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Cutting: Understanding and Overcoming Self-Mutilation.
By Steven Levenkron.
New York: W.W. Norton & Company, 1998, 254 pages, $14.00.
In Cutting: Understanding and Overcoming Self-Mutilation, Steven Levenkron describes an encompassing approach to understanding and treating adolescents and young adults plagued by self-mutilation in a variety of levels and ranges of the disorder. The book provides a very eclectic view of treating the disorder, ranging from behavioral, cognitive, and client-centered schools of thinking. From the behavioral perspective, Levenkron discusses maladaptive learning of the behavior by the client, and refers that they are achieved by the same mechanism as positive behaviors. This learning in some cases, he states, occurs from modeling the behavior of another person, and in more cases than not, it is abusive behavior towards the self-mutilator. The author touches a great deal on the maladaptive thinking of the client and that most have a deep self-hatred and having the client incorporate positive self-thoughts into their everyday lives. In addition, Levenkron makes known the importance of having a genuine and trusting relationship with the client as the basis for treatment.
The book begins with part I: the illness, in which chapters one and two describe the act of self-mutilation and give cases studies of those committing the act. In each of the chapters, the author includes case studies to illustrate both the topic covered in the chapter and the variety of patients the disorder affects. The book points out in the second chapter an important idea to keep in mind about those who mutilate themselves: that most who do so have suffered abuse from those closest to them during their formative years. Because this becomes such a regular part of their life, they recreate the pain that was caused by family members because they identify the pain with security, home and comfort. Meanings in the lives of these children are formed during their earliest years.
The next chapter describes the ‘typical’ self-mutilator and what feelings they are likely to be having, such as powerless, loneliness, and guilt?. It discusses environmental and chemical factors that can come together to play into the occurrence of the behavior. The chapter also discusses differences in self-mutilation; that which is non-dissociative and that which is dissociative. Chapter four focuses on the reactions of others to the illness, including the public, the client’s family, and the therapist, stating that most in those categories misunderstand the behavior and its origins.
Chapter five highlights what moves the behavior from that of an act to the further complexity of a disorder. The text also mentions other disorders that may co-occur with self-mutilation, including eating disorders, obsessive-compulsive disorder, depression, and others. The following chapter deals with the more serious cases of self-mutilators and the fact that the longer the time that an individual relies on their defenses of self-mutilation to ease their emotional pain, the more difficult it becomes to release them from the illness. In the most serious of cases, thoughts of the act are eliminated and the behavior becomes automatic.
In chapter seven, Levenkron approaches the topic of attachment and of its importance in human relationships and as an essential development in the formative years of a child. He goes to explain that attachment in the lives of self-mutilators typically suffers in that clients have difficulty in forming attachments to people in adolescence and later life. Because of the abuse that they have suffered, low self-esteem is prominent and self-mutilators refrain from being dependent on anyone but him or herself and have severe deficits in trusting people. He highlights that an essential step in the process of therapy is to form the therapeutic relationship with the client. They must learn to trust the therapist to begin to gain understanding into what drives their behavior.
The next chapter follows closely behind emphasizing that self-mutilators find their cutting beneficial because it is something over which they can have control. The cutting serves as a type of self-medication, allows the emotional pain they are suffering to disappear for a while. Some self-mutilators experience secondary gain from the act in the form of the negative attention they receive when someone notices the cuts, unconsciously receiving some gratification of attention, although it is negative. This chapter also goes into further depth on dissociative cutting, where self-mutilators go into a ‘trance’ state in which they wake up typically hours later and have cut themselves, but have no memory of the act.
Chapter nine discusses the benefits of pain in our society and how it is seen as a necessity in the path of achieving a goal. The author also speaks of how we as a society must be careful not to overlook pain that is unnecessary. The next chapter explores more deeply the environmental side of the disorder, as it concentrates on the family of the self-mutilator and how parenting styles and the influence that difficult situations, such as financial instability, chronic illness, drug abuse, among others may have. It states that many pitfalls in a child’s development can come from a role reversal, where the child is forced to take on the role of the parent and provide nurturance for those from whom they should be receiving it. Finally, the chapter gives precautions to parents for those children where self-mutilation may be a reality.
The final chapter in this section of the book tackles incest and other abuse. These topics have been previous glossed over in the text, but are gone into with more depth here. Solid insight is given into the damage that can be caused by these types of relationships. What may be most memorable is that much of the pain that is inflicted on themselves occurs because the abuse they receive is paired in their minds with the pleasantness of the relationship they shared with the abuser. The cutting is a way for the patient to relive the pain that they had also shared.
The second and final section of the book focuses on the process of recovery involved in self-mutilation. The majority of the chapters in this section would more likely be most beneficial for the therapist as they provide helpful guidelines on working through recovery and overcoming obstacles along the way. The first chapter illustrates the importance of change in the client for recovery and therapy in general to be successful and lasting. Also included are characteristics of the client, which may give the therapist an idea about their current functioning and a likely prediction of their recovery. The following chapter discusses what steps might prove helpful to the therapist when just beginning therapy with the client. It gives examples of the personalities in which clients may enter therapy and effective ways to break through their walls.
Chapter fourteen addresses those qualities possessed by the psychotherapist that may be advantageous in the therapeutic relationship with the self-mutilator, pointing out the necessity of providing reparenting of the client which allows for a reversion to a more childlike state where security can be provided and ‘correct’ parenting can be established. The next chapter approaches the circumstances of setbacks that occur during the process of recovery and approaches on how the therapist and client should work together to overcome the obstacles.
The following chapters may be useful for the clinician to assign to the client after the relationship has been established and a good deal of progress has been made. Chapter sixteen primarily focuses on the final choice that self-mutilators have to make at some point between cutting and trusting others. Some reference is also made to cultural differences between the client and therapist and how to overcome those possibly difficult situations. The next chapter may be beneficial for clients and/or parents to read when some setbacks in recovery occur. The issue of dual diagnosis with the client is further elaborated.
The final two chapters are dedicated to maintaining the client’s recovery and steps for regaining the client’s life after this is reached. Chapter eighteen highlights the importance of assertiveness in the life of the client and the benefits of role-playing situations in the life of the client for support. The final chapter touches on medications available to the client and the importance of maintaining their use, understanding heredity of the client and what problems that may bring, regret of the client for the time lost to the illness, and the recovery that the family of the client also faces.
The author states that the book is intended for victims engaging in the behavior; the family and friends of those participating; the mental health community; and the general public. While a great deal of that target audience could benefit from reading this book, it may not be appropriate for those under the age of sixteen due to the terminology and the manner in which it was written. It may be too difficult for those under that age to gain anything meaningful from the text.
While the book does mostly address those who are more statistically likely to suffer from this disorder, it does attend to several facets of that group, including clients of different cultures than the clinician, those ranging from children to young adults, clients of a variety of socio-economic backgrounds and a variety of situations which have brought on the disorder in the client. One drawback is that the book is more specific to females, as the vast majority of case studies are of a female character as is the subject of the disorder addressed in the book.
It may not be possible that self-mutilators will be willing to honestly read the book unless they have a willingness to change and to come to terms with their problem. For those that fall into that category, this book may be a very useful guide to clients to learn more about the disorder and its dimensions, while undergoing psychotherapy that is specific to their situation. The book could provide a good springboard for conversation about particular patients or situations described in the book that may resemble their own or other questions it may unearth in the therapy setting.
The text would be very helpful for psychotherapists who are interested in the disorder or who may be confronted with a client suffering from the disorder. While it does contain some language that is very basic in the field of psychology, is contains definitions for those who may not be familiar, making it very readable. However, it also contains some insights and explanations that may be very helpful to a psychotherapist who has not previously dealt with this issue.
It may be suggested that if a psychotherapist is considering prescribing this book to a patient or possibly for family members to read, that one or two chapters, beginning with chapter one, be assigned to be read between sessions or per week. This would only be appropriate once trust is gained from the client, a therapeutic relationship formed, and at least some insight is present from the client and/or family member. It could be helpful to begin each session by discussing or clarifying anything assigned from the book that the client may choose. It might be beneficial to assign the chapters in order to allow for their base of knowledge about the disorder to grow. Chapter eleven and beyond may not be appropriate to use with clients and may be more appropriate for use by the clinician. Also, they may be too difficult for the average client to benefit from?. After chapter five in the text, the clinician should use caution when assigning readings, as some sections may only be appropriate for particular patients based on their situations and individual characteristics. The client may also be asked to read only specific sections of the chapters between sessions, according to the discretion of the psychotherapist, in cases where smaller amounts of reading would be more beneficial. As previously stated, the pace and reading level of the client should be assessed by the therapist by discussing such matters in the session with the client.
As the majority of the book focuses on family involvement in the creation of the disorder in the client, it may be difficult for some caregivers or family members to read because it points the finger at them as typically the cause of the disorder. For some parents who have some insight into their relationship with the child and the child’s condition, reading this book may be productive in further understanding the inner workings of the child in their current state of mind and how the particulars of the family life may have initiated this chain of events. However, some parents or family members may not be ready for the harshness and blunt reality of the stories told in the book and how the disorder comes about. Reading about this may not be beneficial and may even be detrimental to the parents’ relationship with the therapist or child.
There are many valuable and effective uses for this book in the therapeutic process. However, due to the nature of self-mutilation and its causes the psychotherapist should exercise caution when readings are assigned. It is important to be sure that the client is prepared for what will be read and the clinician should actively process the effect of these readings on clients with them. The text was found to be very enlightening on the nature and causes of self-mutilation. It should be a very useful tool in support of the therapeutic process for this particular type of patient.