger or to soothe a frightening sense of abandonment is
through physical contact. Without language, the child will instinctively reach out in a
nonverbal request for holding to affirm that he/she is loved and wanted. If that gesture is
not acknowledged, the child will experience shame through abandonment (Kaufman, 1992,
p. 18).
Every child will experience shame in some form and this is inevitable in life, but it
is the pattern of consistent, shaming experiences within significant relationships over time
that carries a deep impact and is poignant to how shame develops the identity of those that
self-injure. The following are some ways that shame is painfully experienced by a child
when the parent responds in the following ways: 1) becoming emotionally unavailable such
as through excessively long periods of silent withdrawal from the child, which is
experienced by the child as a refusal to relate; 2) by becoming overtly contemptuous either
facially or verbally, which is experienced by the child as complete rejection; 3) by overtly
withdrawing love in a prolonged and unreasonable way (Kaufman, 1992, p. 19).
Parents will sometimes shame their children in an attempt to correct behavior
without realizing the impact this shaming will have on the developing child. Kaufman lists
the following ways that parents will, wittingly or not, induce shame in their children:
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1. Behavior which was acceptable at home or in private but suddenly and
unexpectedly becomes bad when family is in public.
2. Parents’ use of their own shame or embarrassment as a shame-inducing
mechanism to control. “You are embarrassing me” “I am so ashamed of
you.” This tactic will foster a pernicious tie between the two which teaches
the child to experience himself as an extension of the parent, never as a
separate person, responsible for his own actions. This unhealthy attachment
is part of the self-abuser’s inner strife and drive toward self-afflicted
separation.
3. When a parent communicates that the child is a definite disappointment as a
person to either one or both parents. When this message is reinforced,
especially by one who is as significant as the parent, the child’s identity is
immersed in feeling inherently deficient.
4. When some form of belittlement takes place. “When are you going to grow
up and stop asking me to look at everything you do?”
5. Disparagement that results from parental comparison of child with friends or
siblings.
6. When blame is either fixed or transferred to another. Most often something
has gone wrong—an accident, a breakage resulting from poor judgment, or a
mistake. Blaming is like rubbing salt in an open wound; the child’s nose is
further rubbed in the mess he’s made.
7. Expressions of disgust or contempt communicate unambivalent rejection. A
look of contempt from a parent can be the most devastating inducer of
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shame. An overly critical attitude toward the child is one way in which
contempt becomes manifest interpersonally. This experience is often deep
within the self-injurers identity.
8. Derisive laughter, mocking, and ridicule show a contempt that is received by
the child as not fit to belong.
9. Open humiliation. Sexual and physical abuses are violent forms of shaming
that is fertile ground for hatred and revenge. Sexual abuse activates intense
inner feelings of powerlessness, personal violation and humiliation. Yet, in
the midst of this pain is, most often times, added the shame that the victim
feels at fault.
10. Performance expectations of parents. Parents who experience an inordinate
need to have their child excel at a particular activity or skill will behave in
ways that pressure the child to incessantly do more or better. Disabling
expectations make attaining the goal much harder, if not altogether
impossible. The child feels a binding self-consciousness as he faces the real
possibility of failing and disappointing those parental expectations.
(Kaufman, 1992, p. 20-27)
When a child grows up in an environment that reinforces humiliation and shame,
the child’s emerging identity will be bound up with shame and internalized. There are four
critical processes which determine this formation of a shame-based identity: internalized
identification images; development of shame affect, drive and need binding; creation of
defending strategies; and disowning and splitting of self.
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Identification images. Learning how to become a person originates through
identification, as we first bond, attach, and then identify with others. This identification
begins within the family. Identification and then later differentiation alternate with each
other as one goes about the process of becoming a fully separate person. However, both of
these processes become gigantic obstacles to a self-abuser because identification is a
nightmare and differentiation is impossible.
Identity emerges gradually out of the process of identification. Internalization is the
important link that draws outer reality to our inner world which leads to identity.
Internalization involves three distinct aspects which Adlerians recognize as private logic.
First, we internalize specific attitudes (affect-beliefs) about ourselves which form the core
of self and mold the emerging sense of identity. Secondly, we internalize the very ways in
which we are treated by significant others and, thereby, learn to treat ourselves in like
manner. Thirdly, we internalize identifications in the form of images—we take them inside
us and relate to them there. Through internalization, the conscious experience of the self
inside is shaped and a relationship with self develops (Kaufman, 1992, p. 41).
We internalize identification images primarily who are most vital for our survival,
namely our parents. They serve as guiding images for the internal functioning of the self,
and play an excessively controlling role in the inner life. To the degree that such
identifications are based on shame and contempt, the inner life itself becomes perpetually
subject to shame. Thus, when isolated shaming experiences are felt, they become
magnified and fused via imagery and self-talk with past experiences of shame. Scenes of
shame become interconnected and magnified until it controls self-concept. “I feel shame”
is now translated to the self as “I am shameful, deficient in some vital way as a human
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being.” Self-hatred takes shape. Shame has become internalized. It is no longer one
affect among many, but instead comes to lie at the core of a shame-based identity
(Kaufman, 1992, p. 72-73).
This internalization of core beliefs and identification images are readily seen in the
lives and histories of those that self-inflict. There is a common thread in the lives of the
self-abused with parental attitudes and treatment to their own self-concept and selftreatment. An example of this is given in the following history of Fran, a self-abuser who
has been cutting and burning herself for more than thirty years:
“Much of Fran’s anger involves her mother, the child of immigrants who
had earned a masters degree from a top university. She expected her own daughter
to strive the way she had to strive, to do anything to avoid the humble roots she
had once known. Unfortunately, she used criticism as her primary motivating
tool—constant criticism. ‘If you do poorly in school you won’t get into a good
college, and then what am I going to do with you? Send you to work in a factory?’
The sensitive teenager was shattered.
Fran’s relationship with her mother remained painfully entangled until the
end. Just months before the older woman died, Fran’s brother confronted his
mother about never giving him any emotional support. ‘Emotional support—what
bullshit!’ their mother exploded in anger. ‘This was a woman who’d been a wife,
mother, grandmother, teacher, and guidance counselor, and she thought that
emotional support was bullshit.’ Though Fran says she was relieved to have her
mother out of her life, her cutting has actually increased since her mother’s death.
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For the real critic did not go to her grave. She is inside Fran.” (Strong, 1998, p. 78)
Identification images are internalized gradually. They are mainly rooted in our
unconscious, engrained by repetitive reinforcement, with the originating experiences often
times erased from memory. Eventually the identification image comes to be experienced
as an auditory voice inside which remains distinct from one’s own voice. This internal
voice repeats to the self almost verbatim what the child grew up hearing about himself,
about others, or life’s circumstances and form’s what Adlerians and other theorists refer to
as self-talk. It is a powerful influence to guide the individual’s behavior, and attitudes.
An internalized image is recognized when the self-talk turns from first person to third
person, such as, “I’m so stupid” to “You’re so stupid”.
Another example of this strong influence of internalized images and the guiding
internal voice is seen in the following situation as given by Hyman:
“Edith found the thought coming up “How dare you do that to me” conveying a
right to be treated well and to set limits, rights impossible to demand or enforce as
a child. I have this governing belief that I need to be punished for being the kind
of person I’m being; doing the things I’ve done—just, I need to be punished; I
can’t really explain the why behind it. Sometimes it’s as simple as I’ll be doing
the dishes and drop a plastic cup onto the floor. And I’ll be like, ‘You’re so stupid;
you’re such an idiot, you should cut yourself; blah, blah, blah.’ Sometimes it’s a
little bit more sophisticated than that. It’s like my thinking about the type of
person that I am and needing to be punished for that. I think that I’m
manipulative, dishonest, evil, and vile, vile.” (Hyman, 1999, p.25).
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Development of affect-shame, need-shame, and drive-shame binds. There are three
motivational systems that also contribute to shame internalization—affects, drives, and
needs—in which shame can generate and eventually bind whichever has become associated
with shame. In the description of self-abusers, one feature that often stands out is the
inability to articulate thoughts and feelings, or to describe their emotional distress. A
possible answer to this phenomenon can be explained through the development of shame
binds. Kaufman explains some of the physical effects of shame binds:
“The binding effect of shame involves the whole self. Sustained eye contact
with others becomes intolerable. The head is hung. Spontaneous movement is
interrupted. And speech is silenced. Exposure itself eradicates the words, thereby
causing shame to be almost incommunicable to others. Feeling exposed opens the
self to painful, inner scrutiny. It is as though the eyes inexplicable turn
inward…The excruciating observation of the self which results, this torment of selfconsciousness, becomes so acute as to create a binding, almost paralyzing effect
upon the self…This alienating, isolating effect of shame also prevents us from
conversing directly about the experience. However much we long to approach, to
voice the inner pain and need, we feel immobilized, trapped, and alone in the
ambivalence of shame.” (1992, p.9-10).
An affect bind is created when any affect such as fear, distress, anger, happiness—
is met with a shaming response. Then feeling afraid or angry, for example, will become
shameful and not tolerated. When this is reinforced over time, situations that trigger these
emotions will now also trigger shame. In this way, an affect can spontaneously activate
shame without a shame-inducing event. Thus, crying is considered shameful and not to be
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done; anger is shameful and must not be expressed. Even happiness can be thus bound
when a shaming reaction from another has accompanied its expression. Affect binds can
be observed in persons who stoically contain their emotions, or those who unreasonably
apologize for expressing an emotion. Hyman describes this state when she says that cutting
one’s body with a knife or razor can involve a variety of sensations and emotions that
sometimes “feel stuck in the body, inexpressible except through cutting. The emotions can
be so powerful that a woman fears releasing them any other way.” (Hyman, 1999, p. 30).
This chaos of emotion has been a common feature of those that self-abuse themselves and
is illustrated in the lives of three self-abusers in the following accounts. Notice how the
result of an affect-shame bind has created that bound emotion to build to explosive
pressures that can only, apparently be released through self-injury.
“Peggy grew up having to keep all her feelings to herself. If she
expressed even the smallest hint of anger or frustration her mother
would walk away, not look at her, and then, while talking with someone
else, joke about Peggy’s feelings. Because Peggy’s father had two jobs
and was never at home, Peggy had nowhere to turn with her
emotions…For Peggy, beating her head releases mounting emotional
tension, offering temporary soothing for life stresses. She has hit
herself since childhood, a time when any expression of her feelings was
ignored or ridiculed, making her feel like she would explode inside
without some release of her emotions. Nowadays, when she bangs her
head, she feels only self hatred even though her initial emotion was fury
at another person or circumstance.” (Hyman, 1999, pp. 15, 28)
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“Elizabeth, as a child, was not allowed to express anger even
though her parents had fits of rage that they took out on their children at
the slightest provocation. In self defense, she developed what she calls
a ‘good little girl attitude’; she kept everything inside and never showed
anger. As the years went by, she feared that she could not express
anger even in physically safe situations. Now, as an adult, feeling
angry frightens her and she fears losing control. She says that she has
so much anger inside that if she tried to let part of it out, all of it would
escape and her mind would ‘go’ or she would harm someone. She finds
it easier to keep her anger inside until she can discharge it through self
injury.” (Hyman, 1999, p. 56)
“As a child, Jane was punished if she showed anger. Now if she
gets angry at someone or something she becomes angry at herself for
getting angry, ‘because I’m not supposed to get angry’. For a long
time, Jane could not tolerate the mention of anger; she would dissociate
each time her therapist brought up the subject.” (Hyman, 1999, p .57)
Any affect that meets with sufficient shaming can develop into an affect-shame
bind. What is critical to this development is how the expression of that affect is responded
to by significant others. If the affect is met with shaming, a total affect-bind can result so
that the expression of the affect becomes bound and controlled by shame. If at every turn
the child is met with shame, the child is left with the realization that he/she is inherently
shameful as a person and an essential part of the self and free access to one’s feelings,
becomes distorted (Kaufman, 1992, p 71).
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The second motivational system that can be bound is with the drives. The sexual
drive can be most affected by shaming that results from sexual exploration, and intimate
responses. Even the parents’ use of polite childish terms for genitals and sexual activities
sends a message of a shameful attitude toward sexuality. Children are not given slang
terms for eyes or ears, but genitals must be spoken about indirectly. In this way, intimacy
and sexuality is regarded with caution and embarrassment, inducing shame concerning its
approach, and as Kaufman puts it, “the individual is faced with an intolerable dilemma:
how to come to terms with a vital part of the self that is seen as inherently bad.” (1992,
p.48). Many self-abusers battle with this sexual drive dilemma which has been bound and
controlled by shame, and is faced with how to come to terms with a vital part of the self
that is seen as inherently bad.
In the following case example, we can see how sexual shame created a shame bind,
resulting in the abuse of two generations of daughters. We also see how the same shaming,
blaming internal image of the mother was passed from one daughter to another.
“Donna is a compulsive self-injurer. For thirty years she struggled daily
with the compulsion to pick at her face. ‘I would be in the bathroom sometimes
up to three hours at a stretch—picking, repacking, and pulling scabs off—so you
can imagine what my face looked like. It ran my life.’
“Her mother was emotionally abusive and cruelly manipulative to Donna.
The scenarios usually revolved around her daughter’s physical appearance.
When she was 13, her mother bought her bright red lipstick. When the school
principal told her mother at a parent-teacher night that the lipstick was not ageappropriate for Donna, her mother walked out, telling the tearful girl, ‘I’m so
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ashamed of you. I don’t even want you to be my daughter.’ Around the same
time, she also bought Donna a low-cut dress and took her to a modeling agency.
When the men at the agency stared at her breasts, her mother began ridiculing her
figure, saying that one breast was bigger than the other. ‘I wanted to be pretty, but
at the same time, it was painful being pretty. I thought it was the only reason
my mother liked me.’
“One thing that helped free Donna from the demons of the past was the
discovery that her mother had re-created with Donna the same painful dynamic
that her mother had experienced with her own mother. Donna’s mother was
illegitimate and Donna’s grandmother, deeply ashamed of that fact, showed her
daughter little love or attention. ‘I was able to take some of the blame off myself,
and my mother, too. It’s amazing how we re-create these patterns of our abuse.’”
(Strong, 1998, p. 28).
One’s needs can, also, be bound by shame. There are several human needs that
must be met in order for the formation of a healthy, secure identity. Kaufman (1992) lists
the needs that are foundational to a nurtured self as the need for relationship, need for
touching/holding, need to identify with a valued other, need for differentiation, need to
nurture, and need for affirmation (pp. 51-70). In an Adlerian context, Forgus and Shulman
give four primary needs that appear to be hard wired into infants at birth: nourishment and
contact, protection and safety, mastery, and sensory variation (Mosak & Maniacci, 1999, p.
36).
However, the most potent of these needs is within human relationship with the need
to attach and bond with a significant person. This translates into needing to feel that that
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other person also wants a relationship with us. A bond is formed when relationships show a
reciprocal interest in each other, as well as valuing each other’s needs and feelings.
Failure to fully hear and understand the other’s needs and to communicate its validity
breaks what Kaufman refers to as “the interpersonal bridge” and induces shame. The child
is left with feeling, “If I’m not bad, then my need would have been met” or “If there wasn’t
something wrong with my need, it would have been responded to.” (Kaufman, 1998, p.
14). In the life of the self-abuser, we can often see that several of these needs have been
unmet or abused, destroying a trust relationship and forcing these needs into a shame-bind
oblivion. The following case was shared by Strong (1998) and reflects needs that were not
nurtured by parents, resulting in self-injury.
“One reason Lukas thinks he cuts so savagely is because he has
internalized his father’s contempt. ‘I hate myself. It’s almost an insult for
people to refer to it as a self-esteem problem. I’m talking active, passionate
hatred. Even now I still have enough of the image he tried to force into me to
think that whining just because your dad didn’t compliment you enough is weak
and lazy.’
“His father was an immigrant engineer. Lukas explains, ‘He wanted a son
who would do all the things American boys do and instead he got me. Nothing I
ever did was good enough. If I got good grades, I should have gotten better
grades. And I didn’t share his tastes. I watched PBS instead of football. I read too
many books. I didn’t have any real athletic skills. The funny thing is that he
didn’t have any either.’
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“His father abandoned his mother and family for another woman when he
was sixteen. When his father died, he didn’t even attend the funeral. Yet he also
seethes with anger toward the mother who never intervened in the denigration his
father heaped on him. He fantasizes about showing his mother his scar-riddled
arms on Mother’s Day and telling her ‘The cheerful, perfect boy you think
you raised doesn’t exist.’” (p. 11-12)
We can clearly see in these cases examples of how affect, imagery, and language
(self-talk) were central processes that shaped the self and identity of these self-abusers.
Though these case studies where not drawn from Kaufman, but from Hyman in her study
of self-injury, we can follow the intense power of shame in self-injury. We can conclude
with Kaufman when he says that shame so disturbs the functioning of the self that
eventually distinct syndromes of shame can develop. Each is rooted in significant
interpersonal failure (1985 ed., p. xix).
Defending strategies. Normally, when we feel embarrassed or shameful, we are
able to either leave the situation or have attention focused elsewhere and so escape from the
watching eyes of others. But, when shame has become internalized, a new shame
experience becomes intolerable and activates an acute need for defending oneself. For
most self-abusers, there is no one to trust and so the self must take on the task of defending
the self.
There are two strategies that are basically used: one is forward-looking and aims at
protecting the self against further shame exposure, and the other is a strategy of transfer
which aims at making someone else feel shame in order to reduce ones own shame.
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Other feelings or affects usually accompany shame and are manifested as secondary
reactions, most usually fear, distress and anxiety, and/or rage. Hurt feelings are
experienced as distress, and fear and anxiety mount to react against further exposure and
experiences of shame. When rage predominates in reaction to shame, it is as though the self
were vehemently saying “keep away”. In this manner the self protects itself, yet
paradoxically fights against either comforting the inner wound or allowing reunion, thus
preventing escape from inner loneliness (Kaufman, 1992, p. 12).
In studying self-abuse, there is much description of feelings of anxiety and rage. It
is my opinion that these are acute secondary reactions to internalized shame which has
paralyzed the inner world of the self-abuser. The preceding examples of Edith and Lukas
show the powerful effects of rage and anxiety to these self-abusers, and the shame that
dominates their inner world. Because Levenkron (1998) states that rage is consistently
encountered in all self-injurers toward a powerful figure in their life (p. 44), it is important
to address rage as it is associated with internalized shame.
Kaufman (1992) explains that “when our response to another who holds us in high
regard involves disparagement, contempt, a direct transfer of blame, or humiliation, the
consequent shame experienced at our hands is more intense, accompanied by rage
bordering on hatred and, possibly, that burning longing for revenge as well.” (p. 33.) This
description is clearly accurate in the account of Lukas.
As a defending strategy, rage manifests itself in hostility or bitterness. Kaufman
says that although this hostility or bitterness arises as a defense to protect the self against
further experiences of shame, it becomes disconnected from its originating source and
becomes a generalized reaction directed toward almost anyone who may approach. What
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has happened is that along with shame, rage as a defending strategy has become
internalized as well; it no longer is a passing affect, but is actively held onto and thereby
prolonged, whether expressed or only felt inside (Kaufman, 1992, p. 83). We see this again
illustrated in Lukas’ account:
“Lukas had been a successful, hard-driving attorney…but throughout his adult life,
alcoholism and workaholism kept his demons in check….But a huge blow-up with his
partner led his colleagues to question his sanity. The sense of betrayal he felt seemed to
unleash something deep inside him…While struggling to find a psychologist who could
help him, Lukas began cutting.” (Strong, 1998, p. 11).
Another defense that is used to insulate against further shame, and when especially
internalized early in life is power. To the degree that one can now feel powerful in relation
to others, through gaining power over them, one has reversed roles from the way it was in
early life.
Transfer of blame as a defending strategy is seen in self-abusers, not so much in
transferring blame to others, but as they internalize blame on themselves as a way of
avoiding blame from significant others. Such a person learns that if he is quick enough to
blame himself, a parent’s blaming will subside or be avoided. It is as though the child
makes an implicit contract with the parent: I will do the blaming so you will not have to. In
this way the intolerable blaming, which induces shame in the child, is placed under the
child’s own internal control. It becomes internalized such that the child’s inner life is
forever subject to spontaneous self-blame (p. 94).
When blaming or contempt becomes internalized secondarily to shame, the self
begins to inflict punishment upon itself through self-blame and what Tomkins views as
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internalized contempt. And, while effective barriers have been utilized to defend against
the outer world, now the self must cope with the “enemy within”.
Certain defenses become directed inward and aimed at the very self of the
defending individual. This we see in self-injury. Rage, contempt, and blame boil within
the victim of self-injury and the defense now comes to function in the inner world where it
is directed at specific parts of the self (Kaufman, 1992, p. 97).
This defending strategy
helps explain the compulsive, directed decision to abuse oneself.
Disowning and splitting of self. The three processes, thus far, involved in the
formation of shame internalization are internalized guiding images, affect binds, and
internally directed defending strategies. The final process in the development of shame
internalization is the disowning of self.
This active process of disowning of self which leads to the splitting of the self into
parts that are owned and parts that are disowned is similar to what Sullivan described in the
“Me” versus the “Not-me” or the “Bad-me”. This disowning process is pursued relentlessly
by the self in order to cope with the internalized belief and feeling of intolerable
defectiveness (for it must reside within the self since parents are, after all, “infallible”).
Disowning may also be relentless in an effort to assuage a punitive parental identification
image. When that disowning begins at too early an age, or there lacks any positive
counterbalancing experience with other significant humans, then disowning can result in
such a profound splitting of the self that independent, split-off parts may emerge (Kaufman,
1992, p. 104-05).
Kaufman gives an example of this and how it resulted in self-abuse.
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“In the case of Martha, there had been such contempt shown for the girl by
her mother whenever she needed anything emotionally from mother that Martha
learned to continue this internalized relationship with herself. She began to feel
loathing and disgust for the needy little girl inside of her. As a grown woman, she
felt reasonably okay only as long as that weak, disgusting part of her did not show
itself. But whenever it approached conscious awareness, let alone interpersonal
expression, Martha meted out swift punishment to herself including physical selfabuse. This was her way of trying to destroy the needy little girl inside of her, the
part of her so painfully disowned by her mother.” (Kaufman, 1992, p. 107).
Childhood incest and sexual and physical abuse generates intense and crippling
shame within the victim, which can often result in a profound splitting of the self. Sexual
abuse activates intense inner states of powerlessness, personal violation, and humiliation,
and in the young child is compounded by self-blame and self-contempt. This experience of
violation and helplessness is disowned, and the self withdraws deeper inside itself to escape
the terror of exposure. This is evidenced in a state of dissociation, or multiple personalities
created to justify the conflicting emotions within. In the case of all self-abusers, it is
evidenced in the self tormenting the self brutally with disgust or contempt turned against
the self in self-injury and physical pain.
Discussion
Adlerian assumptions and how they relate to self-injury
Adlerian Psychology, as a model, could easily address the major issues that
confront the self-injurer: traumatic childhood and parental abuses, low self-esteem, poor
relationships, body alienation. Adler, himself, never directly addressed the syndrome of
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self-injury, and of his followers, only Mosak mentions it briefly. Mosak cites selfmutilation as a clinical example of someone moving from a real minus to a plus, especially
in the short-term situation. “That person may receive attention, others may ‘walk on
eggshells’ when near that person (so as to not ‘upset’ him or her), and he or she may gain
some sense of subjective relief from the act, including a sense of being able to tolerate pain.
The self-mutilator may even develop moral superiority, quoting Jesus (Mark 9:47): “And if
your eye causes you to stumble, cast it out; it is better for you to enter the kingdom of God
with one eye, than having two eyes, to be cast into hell” (Mosak & Maniacci, 1999, p. 23).
It is clear that under the weight of established research by experts in the field of
self-injury that Adlerians need more guidance than this passing analysis of self-injury.
Mosak, in this reference, is using self-injury to show that “sometimes, the price one pays to
get to the perceived plus (i.e., superiority), may be a ‘real’ (i.e., concrete) minus.” (p. 22).
And it is a good example, indeed. However, he leaves the subject of “self-mutilation” after
a brief glimpse of the self-injurer as striving for attention, which is not the norm, or of
moral superiority, which in this example would be quite farfetched and rare, and not the
goal of most self-injurers. In an optimistic tone, Mosak acknowledges that the act of selfinjury can bring relief, and a sense of being able to tolerate pain which coincides with what
has been established by research in this field and in other disciplines. Actually, Adlerian
theory is a glaringly appropriate model to use when working with self-injury. Mosak
scratched the surface; I would like to cut deeper into an Adlerian approach to self-injury.
Though not directly stated, the underpinnings of self-injury as reviewed thus far,
can be recognized in Adlerian concepts. Mosak & Maniacci in their Adlerian primer could
be describing the profile of a self-injurer when they say that “the private logic of some
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people is very private, so private that they have a hard time sharing their reality with
us…Sometimes, they believe that to hurt themselves is natural; to believe they are the devil
is a matter of fact; to see themselves as horrible, worthless, and totally unlovable is the
nature of their reality” (Mosak & Maniacci, p. 48). Adler (1998), also, describes a
condition that could be applied to a self-injurer: “Individuals who do not have sufficient
confidence in their ability to achieve their goal tend not to give up their aim because of
their feeling of insecurity, but rather to approach it with greater efforts and with the aid of
additional feelings and emotions. In this way an individual, stung by a sense of her
inferiority gathers together her powers and attempts to win a desired objective in a manner
reminiscent of a brutal, uncivilized savage.” (p.217-18). Mosak (1999) tells us that Adler
considered three overburdening situations that could elicit behavior and psychopathology
in individuals: pampering, neglect, and being born with inferior organs. (p. 34). We will
see that all three of these relate to cutters and those who self-injure themselves.
As previously shown, virtually all self-abusers have suffered a damaged childhood
in some way, either through physical or emotional abuse, or pampering (over-parenting), or
neglect (under-parenting) that leaves emotional scars. These emotional scars turned inside
out result in the physical scars of self-injury.
A life style assessment of a self-injuring client would be a valuable tool to expose
the early childhood memories of experiences that have influenced this client’s private logic
that turns to cutting as a safeguarding behavior. Virtually all cutters come from a severe
family atmosphere. Adler (1998) states that “in some cases we are dealing with an
environment that is threatening to the child and give him the impression that the whole
world is hostile territory…the personality of such a child may develop so that he always
Self-Injury 79
acts as if the world really were hostile territory. His impression of its hostility will grow
with every difficulty he encounters.” (p. 18). Attachment and family atmosphere become
important elements to explore during a life style assessment, since cutters most often come
from homes that have hypercritical, abusive fathers, and emotionally cold mothers.
Organ inferiority is applicable in probing the life style of a cutter, since skin is a
sense organ. This organ defect, if not seen, can be felt by the child either through pain,
violation, or lack of affectionate touch. Adler (1998) says that “of all the tools with which
a child attempts to conquer the world, the sense organs play the most important part in
determining the essential relationships with the world in which the child lives. She
constructs her own cosmic picture through the sense organs.” (p. 38). Adler continues to
explain that virtually every child approaches the world with “heightened interest” in one
particular organ, or group of organs, be it sense or musculature. He says, “Each child
constructs a picture of the world in which she lives from the impressions that her most
sensitive organ gathers from her surroundings. Consequently we can only understand a
human being when we know what sense organs…she approaches the world with, because
this colors all her relationships. We can only interpret her actions and reactions if we first
understand the influence her organ defects have had on her attitude toward the world—on
her cosmic picture—in childhood, and thus on her later development.” (p. 39). Could this
organ inferiority, the skin, explain in part why the cutter is drawn to her skin in order to
play out the explosive emotions that move her?
And what does move her? The Adlerian assumption of teleology would seek to
determine her goal and her line of movement in self-injury. Levonkron (1998) states that
the goal in self-injury is pain. He also gives some goals toward which self-injurers direct
Self-Injury 80
their behavior: anger toward self, anger toward others (ability to hurt self but the inability
or permission to hurt others), self-medication, protecting self against emotional pains of the
past, and negative attention (Levonkron, 1998, p. 104-112). But for the Adlerian clinician,
finding the private logic would be the challenge
As previously discussed, experts have summarized characteristics most often seen
in self-injurers. Adlerians would recognize a common pattern of those life style goals of
belonging, perfection, control, power, and for some, attention. Perhaps we would see the
most common goal for cutters as the goal to belong. Karen Horney (1950, p.18) describes
this goal of belonging as “basic anxiety” with the feeling of being isolated and helpless in a
potentially hostile world. Whether the person grew up rejected by parents, family, peers, or
pampered, “over-parented” in an enmeshed family atmosphere, either situation would
create confusion as to where they belong.
Self-injury would be addressed by Adlerians as a safe-guarding mechanism.
Psychology of use would look at the act of self-injury as symptoms directed toward a
purpose. With often a severe background of abuse, the purpose is most often survival.
Adlerians look at control in one way, having control of a relationship or situation; selfabusers seek control to survive. One cutter describes the purpose of her “symptoms” in this
way: “I feel I have to control or contain the rage or whatever emotion is overwhelming me,
and hurting does that. Cutting substitutes the pain inside with a physical pain that I can
control, which is easier to handle. The pain is now real, tangible. It can be seen.” (Strong,
1998, p.43). Punishment of abusive parents, often the mother, is a purpose. Scott Lines
says that self-mutilation may be not so much self-punishment as it is a way to punish the
rejecting mother (Strong, 1998, p.47). Self-injury is a safe guarding mechanism that
Self-Injury 81
becomes a primary strategy for regulating emotions and avoiding further mental
deterioration. It is a means of self-soothing and in a sense can be viewed as a flawed
attempt at self-mothering (Strong, 1998, p.48).
Massachusetts therapist Barent Walsh conducted a study of 52 adolescent cutters
and 52 adolescent non-cutters whom he used for a control group. The cutters were
significantly more likely than the controls to have lost a parent or been placed outside the
home, suffered a childhood illness or had surgery, been the victim of sexual or physical
abuse, and witnessed impulsive, destructive behavior in their homes. In answering the
question of why the specific behavior of self-mutilation was chosen by these teens, their
answer was found that cutters have “acted out all the familiar roles from childhood: the
abandoned child, the physically damaged patient, the abused victim, the (dissociated)
witness to violence and self-destructiveness, and finally, the aggressive attacker” (1998,
p.34).
Experts agree that rage is a driving force in self-injury. Adler says of anger (1998,
p. 220) that it is the feeling that most typifies the striving for power and domination and
that its purpose is the rapid destruction of every obstacle in the way of the angered person.
For the self-injurer, this destruction is directed toward herself. Adler continues to say that
this desire to “express herself by destructiveness is plainly evident, for she chooses to
destroy something valuable and never confines her rage to worthless objects. A plan of
some kind must have been behind her action.” (p. 221). Adler is describing here about
destruction of expensive objects, such as vases, etc. thrown in a temper tantrum. However,
the point can be directed toward self-injury and one could ask; what is the deep, directed
plan of the psyche that drives the action of destruction toward oneself?
Self-Injury 82
Contrary to Adler’s statement; however, virtually all of those that injure themselves
have low self-esteem; they consider themselves worthless, and suffer self-hatred. So
according to Adler, in the case of a self-injurer, if the rage that fuels the cutting is not
directed toward the self, what/who would be the object of value to the client that she
chooses to destroy?
Virtually all of those that self-injure have low self-esteem, suffering a difficult
movement from a minus to a plus. Adlerian psychology which specializes in
inferiority/superiority movements is an excellent discipline to work with self-injurers.
Searching the hidden goals within the private logic of the client can help determine
direction of movement, purpose and change. Encouragement and optimism are Adlerian
assumptions that would be necessary to re-parent and nurture the client.
Is shame the foundation of inferiority?
But where does inferiority feelings/complex come from, and what feeds its
formation? Adlerian psychology seems to start from the base of inferiority and move
upward. I would like to explore, what I feel is the foundation of inferiority
feelings/complex and go down to its root. As Mosak & Maniacci stated (1999, p.166)
“Adlerians are more prescriptive rather than descriptive. Adlerians spend considerable time
telling what to do without describing in any great detail what is going on.” They mention
Shulman’s work in schizophrenia as an exception to that. In a small way, I would like to
provide inferiority with a more detailed definition, and as it also relates with self-injury.
Kaufman closely follows Adlerian tenets as he describes the strong association
between the striving to identify and to belong, but takes us further into the human psyche
with the consequences of shame affect: “So powerful is that striving (to belong) that we
Self-Injury 83
might feel obliged to do most anything in order to secure our place [very Adlerian
concept]. Yet, equally powerful is the alienating affect [overlooked by Adlerians]. For
shame can generate, can even altogether sever, one’s essential human ties, that we might
either feel barred from entry forever or forced to renounce the very striving to belong itself
and resignedly accept an alienated existence. No matter how strong one’s inner yearning to
belong, one’s essential dignity as a fellow human being matters more.” (Kaufman, 1992, p.
31). Adlerians expend most of their effort toward the individual’s strong yearning or
striving to belong, but seem to miss the striving to preserve one’s essential dignity as a
human being. This is not to say that Adlerians would not consider this an important value,
but seem to disregard the aspect in their search to understand the individual. Without an
astute understanding of human dignity as a powerful striving force within the individual,
the consequences of experienced shame cannot be fully appreciated.
Shame theory is consistent with Adlerian theory in identifying a learned pattern of
thoughts and feelings about ourselves, others, and the world we live in. Although,
Kaufman does not label this as a Life Style, he does echo the phenomenon that Adler
identified as life style and private logic. Kaufman says, “Specific ways of thinking and
feeling about ourselves are learned in relationship with significant others, parents most
especially, but including anyone who becomes important to us.” (p.42).
The Adlerian, in order to help understand how the individual is functioning in the
present, will assess the three Life Tasks. In following the areas of work, relationship and
intimacy the clinician is able to determine how the client is adjusting, or not adjusting to
the stresses presented in these life tasks. Again, Kaufman closely follows this line of
thought. “The central task of life-work can be construed as one of evolving a uniquely
Self-Injury 84
personal identity that gives inherent meaning to one’s life, provides direction and purpose
to one’s work, and enables one’s self to retain a sense of inner worth and valuing in the
face of all those vicissitudes of life with which we must contend, not the least of which are
anxiety, suffering, and the lack of absolute control over our own lives [especially and
inevitably in old age]. It is this last which guarantees a perpetual vulnerability to shame.”
(p. 77).
There are many other similarities that make Adlerian theory compatible with
Kaufman’s developmental theory of shame and identity. These include identifying defense
strategies of control or striving for power, striving for perfection, internal withdrawal or
avoiding, and use of active fantasy. An important connection with Alfred Adler concerning
the creative self is used by Kaufman as he has adopted Tomkins’ concept of scenes, which
are internalized images of significant individuals such as an alcoholic parent. These scenes
help shape the self, but the self is not just passive recipients of particular events. Kaufman
adds that one participates actively in how those events are interpreted as to meaning as it is
lived. He quotes Alfred Adler at this point, “Do not forget the most important fact that not
heredity and not environment are determining factors. Both are giving only the frame and
the influences which are answered by the individual in regard to his styled creative power.”
(Kaufman, 1992, p.184)
The Adlerian feel within Kaufman’s shame theory is evident enough. He has stated
(Preface to 1985 edition, p. xix) that he has integrated interpersonal theory and object
relations theory, both which have been influenced by Adler, and affect theory which is not
altogether in antipathy to Adlerian thought. I believe he has been influenced by Adler,
though not acknowledging his theory directly, has made enough indirect references to it. It
Self-Injury 85
is as with so many other theorists; Adler’s genius presented the concept, and others got the
credit.
Conclusion
Self-injury is a complex behavior driven by overwhelming emotions that can find
an outlet only through the action of producing pain inflicted upon itself. The skin is used
as the palette for several reasons as a tactile object by which the self-injurer draws inner
emotional pain to the surface. Other forms of self-injury utilize other methods of
producing pain. This shock of controlled pain results in a release of inner turmoil in a
process similar to what Gershen Kaufman refers to as an internal shame spiral as a result of
backed up affect. The observable outer scars and blood is the result of hidden emotional
turmoil which is buried, denied, forced to remain secret within. This build up of emotional
pain becomes bound and finds relief in a coping mechanism of self-injury.
In most all cases, the self-injurer has suffered a childhood of emotional conflict
which has not been addressed, allowed, or acknowledged within a narcissistic family
system which has failed to nurture a secure attachment. Shame is felt to the core and
through the process of internalized shame becomes an active, but paralyzing, part of
identity. The result is self-hatred and low self-esteem which reacts in self-protective
expression of anxiety and hidden rage. This acute anxiety and rage is bound within the
self. Since it is not allowed to be expressed toward another person it is instead directed
toward the self through self-injury.
Internalized shame is an all consuming condition focused inward on a
defective, vile self-image which needs to be purged and punished. An internalized
parental or other significant image constantly berates and reinforces the humiliating shame
Self-Injury 86
already so profoundly felt. This shame is the propelling factor that drives self-injury, and
is the fabric of inferiority feelings. For neither shame nor inferiority can exist in isolation,
but requires a social platform of comparison, social interaction and inter-relational
failures. Both focus inward to a perceived defective self, for one cannot feel inferior
without feeling shame.
Toward Further Study
As a continuation in this study of self-injury, Adlerians could develop typologies
to sort the varied goals that we have observed thus far. Certainly there is a difference
between the cutting of those who injure themselves during dissociative states and those
teens caught up in a contagion that slash themselves to belong to the group. There are
those who direct their injury toward different areas of their body, and with various means.
Each of these could be sorted out according to type. This would be helpful both in
treatment and in referrals.
A critical contribution to Adlerian Psychology would be a more in-depth
consideration of affect as a primary human motivator in identity formation, especially
during early childhood. Adlerians already recognize this through the emotional impact of
early recollections and dreams, but dismiss the power of affect, and especially of shame,
in the formation of life style and private logic. Since Adlerians consider emotions simply
as a manipulative tool in order to achieve a goal, it would be worth the effort to pursue a
revised Adlerian assumption of emotion in identity development.
Self-Injury 87
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