Healthcare Training Institute - Quality Education since 1979
Psychologist, Social Worker, Counselor, & MFT!!

Section 1
Track #1 - Introduction & The Reason Behind the Pain

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Introduction
Welcome to the Home Study Course sponsored by the Healthcare Training Institute, homestudycredit.com. This course is entitled, Physical Pain Stops my Pain.

Our primary intent for this home study course is to provide quality education to foster your professional growth. The Institute has provided quality education since 1979.

Hi. My name is Tracy Catherine Appleton. I will be the narrator of this CD set. We appreciate that you have chosen us as a vehicle for you to earn your Continuing Education Credit.

The purpose of the course is to assist you in increasing your knowledge regarding how to treat patients, clients, etc. dealing with self mutilation. As each case study is given, if the concepts seem to be applicable to your situation, I encourage you to turn your CD player off and make a few notes regarding the application of the principle to your setting. However, these notes are for your purposes only and are not to be sent to the Institute. Also each track is very content dense. So feel free to replay the track to review the content either for your own purposes, or if you feel appropriate play the track in an individual or group session for client education. Also permission is granted to reproduce this CD.

Each of the questions that are included on this CD set is reprinted in your Answer Booklet. These questions are sequential and deal with the section of content that preceded it. For this reason, to facilitate the answering of each question, you might read the question from the Answer Booklet prior to listening to that CD track. By knowing what the question is ahead of time, you will then know the content to listen for that contains the answer. So just a hint, after you write down the answer to a question in your Answer Booklet, read on to the next question in order to give you a "heads up" to listen for the content that contains the answer to the next question. Each answer is only used once. Keep in mind there is nothing trick or hard about these questions. They are merely intended to verify the playing of this CD set.

For the purpose of brevity, most generally, I will use the term "therapists" or "mental health professional." However, don't let these terms deter you from applying the concepts to your situations. When you hear the word "therapists," if your job title is social worker, psychologist, marriage and family therapist, mental health counselor, professional counselor, resident director, program assistant, etc. merely substitute the appropriate term that is the most meaningful to you. In short, don't let my use of the term "therapists" cognitively set you off track from hearing the content because your job title is school counselor, for example. I will also use the term "client" for the purposes of brevity. However, if you deal with patients, residents, students, consumers, etc., transpose "client" for the term that is the most meaningful to you in your work setting.

On this CD set we will discuss such topics as: the reason behind the pain, feeling the pain, hospitalization, the vulnerable teen, body image, effect on the family, therapy tactics, substituting self-control, DSM Diagnosis, justifying the pain, cultural pressures, attachments, resistant clients, and challenges in the final stages of recovery.

So let's get started.

It seems that a logical place to start is with the obvious. Why the teens become cutters. On this track, we will examine the five reasons I have found why clients self-injure. These reasons are: to relieve anger; to indirectly retaliate; to test loyalty; to maintain control; and to induce caring responses from others.

As you probably have observed, self-mutilating clients tend to live with the myth that when someone gets mad, somebody has to get hurt. Usually, this stems from a childhood home that valued repressing angry emotions. Crystal, age 16, stated "My family almost never showed any anger, but when they did, it sure got bad. My fantasies are that I want self-injury to the point of death. Sometimes I feel like if I self-injure, maybe someone will notice me." Crystal's emotionally repressive family left little room for self-expression. I felt Crystal's need for someone to notice her is a way for her suppressed emotions to make themselves known. Many times, Crystal believed that it was better for her to hurt herself than to hurt someone else, or to let someone else hurt her first.

A second reason for self-mutilation in addition to a "notice me" kind of anger is it can serve as an indirect means of retaliation. In this case, self-injurers who have been abused as children think that mutilation of themselves will cause pain to their aggressor. Unable to express their feelings of wrongdoing coupled with their belief that those feelings would be ignored, clients like Sylvia repress their emotions until they're released through self-injury. Sylvia, age 19, was abused by her father when she was 7. She stated, "My parents never publicly recognized the abuse. Every time I confronted them, they denied the whole thing. They really never addressed my feelings of betrayal or loss of trust. I thought 'I'll show them' and that's when I started cutting." At the end of this track, I will discuss how I how I utilized a "Fantasy" exercise with Sylvia's feeling of indirect retaliation.

A third reason for self-mutilation in addition to a "notice-me" kind of anger and indirect retaliation, I have found clients sometimes use self-mutilation as a means of control. Generally, this is a result of an abusive or traumatic childhood. As you know, clients who experienced sexual manipulation have lost a sense of control of their environment and self-mutilation is a way to regain it. They decide when and how long the pain will endure, not their aggressor. Sylvia stated, "I felt that when I inflicted pain on myself, I was reclaiming what I had lost." Sylvia described her pain as a way of forcibly establishing a line between herself and her aggressor, in this case mainly her father.

A fourth reason for self-mutilation: Sylvia also used her self-injuries to test a person's loyalty to her. She would be very open about her self-mutilation. She stated, "One pattern in my life that I'd like to change is my need to sort of poke at people in order to see how much I can trust them and whether or not they'll leave me." Her loss of trust as a result of her childhood abuse caused her to feel alone and helpless. Cutting herself and talking openly about it was her way of protecting herself from a second loss should someone she trusted betray her. As you are aware, many times, clients who reveal their self-mutilation in public also want to assert a personal declaration. Tony, age 17, stated, "I liked the attention I got from people. I felt like I was different or tough. I told myself that I was strong enough to take it and everyone else was impressed with my strength."

In addition to relieving anger, maintaining control, indirect retaliation, and a test of loyalty, clients use self-mutilation to engage people's caring responses. Kristen, age 18, stated, "When I knew someone would be seeing the cuts, I was hoping they would feel compassion and want to help me." There's a fantasy behind Kristen's line of thinking, that if the other person cared enough, he or she would prevent the mutilation from happening. In reality, her dramatic actions drive her loved ones away in understandable fear. This only strengthens Kristen's view that the world is uncaring and apathetic to her needs. Also, clients like Kristen tend to rely on the therapist to rescue them from themselves. Ultimately, though, only Kristen can save herself. Eventually, when all human relationship disintegrated, Kristen looked to her scars and the instruments she used to self-injure as her friends.

One way I helped Sylvia to begin to overcome the abuse by her father was to help her express in words what her self-mutilation was trying to communicate. To do this, I used a "Fantasy" technique. I had Sylvia who was abused by her father write down and identify the people she felt who wronged her, create a fantasy of revenge, and then imagine what actual apologies, punishments, or retribution might reasonably occur. In this way, Sylvia could express the things she needed in order to put her traumatic childhood behind her.

Sylvia wrote, "I feel that my mom hurt me as a child by ignoring my needs and focusing on my brother's needs. She heard my brother's cries but not mine. My dad abused me emotionally and sexually. I don't feel that any of my mom's actions have ever been talked about. I still feel that she loves me, but I still have problems believing that she loved me when I was younger and dad was going what he did." After expressing her feelings of wrongdoing, Sylvia went on to explain a necessary retribution for her reconciliation with her past. "I would like to see my dad go to jail for the crimes he did to me when I was younger. I would also like to see a confession from him, but that won't happen. I guess a confession from both of my parents would make me feel better." In articulating her emotions through the fantasy and words but not self-injury, Sylvia began to learn how the abuse was leading to her cutting.

On this track, we discussed the five reasons clients initiate self-injury. Those reasons were to relieve anger; to indirectly retaliate; to test loyalty; to maintain control; and to induce caring responses from others. Think for a moment of you self-injuring client do any of these reasons apply to them? If so which one? Would the fantasy technique I used with Sylvia be beneficial? We also saw how the "Fantasy" technique can help self-injurers express their emotions.

On the next track, we will discuss several examples of clients suffering from dissociation: those who feel numb; those who use pain to reassure themselves of their own existence; and those who view the pain as a penance for wrongdoing.

QUESTION 1
What are five reasons why your client may self-mutilate? To select and enter your answer go to Answer Booklet.