- Email: [email protected]
Cutting: Understanding and Overcoming Self-Mutilation
BOOK REVIEWS
Still, this book is an important one for both families of children with special needs and the professionals who work with these children. Its emphasis on intervention, on the active role of the parent, and on the need for attunement to the emotional development of the child motivates us to reexamine our typical reactions of hopelessness and resignation when faced with a child with a severe developmental disability. Trainees who read this book will be encouraged that there are real skills they can impart to the families of these children, and professionals who have long worked with children with special needs and their parents will benefit from the detailed clinical examples and the fresh theoretical perspectives so well presented here.
to borrow from a number of theoretical frameworks but does not offer any specific psychodynamic, cognitive, or behavioral theory as the basis for his interpretations. His clinical examples and explanations offer the reader a possible understanding of this bizarre behavior in a way that seems reasonable, whether or not his explanation is correct. He appears to incorporate learning theory in some cases and a more psychodynamic approach in others. For example, he describes a cycle in which people learn that the tactile and visual experience of cutting can neutralize feelings of rage, self-hatred, and fear of personality disintegration. Once someone learns that cutting works, he or she may begin to use the technique in anticipation of negative feelings. A more psychodynamic explanation appears in a vignette about Tracey (pp. 73-76), who respected her father and worried about the ill effects his drinking was having on his health despite his frequent beatings of her with a belt buckle. One day, when she was feeling disconnected from her father, Tracey cut herself with the belt buckle. Levenkron explains this behavior by writing, "Tracey had fused attachment with pain" (p. 75). His description and interpretation of self-mutilating behavior offer the reader some ways to make sense of it, which may enable the reader to become more empathetic and less judgmental toward people who cut themselves. It does not, however, offer the clinician a comprehensive framework within which this and other behaviors might be understood. Although the DSM considers self-mutilation as a symptom that can occur in a variety of psychiatric illnesses, Levenkron presents self-mutilation as a disorder. If a patient with an obvious psychiatric illness occasionally curs, he refers to the cutting as a feature of that patient's illness. However, he defines self-mutilation as a distinct disorder when it becomes the most prominent symptom. When he uses the term "dual diagnosis," he refers to people with self-mutilation and another disorder such as borderline personality disorder, depression, or an eating disorder. He does not mention that his definitions differ from conventional psychiatry. While there may be some benefits to using Levenkron's definitions, he does not offer any arguments to support such a change. These new definitions may confuse patients who are seeking treatment from clinicians who use conventional definitions. A variety of reactions toward cutting is the topic of chapter 4, "The Reactions of Others." The author notes that the public often describes CUtting as disgusting, despite the frequent exposure to violence in the media. Parents may be caught up in their own guilt; they may perceive their child's cutting as an attack against them and may say things such as "How ungrateful of you!" Mental health professionals may react with "fear, anger, disgust, and revulsion" (p. 60). As I carried this book around the hospital, I encountered many similar reactions from child psychiatrists and pediatricians. I heard comments such as "those people are really sick" and "I'm glad somebody wants to treat
Shannon S. Croft, M.D. Assistant Professor Sandra Sexson, M.D. Chief, Child and Adolescent Psychiatry Department of Psychiatry and Behavioral Sciences Emory University School of Medicine, Atlanta
Cutting: Understanding and Overcoming Self-Mutilation. By Steven Levenkron. New York: WW Norton & Company, Inc., 1998,269 pp., $25.00 (hardcover). For most people, the idea of using self-mutilation to cope with painful emotions seems illogical at best. Cutting was written by a therapist who has treated many patients who selfmutilate. The author's goal is to help readers develop some understanding of this unusual symptom. His target audience includes people who discover that someone close to them uses self-mutilation, people who are horrified or curious about the behavior (including therapists), and people who want to better understand their own cutting behavior. The book is written from his own practice; it is not a review of the literature. It also is not a treatment manual, although he does give examples of techniques that he believes have been useful. Throughout the book, the author offers vignettes to help the reader understand why people may cut themselves. During the first 3 chapters, he explores some ways that his patients have described experiencing self-mutilation. One patient, Annika, reported that she experienced cutting as "an injection of Novocaine" (p. 27). Another patient, Juanita, is quoted as saying, "It's never about liking the pain. If I liked the pain, then it wouldn't help. I hate it. That's why it helps" (p. 38). These chapters offer insight for readers into what some people gain from cutting. The examples and discussions try to reframe cutting as a solution to a difficult problem, albeit one with long-term negative consequences. The author comes closest to revealing his theoretical perspective in chapter 5, "How The Disorder Takes Shape." He appears
1058
J.
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 38:8, AUGUST 1999
BOOK REVIEWS
those patients.... I sure don't." Patients also hear these comments. This book brings these reactions into the consciousness of the reader and could help child psychiatrists begin to examine our countertransference toward this population. In part 2 of the book, Levenkron focuses on techniques that he uses in treating his patients. Again, he offers examples that illustrate his techniques. The techniques make sense, but they are not organized by any particular theory. In chapter 12 he gives an example of reacting to a patient in a way that the patient does not expect. When a patient complained of feeling hot and took off her sweater so that she was covered only by a bra, he covered her with an afghan and told her, "There will be no abuse or sexual exploitation allowed here" (p. 159). In chapter 13 he illustrates how he uses observations about the patient to help get a silent patient talking. In chapter 18 he uses role playing to help patients learn to become more assertive. Each technique makes sense, but again, the success of these techniques is based on Levenkron's own experiences and is not supported by empirical data or theoretical framework. In chapters 15 through 17 Levenkron does make it clear that clinicians, patients, and patients' families should expect a slow course of treatment. He reminds readers that a relapse of symptoms does not mean that the gains of therapy have been erased. He also acknowledges that many patients have relied on self-injury for years and may miss it; when self-mutilation resolves, other symptoms may emerge. This section of the book may help patients, their families, and clinicians not to become demoralized when the patient appears to regress. This book is successful in its mission of explaining to readers why someone may develop a pattern of self-mutilation. A clinician who would like to make a start in understanding this population may benefit from reading it. However, the clinician should not expect either a comprehensive theoretical framework or any specific treatment guidelines. A group of clinicians could use this book to begin discussing their countertransference toward this population. The book could also be used as an opening for a clinician to help family members understand an individual patient and might facilitate discussion among the clinician, the patient, and the family. However, the book does not offer many suggestions on how families can actively participate in helping the patient stop self-injuring nor is it a self-help book for patients. Patients and families who read the book on their own may finish it with an increased understanding of self-mutilation, but they may not be sure how to start changing the behavior. Shannon Rae Barnett, M.D. Child and Adolescent Psychiatry Resident Emily Frosch, M.D. Assistant Professor The Johns Hopkins Medical Institutions Baltimore
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 38:8, AUGUST 1999
Needs, Urges arId Feelings in Early Childhood: Helping Young Children Grow. By Erna Funnan. Madison, CT: International Universities Press, Inc., 1998, 129 pp., $24.95 (softcover). Relationships in Early Childhood: Helping Young Children Grow. By Erna Furman. Madison, CT: International Universities Press, Inc., 1998, 161 pp., $24.95 (softcover). Self-Control and Mastery in Early Childhood: Helping Young Children Grow. By Erna Furman. Madison, CT: International Universities Press, Inc., 1998, 169 pp., $24.95 (softcover). Erna Furman, a child analyst at The Cleveland Center for Research in Child Development, has re-released her volume Helping Young Children Grow (International Universities Press, 1987) as a set of 3 slim paperback volumes. She hopes that the re-release of this work in a new form will allow readers easier access to a topic of special interest. She also notes that the reference and related readings sections have been updated. The book was designed as a textbook for a child developmentparenting course and is geared more for the layperson, or early student of child development, rather than the more seasoned professional. Her psychoanalytic perspective is clear throughout; these volumes are intended to help parents and students understand the internal perspectives and motivations of young children. Overall, they make for an excellent grounding, both theoretical and practical, in the emotional and intellectual development of children. In Needs, Urges and Feelings in Early Childhood, Furman explores the dynamic inner source of a child's emerging personality. In different sections on needs, urges, and feelings, she traces the development of each from its primitive roots, to its more subtle variations in the toddler and preschool child. For instance, in the section on urges, which are also known as impulses or drives, Furman asserts the fundamental presence of a pleasure-seeking drive and an aggressive one. This is familiar territory to students of psychoanalytic theory. She then traces these drives developmentally for the reader, suggesting that the fascination with and pleasure drawn from the body in early childhood forms the basis, in successful development, for a child's interest in the world around him or her. In a similar way she asserts that the innate aggressive urge can be essential in later life as a drive for self-defense and as an energy source for activity and action in the world. Furman is strongest when discussing the tasks and potential pitfalls for the mothering figure. In many different examples she suggests the need for parents to find a middle way between parenting that is too permissive and therefore does not help the child develop away from his or her immature expressions of needs, urges, and feelings, and parenting that is too strict and developmentally too demanding. The latter type of par-
1059
Still, this book is an important one for both families of children with special needs and the professionals who work with these children. Its emphasis on intervention, on the active role of the parent, and on the need for attunement to the emotional development of the child motivates us to reexamine our typical reactions of hopelessness and resignation when faced with a child with a severe developmental disability. Trainees who read this book will be encouraged that there are real skills they can impart to the families of these children, and professionals who have long worked with children with special needs and their parents will benefit from the detailed clinical examples and the fresh theoretical perspectives so well presented here.
to borrow from a number of theoretical frameworks but does not offer any specific psychodynamic, cognitive, or behavioral theory as the basis for his interpretations. His clinical examples and explanations offer the reader a possible understanding of this bizarre behavior in a way that seems reasonable, whether or not his explanation is correct. He appears to incorporate learning theory in some cases and a more psychodynamic approach in others. For example, he describes a cycle in which people learn that the tactile and visual experience of cutting can neutralize feelings of rage, self-hatred, and fear of personality disintegration. Once someone learns that cutting works, he or she may begin to use the technique in anticipation of negative feelings. A more psychodynamic explanation appears in a vignette about Tracey (pp. 73-76), who respected her father and worried about the ill effects his drinking was having on his health despite his frequent beatings of her with a belt buckle. One day, when she was feeling disconnected from her father, Tracey cut herself with the belt buckle. Levenkron explains this behavior by writing, "Tracey had fused attachment with pain" (p. 75). His description and interpretation of self-mutilating behavior offer the reader some ways to make sense of it, which may enable the reader to become more empathetic and less judgmental toward people who cut themselves. It does not, however, offer the clinician a comprehensive framework within which this and other behaviors might be understood. Although the DSM considers self-mutilation as a symptom that can occur in a variety of psychiatric illnesses, Levenkron presents self-mutilation as a disorder. If a patient with an obvious psychiatric illness occasionally curs, he refers to the cutting as a feature of that patient's illness. However, he defines self-mutilation as a distinct disorder when it becomes the most prominent symptom. When he uses the term "dual diagnosis," he refers to people with self-mutilation and another disorder such as borderline personality disorder, depression, or an eating disorder. He does not mention that his definitions differ from conventional psychiatry. While there may be some benefits to using Levenkron's definitions, he does not offer any arguments to support such a change. These new definitions may confuse patients who are seeking treatment from clinicians who use conventional definitions. A variety of reactions toward cutting is the topic of chapter 4, "The Reactions of Others." The author notes that the public often describes CUtting as disgusting, despite the frequent exposure to violence in the media. Parents may be caught up in their own guilt; they may perceive their child's cutting as an attack against them and may say things such as "How ungrateful of you!" Mental health professionals may react with "fear, anger, disgust, and revulsion" (p. 60). As I carried this book around the hospital, I encountered many similar reactions from child psychiatrists and pediatricians. I heard comments such as "those people are really sick" and "I'm glad somebody wants to treat
Shannon S. Croft, M.D. Assistant Professor Sandra Sexson, M.D. Chief, Child and Adolescent Psychiatry Department of Psychiatry and Behavioral Sciences Emory University School of Medicine, Atlanta
Cutting: Understanding and Overcoming Self-Mutilation. By Steven Levenkron. New York: WW Norton & Company, Inc., 1998,269 pp., $25.00 (hardcover). For most people, the idea of using self-mutilation to cope with painful emotions seems illogical at best. Cutting was written by a therapist who has treated many patients who selfmutilate. The author's goal is to help readers develop some understanding of this unusual symptom. His target audience includes people who discover that someone close to them uses self-mutilation, people who are horrified or curious about the behavior (including therapists), and people who want to better understand their own cutting behavior. The book is written from his own practice; it is not a review of the literature. It also is not a treatment manual, although he does give examples of techniques that he believes have been useful. Throughout the book, the author offers vignettes to help the reader understand why people may cut themselves. During the first 3 chapters, he explores some ways that his patients have described experiencing self-mutilation. One patient, Annika, reported that she experienced cutting as "an injection of Novocaine" (p. 27). Another patient, Juanita, is quoted as saying, "It's never about liking the pain. If I liked the pain, then it wouldn't help. I hate it. That's why it helps" (p. 38). These chapters offer insight for readers into what some people gain from cutting. The examples and discussions try to reframe cutting as a solution to a difficult problem, albeit one with long-term negative consequences. The author comes closest to revealing his theoretical perspective in chapter 5, "How The Disorder Takes Shape." He appears
1058
J.
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 38:8, AUGUST 1999
BOOK REVIEWS
those patients.... I sure don't." Patients also hear these comments. This book brings these reactions into the consciousness of the reader and could help child psychiatrists begin to examine our countertransference toward this population. In part 2 of the book, Levenkron focuses on techniques that he uses in treating his patients. Again, he offers examples that illustrate his techniques. The techniques make sense, but they are not organized by any particular theory. In chapter 12 he gives an example of reacting to a patient in a way that the patient does not expect. When a patient complained of feeling hot and took off her sweater so that she was covered only by a bra, he covered her with an afghan and told her, "There will be no abuse or sexual exploitation allowed here" (p. 159). In chapter 13 he illustrates how he uses observations about the patient to help get a silent patient talking. In chapter 18 he uses role playing to help patients learn to become more assertive. Each technique makes sense, but again, the success of these techniques is based on Levenkron's own experiences and is not supported by empirical data or theoretical framework. In chapters 15 through 17 Levenkron does make it clear that clinicians, patients, and patients' families should expect a slow course of treatment. He reminds readers that a relapse of symptoms does not mean that the gains of therapy have been erased. He also acknowledges that many patients have relied on self-injury for years and may miss it; when self-mutilation resolves, other symptoms may emerge. This section of the book may help patients, their families, and clinicians not to become demoralized when the patient appears to regress. This book is successful in its mission of explaining to readers why someone may develop a pattern of self-mutilation. A clinician who would like to make a start in understanding this population may benefit from reading it. However, the clinician should not expect either a comprehensive theoretical framework or any specific treatment guidelines. A group of clinicians could use this book to begin discussing their countertransference toward this population. The book could also be used as an opening for a clinician to help family members understand an individual patient and might facilitate discussion among the clinician, the patient, and the family. However, the book does not offer many suggestions on how families can actively participate in helping the patient stop self-injuring nor is it a self-help book for patients. Patients and families who read the book on their own may finish it with an increased understanding of self-mutilation, but they may not be sure how to start changing the behavior. Shannon Rae Barnett, M.D. Child and Adolescent Psychiatry Resident Emily Frosch, M.D. Assistant Professor The Johns Hopkins Medical Institutions Baltimore
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 38:8, AUGUST 1999
Needs, Urges arId Feelings in Early Childhood: Helping Young Children Grow. By Erna Funnan. Madison, CT: International Universities Press, Inc., 1998, 129 pp., $24.95 (softcover). Relationships in Early Childhood: Helping Young Children Grow. By Erna Furman. Madison, CT: International Universities Press, Inc., 1998, 161 pp., $24.95 (softcover). Self-Control and Mastery in Early Childhood: Helping Young Children Grow. By Erna Furman. Madison, CT: International Universities Press, Inc., 1998, 169 pp., $24.95 (softcover). Erna Furman, a child analyst at The Cleveland Center for Research in Child Development, has re-released her volume Helping Young Children Grow (International Universities Press, 1987) as a set of 3 slim paperback volumes. She hopes that the re-release of this work in a new form will allow readers easier access to a topic of special interest. She also notes that the reference and related readings sections have been updated. The book was designed as a textbook for a child developmentparenting course and is geared more for the layperson, or early student of child development, rather than the more seasoned professional. Her psychoanalytic perspective is clear throughout; these volumes are intended to help parents and students understand the internal perspectives and motivations of young children. Overall, they make for an excellent grounding, both theoretical and practical, in the emotional and intellectual development of children. In Needs, Urges and Feelings in Early Childhood, Furman explores the dynamic inner source of a child's emerging personality. In different sections on needs, urges, and feelings, she traces the development of each from its primitive roots, to its more subtle variations in the toddler and preschool child. For instance, in the section on urges, which are also known as impulses or drives, Furman asserts the fundamental presence of a pleasure-seeking drive and an aggressive one. This is familiar territory to students of psychoanalytic theory. She then traces these drives developmentally for the reader, suggesting that the fascination with and pleasure drawn from the body in early childhood forms the basis, in successful development, for a child's interest in the world around him or her. In a similar way she asserts that the innate aggressive urge can be essential in later life as a drive for self-defense and as an energy source for activity and action in the world. Furman is strongest when discussing the tasks and potential pitfalls for the mothering figure. In many different examples she suggests the need for parents to find a middle way between parenting that is too permissive and therefore does not help the child develop away from his or her immature expressions of needs, urges, and feelings, and parenting that is too strict and developmentally too demanding. The latter type of par-
1059