Okay, my friend, this page might just be what you need! But be careful with the information here. Let me say it again -

BE CAREFUL

I say that because if you handle it right, he won't catch on. This info is designed to help you begin to take yourself back from his control and manipulation. It will be a long, hard road, but if you follow these instructions EXACTLY and be STRONG, you will BREAK FREE of his control.

Are you ready?

Okay, first of all, let me tell you that all the techniques I am describing here are in THE BOOK - The Verbally Abusive Relationship by Patricia Evans. They work. How do you think I got here? I encourage you to GET THE BOOK!!! It would be the best $10 or so you'll ever spend.

Here we go...

Whatever you are talking about at the time, the abuser is good at "turning it around" on you. You know what I mean:

YOU: Where is the money in the savings account?

HIM: You just don't trust me - you've NEVER trusted me.

YOU: Yes, I do.

HIM: No, you always accuse me of stuff I didn't do.

YOU: I didn't accuse you of anything.

HIM: And you always think I'm up to something.

Sound familiar? That's called "diverting." You start one conversation, then all of a sudden YOU are on the defense! And later you think, "how did that happen?!"

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This is what you do: whatever your question, ask it. Then, when he starts his diversion tricks, ASK THE SAME QUESTION EXACTLY THE SAME WAY AGAIN. No matter what he says, no matter where he tries to take you, EXACTLY AS BEFORE.

YOU: Where is the money in the savings account?

HIM: You just don't trust me - you've NEVER trusted me.

YOU (calmly): Where is the money in the savings account?

HIM: It's my money! You didn't work for it!

YOU (still calm): Where is the money in the savings account?

After a few minutes, he will become confused, which will be a small victory for you, since you are usually the one confused by now. DO NOT LET HIM DIVERT YOU! If you practice this technique, after a while it will get easier and easier. BE WARNED: once he sees that this doesn't work anymore, he may try something new.

Another thing that I noticed I was doing was trying to defend myself against his accusations. If he accused me of having a boyfriend (which was one of his favorites), I'd deny it. DON'T DENY ANYTHING TO DEFEND YOURSELF. Check this out:

HIM: You've been gone too long. Have a good time with your boyfriend?

YOU: I don't have a boyfriend. The grocery store was just busy.

HIM: Oh, sure. The meat is probably gone bad. You were in some motel.

YOU: No, I wasn't. I told you, it was crowded and the cashier was really slow.

Been there? Okay, try this next time:

HIM: You've been gone too long. Have a good time with your boyfriend?

YOU (calmly): I do not have to listen to this. I'm leaving.

[at this point, leave the room - chances are, he'll follow you]

HIM: Your boyfriend must be really good in bed. Where did you meet this time?

YOU (still calm): I do not have to listen to this. I'm leaving.

[leave the room again - sometimes I ended up leaving the HOUSE - go for a walk!]

Again, just stay calm, and keep repeating. DO NOT DIGNIFY HIS ACCUSATION WITH DENIAL. After a while, as before, it'll get easier.

WARNING! After some time, this becomes FUN. Yes, you will begin to think of it as a game, how do I get him this time? This is sad, in a way, but it's true. I will be saying "I told you so."

next: For Friends and Family of Domestic Violence Victims
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~ all articles on abuse issues

Detailed information on self-mutilation. Definition, reasons for self-mutilating behavior, misconceptions, treatment for self-mutilation.

Individuals who self-injure often have suffered sexual, emotional, or physical abuse

Introduction

Suyemoto and MacDonald (1995) reported that the incidence of self-mutilation occurred in adolescents and young adults between the ages of 15 and 35 at an estimated 1,800 individuals out of 100,000. The incidence among inpatient adolescents was an estimated 40%. Self-mutilation has been most commonly seen as a diagnostic indicator for borderline personality disorder, a characteristic of Stereotypic Movement Disorder (associated with autism and mental retardation) and attributed to Factitious Disorders. However, practitioners have more recently observed self-harming behavior among those individuals diagnosed with bipolar disorder, obsessive-compulsive disorder, eating disorders, dissociative identity disorder, borderline personality disorder, schizophrenia, and most recently, with adolescents and young adults. The increased observance of these behaviors has left many mental health professionals calling for self-mutilation to have its own diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (Zila & Kiselica, 2001). The phenomenon is often difficult to define and easily misunderstood.

Definition of Self-Mutilation

Several definitions of this phenomenon exist. In fact, researchers and mental health professionals have not agreed upon one term to identify the behavior. Self-harm, self-injury, and self-mutilation are often used interchangeably.

Some researchers have categorized self-mutilation as a form of self-injury. Self-injury is characterized as any sort of self-harm that involves inflicting injury or pain on one's own body. In addition to self-mutilation, examples of self-injury include: hair pulling, picking the skin, excessive or dangerous use of mind-altering substances such as alcohol, and eating disorders.

Favazza and Rosenthal (1993) identify pathological self-mutilation as the deliberate alteration or destruction of body tissue without conscious suicidal intent. A common example of self-mutilating behavior is cutting the skin with a knife or razor until pain is felt or blood has been drawn. Burning the skin with an iron, or more commonly with the ignited end of a cigarette, is also a form of self-mutilation.

Self-mutilating behavior does exist within a variety of populations. For the purpose of accurate identification, three different types of self-mutilation have been identified: superficial or moderate; stereotypic; and major. Superficial or moderate self-mutilation is seen in individuals diagnosed with personality disorders (i.e. borderline personality disorder). Stereotypic self-mutilation is often associated with mentally delayed individuals. Major self-mutilation, more rarely documented than the two previously mentioned categories, involves the amputation of the limbs or genitals. This category is most commonly associated with pathology (Favazza & Rosenthal, 1993). The remaining portion of this digest will focus on superficial or moderate self-mutilation.

Additionally, self-injurious behavior may be divided into two dimensions: nondissociative and dissociative. Self-mutilative behavior often stems from events that occur in the first six years of a child's development.

Nondissociative self-mutilators usually experience a childhood in which they are required to provide nurturing and support for parents or caretakers. If a child experiences this reversal of dependence during formative years, that child perceives that she can only feel anger toward self, but never toward others. This child experiences rage, but cannot express that rage toward anyone but him or herself. Consequently, self-mutilation will later be used as a means to express anger.

Dissociative self-mutilation occurs when a child feels a lack of warmth or caring, or cruelty by parents or caretakers. A child in this situation feels disconnected in his/her relationships with parents and significant others. Disconnection leads to a sense of "mental disintegration." In this case, self-mutilative behavior serves to center the person (Levenkron, 1998, p. 48).

Reasons for Self-Mutilating Behavior

Individuals who self-injure often have suffered sexual, emotional, or physical abuse from someone with whom a significant connection has been established such as a parent or sibling. This often results in the literal or symbolic loss or disruption of the relationship. The behavior of superficial self-mutilation has been described as an attempt to escape from intolerable or painful feelings relating to the trauma of abuse.

The person who self-harms often has difficulty experiencing feelings of anxiety, anger, or sadness. Consequently, cutting or disfiguring the skin serves as a coping mechanism. The injury is intended to assist the individual in dissociating from immediate tension (Stanley, Gameroff, Michaelson & Mann, 2001).

Characteristics of Individuals Who Self-Mutilate

Self-mutilating behavior has been studied in a variety of racial, chronological, ethnic, gender, and socioeconomic populations. However, the phenomenon appears most commonly associated with middle to upper-class adolescent girls or young women.

People who participate in self-injurious behavior are usually likable, intelligent, and functional. At times of high stress, these individuals often report an inability to think, the presence of inexpressible rage, and a sense of powerlessness. An additional characteristic identified by researchers and therapists is the inability to verbally express feelings.

Some behaviors found in other populations have been mistaken for self-mutilation. Individuals who have tattoos or piercings are often falsely accused of being self-mutilators. Although these practices have varying degrees of social acceptability, the behavior is not typical of self-mutilation. The majority of these persons tolerate pain for the purpose of attaining a finished product like a piercing or tattoo. This differs from the individual who self-mutilates for whom pain experienced from cutting or damaging the skin is sought as an escape from intolerable affect (Levenkron, 1998).

Common Misconceptions of Self-Mutilation

Suicide

Stanley et al., (2001) report that approximately 55%-85% of self-mutilators have made at least one attempt at suicide. Although suicide and self-mutilation appear to possess the same intended goal of pain relief, the respective desired outcomes of each of these behaviors is not entirely similar.

Those who cut or injure themselves seek to escape from intense affect or achieve some level of focus. For most members of this population, the sight of blood and intensity of pain from a superficial wound accomplish the desired effect, dissociation or management of affect. Following the act of cutting, these individuals usually report feeling better (Levenkron, 1998).

Motivation for committing suicide is not usually characterized in this manner. Feelings of hopelessness, despair, and depression predominate. For these individuals, death is the intent. Consequently, though the two behaviors possess similarities, suicidal ideation and self-mutilation may be considered distinctly different in intent.

Attention-seeking behavior

Levenkron (1998) reports that individuals who self-mutilate are often accused of "trying to gain attention." Although self-mutilation may be considered a means of communicating feelings, cutting and other self-harming behavior tends to be committed in privacy. In addition, self-harming individuals will often conceal their wounds. Revealing self-inflicted injuries will often encourage other individuals to attempt to stop the behavior. Since cutting serves to dissociate the individual from feelings, drawing attention to wounds is not typically desired. Those individuals who commit self-harm with the intent of gaining attention are conceptualized differently from those who self-mutilate.

Dangerousness to others

Another reported misconception is that those individuals who commit self-harm are a danger to others. Although self-mutilation has been identified as a characteristic of individuals suffering from a variety of diagnosed pathology, most of these individuals are functional and pose no threat to the safety of other persons.

Treatment of the Individual Who Self-Mutilates

Methods employed to treat those persons who self-mutilate range on a continuum from successful to ineffective. Those treatment methods that have shown effectiveness in working with this population include art therapy, activity therapy, individual counseling, and support groups. An important skill of the professional working with a self-harming individual is the ability to look at wounds without grimacing or passing judgment (Levenkron, 1998). A setting that promotes the healthy expression of emotions, and counselor patience and willingness to examine wounds is the common bond among these progressive interventions (Levenkron, 1998; Zila & Kiselica, 2001).

Sources:

• Favaro, A. & Santonastaso, P. (2000). Self-injurious behavior in anorexia nervosa. The Journal of Nervous and Mental Disease, 188(8), 537-542.
• Favazza, A.R. & Rosenthal, R. J. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.
• Levenkron, S. (1998). Cutting. New York, NY: W. W. Norton and Company.
• Stanley, B., Gameroff, M. J., Michalsen, V., & Mann, J. J. (2001). Are suicide attempters who self-mutilate a unique population? American Journal of Psychiatry, 158(3), 427-432.
• Suyemoto, K. L. & MacDonald, M. L. (1995). Self-cutting in female adolescents. Psychotherapy, 32(1), 162-171.
• Zila, L. M. & Kiselica, M. S. (2001). Understanding and counseling self-mutilation in female adolescents and young adults. Journal of Counseling & Development, 79, 46-52.

Department of Psychiatry, Indiana University School of Medicine

Abstract: The syndrome of multiple personality is associated with a high incidence of physical and/or sexual abuse in childhood. Occasionally those with multiple personality abuse their own children. Multiple personality is difficult to diagnose both because of the nature of the syndrome and because of professional reluctance. Although multiple personality is most difficult to diagnose during childhood because of the subtlety of the syndrome. The much higher morbidity found in adult cases makes it imperative that it be diagnosed and treated early in order to avoid further abuse and greater morbidity and to shorten treatment time. This review describes the history, clinical features and treatment of multiple personality, particularly in children, in addition to exploring the professional reluctance to make the diagnosis.

Introduction: MULTIPLE PERSONALITY DISORDER is of special interest to clinicians interested in child abuse and neglect because patients with multiple personality were almost invariably abused either physically or sexually when they were children. Like other victims of child abuse. sometimes those with multiple personality abuse their children. Also. like child abuse. there is a professional reluctance to diagnose multiple personality. Perhaps most importantly, clinicians working in the area of child abuse have the opportunity of diagnosing incipient multiple personality in children and initiate early intervention leading to successful treatment.

History Of Multiple Personality

The history of the dissociative disorders, which include multiple personality, extends back into the New Testament times of the first century when numerous references to demon possession, a forerunner of multiple personality, were described [1, 2]. The phenomenon of possession continued to be prevalent until well into the 19th century and is still prevalent in certain areas of the world [2, 3]. However, beginning in the 18th century, the possession phenomenon began to decline and the first case of multiple was described by Eberhardt Gmelin in 1791 [2]. The first American case, that of Mary Reynolds, was first reported in 1815 [2]. The late 19th century saw a flurry of publications about multiple personality [4], but the relationship of multiple personality to child abuse was not generally recognized until the publication of Sybil in 1973 [5]. The growth of interest in multiple personality has paralleled that of incest with which it is closely related. The reports of both incest and multiple personality have greatly increased since 1970 [6].

Clinical Description Of Multiple Personality

Multiple personality is defined by the DSM-III as:

1. The existence within the individual of two or more distinct personalities. Each of which is dominant at a particular time.
2. The personality that is dominant at any particular time determines the individual's behavior.
3. Each individual personality is complex and integrated with its own unique behavior patterns and social relationships [7].

Unfortunately the description of multiple personality in the DSM-111 has led, in part, to frequent misdiagnosis and under diagnosis [8]. Multiple personality most often presents with depression and suicidality rather than personality changes and amnesia which are obvious clues to dissociation |3, 8]. The amnesia in multiple personality includes amnesia for traumatic experiences in the remote past and amnesia for recent events which occurred while the individual was dissociated into another personality. Often emotional stress precipitates dissociation. The amnesiac episodes generally last from a few minutes to a few hours but occasionally may last from a few days to a few months. The original personality is usually amnesiac for the secondary personalities while the secondary personalities may have varying awareness of one another. Sometimes a secondary personality may exhibit the phenomenon of co-consciousness and be aware of events even when another personality is dominant. Generally the original personality is rather reserved and depleted of affect [5]. The secondary personalities usually express affects or impulses unacceptable to the primary personality such as anger, depression, or sexuality. Differences between personalities may be quite subtle or quite striking. Personalities may be of different age, race, sex, sexual orientation, or parentage from the original. Most often the personalities have chosen proper names for themselves. Psychophysiologic symptoms are extremely frequent in multiple personality [9]. Headaches are extremely common as are hysterical conversion symptoms and symptoms of sexual dysfunction [3, 10].

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Transient psychotic episodes may occur in multiple personality [11]. Hallucinations during such episodes are usually of a complex visual nature indicating an hysterical type of psychosis. Sometimes a personality will hear the voices of other personalities. These voices, which occasionally are of a command type, appear to come from inside the head, and should not be confused with the auditory hallucinations of the schizophrenic which usually come from outside the head. Most often stress precipitates the transition between personalities. These transitions may be dramatic or quite subtle. In a clinical situation the transition may be facilitated by asking to speak to a particular personality or by the use of hypnosis. The switching process usually takes several seconds while the patient closes the eyes or appears to look blank, as if in a trance.

The onset of multiple personality generally occurs in childhood, although the condition is not usually diagnosed until adolescence or early adulthood. The sex incidence is about 85% female [11]. This increased incidence of multiple personality in women may occur because sexual abuse and incest, which are strongly associated with multiple personality, occur predominantly in female children and adolescents. The degree of impairment in multiple personality may vary from mild to severe. Although multiple personality was thought to be quite rare, recently it has been reported to be more common [8].

Types Of Child Abuse Experienced By Multiple Personality Victims

Trauma has long been recognized as an essential criterion for the production of dissociative disorders including multiple personality [12]. The various types of trauma include childhood physical and sexual abuse. rape, combat, natural disasters, accidents, concentration camp experiences, loss of loved ones, financial catastrophes. and severe marital discord [12]. As early as 1896, Freud recognized that early childhood seduction experiences were responsible for 18 female cases of hysteria, a condition closely associated with dissociative disorders [13]. In the famous case of Dora. the patient's complaint of a sexually seductive adult was corroborated by other family members [14. 15]. In another famous case of hysteria, Anna O, who suffered from dual personality, the initial trauma was the death of Anna O's father [16. 17].

It was not until the publication of Sybil in 1973 that childhood physical and sexual abuse became widely recognized as precipitants of multiple personality [5]. Since 1973 numerous investigators have confirmed the high incidence of physical and sexual abuse in multiple personality [6, 18, 19]. In 100 cases Putnam found an 83% incidence of sexual abuse, 75% incidence of physical abuse, 61% incidence of extreme neglect or abandonment. and an overall 97% incidence of any type of trauma [20]. In Bliss' series of 70 patients, of whom only 32 met the DSM-111 criteria for multiple personality, there was a 40% incidence of physical abuse and a 60% incidence of sexual abuse in the female patients [21]. Coons reports a 75% incidence of sexual abuse. a 55% incidence of physical abuse, and an overall 85% incidence of either type of abuse in a series of 20 patients [10]. The types of child abuse experienced by victims of multiple personality are quite varied [22]. Sexual abuses include incest, rape, sexual molestation. sodomy. cutting of the sexual organs, and inserting objects into the sexual organs. Physical abuses include cutting, bruising. beating, hanging. tying up, and being locked in closets and cellars. Neglect and verbal abuse are also common.

The abuse in multiple personality is usually severe, prolonged. and perpetrated by family members who are bound to the child in a love-hate relationship [IO, 22, 23]. For example, in one study of 20 patients. abuse occurred over periods ranging from 1 to 16 years. In only one instance was the abuser not a family member. The abuses included incest. sexual molestation, beating, neglect, burning and verbal abuse.

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Multiple Personality Disorder In Children

No cases of childhood multiple personality disorder were reported between 1840 and 1984 [24]. In 1840 Despine Pete reported the first case of childhood multiple personality in an Il-year-old girl [2]. Since 1984 at least seven cases of childhood multiple personality disorder have appeared in the literature [24-27]. The reported cases range in age from 8 to 12 years.

From these first few reported cases the symptoms characteristic of childhood multiple personality begin to emerge and reveal some marked differences when compared to adults [25]. In the childhood form of multiple personality the difference between personalities are quite subtle. In addition the number of personalities is fewer. So far an average of 4 (range 2-6) personalities have been reported in children. while the average number of personalities reported in adults is about 13 (range 2 to 100+). Symptoms of depression and somatic complaints are less common in children but the symptoms of amnesia and inner voices are not decreased. Perhaps most importantly, the therapy of children with multiple personality is usually brief and marked by steady improvement. In adults therapy may last anywhere from 2 to over 10 years. while in children therapy may only last a few months. Kluft believes this shorter therapy time is due to the lack of narcissistic investment in separateness [25].

Kluft and Putnam have derived a list of symptoms characteristic of childhood multiple personality disorder [24]. The main characteristics include the following:

1. A history of repeated child abuse.
2. Subtle alternating personality changes such as a shy child with depressed. angry. seductive. and/or regressive episodes.
3. Amnesia of abuse and/or other recent events such as schoolwork. angry outbursts, regressive behavior. etc.
4. Marked variations in abilities such as schoolwork. games. and music.
5. Trance-like states.
6. Hallucinated voices.
7. Intermittent depression.
8. Disavowed behaviors leading to being called a liar.

Childhood Abuse Perpetrated By Adults With Multiple Personality

Relatively little is known about multiple personality parents who abuse their children. In the only study to date. the children of parents with multiple personality disorder tend to have a higher rate of psychiatric disturbance when compared to a control group of children with parents having other psychiatric disturbances.. where. the incidence of child abuse between the two groups was not significant [28]:In this 'study child abuse occurred in 2 of 20 families which included at least one multiple personality parent. In one family the son of a multiple personality mother was severely neglected secondarily to the mother's frequent dissociation and the severe drug abuse by both parents. This child was subsequently removed from the home. In the second family the father. who was not a multiple personality. sexually abused his son. The abuse ceased when the parents divorced but began again when the father regained custody secondarily to the mother's inability to control her teenage son. Most of the multiple personality parents in this series tried to be very good parents in order to insure that their children did not suffer child abuse as they had.

In another reported case an 18-month-old girl was physically abused by her stepfather who was a multiple personality [29]. The abuse ceased when the parents divorced subsequent to the episode of physical abuse which left the child in a transient coma and a retinal hemorrhage.

The management of parents with multiple personality who abuse their children should be handled like any other case of child abuse. The child abuse should be reported to the appropriate child protective services and the child should be removed from the home if necessary. Obviously the parent with multiple personality should be in therapy and attempts to help the abusive personality should be of paramount importance. Management should then proceed on a case by case bases [30, 31].

Professional Reluctance To Diagnose Multiple Personality

Like child abuse, particularly incest, there is a professional reluctance to diagnose multiple personality disorder. In all likelihood this reluctance stems from a number of factors including the generally subtle presentation of the symptoms, the fearful reluctance of the patient to divulge important clinical information, professional ignorance concerning dissociative disorders, and the reluctance of the clinician to believe that incest actually occurs and is not the product of fantasy.

If the patient with multiple personality presents with depression and suicidality and if the differences between personalities is subtle, the diagnosis may be missed. The changes in personality may be attributed to a simple mood change. for instance. In other cases individuals with multiple personality may go through prolonged periods without dissociation, and, therefore, the diagnosis is missed because a "window of diagnosibility" did not exist at the time of the clinical examination [8].

In addition to the subtle presentation of multiple personality, most individuals with this disorder consciously withhold vital clinical information about memory loss, hallucinations, and knowledge of other personalities in order to avoid being labeled "crazy." Others withhold information out of distrust. Still others are totally unaware that they are symptomatic. For instance, they may be completely unaware of alter personalities, and the time loss or time distortion which they experience may have occurred for such a long time that they consider it to be normal.

Professional ignorance about multiple personality is likely to be due to several factors. Because multiple personality was thought to be a rare disorder, many clinicians assumed that they would never see one in their practice. This false assumption caused many clinicians not to consider multiple personality in their differential diagnosis. In addition multiple personality did not appear as an official disorder until the publication of DSM-111 in 1980. Finally. until the past ten years, many psychiatric journals refused to publish articles about multiple personality because the disorder was felt to be rare or nonexistent and of little interest to their readers.

The reluctance of the clinician to believe that incest occurred in their patients is perhaps the most troubling aspect regarding the misdiagnosis of multiple personality. In many cases stories of incest have been assumed to be fantasies or outright lies. This practice of nonbelief has occurred despite examples where sexual abuse has been carefully confirmed with collateral sources [5, 32]. A number of authors [33-35] have written about this problem of clinician disbelief which is thought to be a counter transference reaction to the traumatized victim [34].

Undoubtedly Freud's renunciation of his earlier belief in the seduction theory was a setback to understanding incest [36]. For many years after Freud's renunciation, clinicians assumed stories of incest to be fantasy. Benedek pointed out that the counter transference reactions to victim's traumatic abuse included extreme anxiety about the abuse and resultant avoidance of the topic, a conspiracy to maintain silence about the abuse, and blaming the victim for the abuse [34]. Goodwin suggested that the clinician's incredulity regarding the abuse functions to make one believe that the patient and her family are not as sick as they seem, and, therefore, the uncomfortable reality of having to report abuse or appear in court is unnecessary [35]. Goodwin also suggested that disbelief shields the clinician from the powerful rage expressed by the victim and her family if confrontation about the abuse occurs.

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Treatment Of Multiple Personality Disorder

Since several excellent reviews of the treatment of multiple personality disorder exist [6, 37-40], treatment will only be summarized here. Particular emphasis will be placed on treatment of multiple personality in children. In the initial phase of treatment, trust is an extremely important issue. Trust may be very difficult to obtain because of the previous childhood maltreatment. Trust may also be difficult to obtain because of previous misdiagnosis and disbelief. Once the patient feels understood and believed, however, the patient becomes a steadfast and willing partner in the treatment process.

In adults the making of the diagnosis and the sharing of the diagnosis with the patient is an important part of the initial therapy. This sharing process must be done in a gentle and timely manner to avoid the patient fleeing therapy after becoming fearful of the implications of dissociation. This particular step in therapy with children is relatively unimportant because of their relative lack of abstractive ability and the lack of narcissistic investment in separateness by the alter personalities.

A third task in the initial phase of treatment is to establish communication with all of the alter personalities in order to learn their names, origins, functions, problems, and relationships to the other personalities. In case any of the personalities are dangerous to themselves or others, contracts should be made against acting out in any harmful manner.

The initial phase of therapy may occur very rapidly or may take several months depending on the amount of trust present. The middle phase of treatment is the most lengthy phase and may extend into years of work.

The middle phase of treatment involves helping the original personality and the alter personalities with their problems. The original personality needs to learn how to cope with dissociated affects and impulses such as anger, depression, and sexuality. The traumatic experiences should be explored and worked through with all of the personalities. The therapeutic use of dreams, fantasies, and hallucinations can be very helpful in this working through process. Amnesiac barriers should be broken down during this middle phase. This may be accomplished through the use of audio tapes, videotapes, journal writing, hypnosis, and direct feedback from the therapist or significant relations. Intrapersonality cooperation and communication should be facilitated during this phase of treatment.

The final phase of therapy involves fusion or integration of the personalities. Although hypnosis may facilitate this process, it is not absolutely necessary. Therapy does not end with integration, however, as integrated patients must practice their newfound intrapsychic defenses and coping mechanisms or the risk of renewed dissociation is great. The patient's transference, especially the dependence, hostility, or seductiveness towards the therapist, may sorely test the therapist's patience. Likewise the therapist's counter transference feelings, which may include over fascination, over investment, intellectualization, withdrawal, disbelief, bewilderment, exasperation, anger, or exhaustion, should be closely monitored. Hospital treatment may be useful to protect the patient from self-destructive urges, treat psychotic episodes, or to treat a severely dysfunctional patient who is unable to provide for basic needs. Psychotropic medication does not treat the basic psychopathology of multiple personality. Antipsychotic medication may be useful temporarily to treat a brief psychosis. Antidepressants are occasionally useful for an accompanying affective disorder. Minor tranquilizers should be avoided except for temporary use to decrease massive anxiety because of the significant abuse potential in multiple personality. Alcohol and drugs are frequently used and abused by the patient to avoid painful affects and memories. The treatment of a child with multiple personality takes far less time than treatment of an adult. In the treatment of children Kluft and Fagan and McMahon utilized various techniques including play therapy, hypnotherapy, and abreaction in order to bring about integration [25, 26]. Kluft placed particular emphasis on family intervention and agency involvement both to prevent further abuse and to alter pathological patterns of interaction.

Conclusions

The psychiatric syndrome of multiple personality is associated with an extremely high incidence of physical and/or sexual abuse during childhood. The abuse is usually severe, prolonged, and perpetrated by family members. Multiple personality may be difficult to diagnose because of the subtlety of the presenting symptoms. the patient's fear of being labeled crazy and the clinician's mistaken belief that multiple personality is a rare condition. Currently multiple personality is usually diagnosed in adults who are in their late 20s or early 30s. The diagnosis of multiple personality in children is even more difficult because of the subtlety of symptoms and the ease with which these symptoms are confused with fantasy. Although individuals with multiple personality do not usually abuse their own children, the incidence of psychiatric disturbance in their children is high. Multiple personality is much easier to treat if diagnosed early in childhood or adolescence. Therefore, in order to decrease the morbidity of multiple personality and decrease the psychiatric disturbance in children of multiple personality parents, it behooves the clinician to become well acquainted with the syndrome of multiple personality, to diagnose multiple personality as early as possible, and to insure that the individual with multiple personality obtains effective treatment.

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next:Multiple Personality Mirrors of a New Model of Mind?

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REFERENCES

1. OESTERREICH, T.C. Possession and Exorcism. Causeway Books. New York (1974).

2. ELLENBERGER. H. E The Discovery of the Unconscious. Basic Books. New York

3. COONS. P.M. The differential diagnosis of multiple personality: A comprehensive review. Psychiatric' Clinics of North America 7:51-67 (1984).

4. TAYLOR, W.S. and MARTIN. M. E Multiple personality. Journal of Abnormal and Social Psychology 39:281-300 ( 1944].

5. SCHREIBER. E R. Sybil. Regnery. Chicago (1973).

6. GREAVES, G.B. Multiple personality 165 years after Mary Reynolds. Journal of Nervous and Mental Disease 168:577-596 (1980).

7. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic' and Statistical Manual of Mental Disorders, (3rd ed.). Amencan Psychiatric Association. Washington. DC (1980).

8. KLUFT. R.P. Making the diagnosis of multiple personality (MPD). Directions in Psychiatr*.' 5:1-11 (1985).

9. BLISS, E.C. Multiple personalities: A report of 14 cases with implications for schizophrenia. Archives of General Psychiatry 257:1388-1397 (1980).

10. COONS. P.M. Psychosexual disturbances in multiple personality: Characteristics. etiology. and treatment. Journal of Clinical Psychiatry. (In press). 1. COONS. P.M. Multiple personality: Diagnostic considerations. Journal of Clinical Psychiatry.' 41: 1980).

11. COONS.P.M. Multiple personality: Diagnostic consideration. Journal of Clinical Psychiatry 41:330-336 (1980).

12. PUTNAM. F W. Dissociation as a response to extreme trauma. In: Childhood Antecedents of Multiple Personality, R.P. Kluft (Ed.). pp. 65-97. American Psychiatric Association. Washington. DC (1985).

13. FREUD. S. The etiology of hysteria. In: The Standard Edition of the Complete Psychological Works. (Vol.3). T. Strachey (Ed.). Hogarth Press. London (1962).

14. FREUD. S. Dora: An Analysis of a Case of Hysteria. C. Rieff(Ed.). Collier Books. New York (1983).

15. GOODWIN. J. Post-traumatic symptoms in incest victims. In: Post-Trattmatic Stress Disorder in Children. S. Eth and R.S. Pynoos (Eds.). pp. 157-168. American Psychiatric Association. Washington. DC (1985).

16. BREUER. J. and FREUD. S. Slitdies in Hysteria. J. Strachey [Ed.). Basic Books. New York (1983).

17. JONES. E. The Life and Work of.Sigmund Freud. (Vol. 1). New York. Basic Books 11953).

18 .BOOR. M. The multiple personality epidemic: Additional cases and inferences regarding diagnosis. etiology and treatment. Journal of Nervous and Mental Disease 170:302-304 [1982).

19. SALTMAN, V. and SOLOMON. R.S. Incest and multiple personality. Psychological Reports 50:1127-1141 (1982).

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Depression is common in people who self-injure

Juliet is suffering silently from self-injury syndrome, something that most sufferers suffer alone, and in shame. While some experts have seen self-injury as similar to suicide, just stopping short of it, most see self-injury as a distinct entity. Why do people, and especially women and young women, engage in such activities ranging from hair pulling and cutting one's self to much more severe forms of self-mutilation?

For those of us who don't engage in this kind of activity, it seems bizarre bordering on crazy. The fact is, most people who self-injure are not "crazy" but they often do suffer from psychological problems. Depression is common in people who self-injure. People who self-injure have often suffered physical, emotional or sexual abuse as children.

So why is Juliet going to cut herself again? Self-abusers report feeling calm and peaceful after a certain amount of injury. Many report feeling little or no pain. Is she doing it for the attention that she will get after injuring herself? Perhaps.

Some experts suggest that self-injurers pursue this activity as a way of escaping severe emotional pain. The physical pain they inflict upon themselves allows them to escape, at least for a while, the emotional pain they are experiencing.

The feeling of control that some self-abusers experience can explain in part, the motivation behind self-mutilation. Many self-abusers, like Juliet, are perfectionists, demanding a lot of themselves.

Juliet's your friend-how do you help her?

It's important to recognize that people who self-injure themselves on a regular basis need to get professional help. The first therapist you turn to is not always the right one for you. If Juliet feels that Doug is not a good therapist for her, it may pay to try a different one.

One of the things that both therapists and friends can help Juliet with is letting her know that she is okay, even if she isn't perfect. It sounds like she is setting up tremendously high standards for herself, and ends up creating a lot of tension and self-induced pressure. Learning how to let go a bit, relax, and unwind might be very helpful for Juliet.

As Juliet's friend, you could try to distract her when she begins to talk about self-injuring. Go for a walk, or see a movie together. Often the urge to self-injure will pass with time. But remember, you are not her therapist, you are her friend.

If you have a child that self-injures it is imperative to consult with a mental health professional, both to get a better understanding of what is going on and to get some help for your child. This is one symptom that cannot be overlooked and shrugged off.

There are many treatments available for self-mutilators, and their families. There is light at the end of the tunnel.

About the author: Dr. Naomi Baum has been a child and family psychologist for the past 15 years.

Many people who self-injure are depressed and consider suicide. Here are some suicide warning signs.

Suicide is a scary word, but here's what you should know about it. Most people who are clinically depressed do not commit suicide, but they are more at risk for it. You may have heard people say things like, "Someone who talks about killing himself or herself will never actually do it."

This is important: thinking about, talking about, or trying suicide is ALWAYS SERIOUS. If you or a friend is doing any of these, talk to a trusted adult IMMEDIATELY. If you're worried that someone close to you may be thinking about suicide, watch for these warning signs:

• Talking, reading, or writing about suicide or death.
• Talking about feeling worthless or helpless.
• Saying things like, "I'm going to kill myself," "I wish I were dead," or "I shouldn't have been born."
• Visiting or calling people to say goodbye.
• Giving things away or returning borrowed items.
• Organizing or cleaning bedroom "for the last time."
• Hurting oneself or purposely putting oneself in danger.
• Obsessed with death, violence, and guns or knives.
• Previous suicidal thoughts or suicide attempts.

Once again: if you notice one or more of these signs in someone you know, get help right away.

Self-injury is when a person physically hurts himself or herself on purpose. When someone who is clinically depressed does this, it might be because:

• He's trying to change the way he's feeling.
• She's desperately trying to get the attention she needs.
• He wants to express how hopeless and worthless he feels.
• She is having suicidal thoughts. Self-injury can be just as dangerous as suicidal talk and thoughts, so don't hesitate to seek help if you or someone you know is experiencing this.

Foreword from BirthQuake: A Journey to Wholeness

"If you will dive long enough, deep enough, some great sea change takes place - bringing bounty forever. I do not know if we can choose this path. More so, I would say certain ones are chosen."
-- Clarissa Pinkola Estes

My office clock stopped running on the day I closed my psychotherapy practice in Maine. I walked into the room on that final morning to see its hands frozen. I stood before it for a moment and waited for it to resume its slow and deliberate march. Then I was struck by the irony of the clock's demise on this of all days, as I acknowledged it's final message. "We're finished for now. It's time to go." Time to go...

I was unsteady on my feet as I moved around the room. I looked long and hard at my desk, at my old rockers, at my beloved sectional couch, and at the sunlight coming through the stained glass just above it. I'd lived so much of my life in this room and yet it, along with so much else that belonged to me, would be dismantled very soon. I felt empty and sad. I wasn't prepared for this. I was exhausted already by the good-byes I'd struggled through the past few weeks, and I wanted to reject this day even as I got ready for it

It wasn't supposed to end this way. (How many times have you heard that?) I'd told Lori long ago that she would choose when our work together was completed. It would be she who would tell me that we wouldn't be making another appointment. Instead, it was I who was leaving her.

When she walked through the door, she immediately moved into my arms and began to cry. As I held her, the guilt inside of me rose up to meet her grief. I wasn't supposed to leave her. I wasn't supposed to abandon my family, my friends, my partner, my practice, and my home either. And yet, it was in part, through my leaving, and loss, and letting go that I began to attempt to put into words the culmination of many years of research, clinical experience, and most importantly - critical life lessons.

This book is about a phenomenon which is presently challenging numerous members of my generation in particular. It's about the "Birthquakes" so many of us are struggling with and through. Where everything is rocked and shifted, where foundations crack, and treasures lie buried beneath the rubble.

At a glance, Birthquakes can understandably be confused with what has been identified for decades as the "midlife crisis," as they, too, appear in almost all cases during the second half of life. They also are, at least initially, profoundly difficult experiences. Being caught up in the confusion of a mid-life crisis, however, doesn't always lead to a desirable destination. Those who brave the mighty storms of a Birthquake on the other hand, are in every case ultimately transformed.

I have been a witness to its power and its fury. I have experienced the anguish, and I have stood in the center of its triumph. How do I tell you about what that feels like? I don't tell you. I attempt to explain it to you to the best of my ability, and if you have been there, you immediately recognize it. If you haven't, I'll try to be clear enough for you to grasp it in your imagination. I will also remind you that what you envision is not the same as what you actually experience. It may in part be less, while at the same time it is most certainly also significantly more.

The Quake arrives for most of us when we're standing at a crossroad. When the forces inside of us which contain a vast amount of wisdom erupt, pushing us forward towards growth and opportunity, we often push back. In spite of how uncomfortable our present situation may be, it's familiar. We know for the most part what to expect, and so we often attempt to distract ourselves from this inner voice which calls upon us to venture into foreign territory. Still, the voice refuses to be silenced. It taunts us, it haunts us, and it will not go away.

Encountering the Quake is much like the process of giving birth. Initially, there are feelings of inadequacy and fear delicately linked with anticipation and hope. As the process unfolds, the pain often intensifies until it can seem unbearable. As this period of transition is entered into, many want to turn back. Later, while engulfed in the agony, they become aware that in spite of the pain, they must not surrender. Instead, they must push on until the end - when they are finally delivered.

A Birthquake generally occurs when you're confronted with a significant challenge in your life. It may be the loss of a significant relationship, a job, your health, or your dream. It may evolve from a growing awareness that you're not satisfied with your present situation, or that you feel lost and confused. During this troubling period, you're often confronted with difficult choices. Will you attempt to ignore your inner voices by retreating to the familiar? Or will you brave the unknown, make the necessary changes, and take the risks that a Birthquake demands?

I want to make it perfectly clear that the intent of this book is not to propose that a crisis or painful episode in one's life is always ultimately a positive experience from which one learns and grows. A crisis can be devastating, and can wound so deeply that complete healing never occurs. I can't think of a time in my life that I've ever welcomed one, nor would I for a moment suggest that you consider yourself fortunate for having the opportunity to become stronger and wiser when having a painful experience. More often then not, I suspect I would choose to gladly give up the gains of my pain, if I could just be spared the hurt.

The reality though, as we all know, is that ready or not - difficulty, confusion, loss, risk, and potential danger befalls us all. Ultimately, at some point in each of our lives, a crisis becomes unavoidable. What differentiates a Birthquake from a typical life crisis is not what triggers the journey, instead, it's the choices one makes and the lessons one learns along the way. In the simplest terms, a Birthquake is a painful experience which eventually leads an individual to significant emotional and spiritual growth.

---

If you've found yourself at a turning point, or are attempting to find meaning and purpose in your life, then Birthquake was written for you. It will assist you in looking at several very important aspects of yourself and your world. It will offer you hope, guidance and insight. It's not a book that will provide you with easy solutions to your present dilemma. It's not that simple - emotional and spiritual growth never is.

In order to achieve maximum benefits from Birthquake, I recommend that you take your time reading, pausing periodically to reflect upon your own experiences. You'll find that this book is as much about you as it is about anybody. At the end of each chapter, I've incorporated a workbook that was designed to accompany the text. When you finish a chapter, before moving on to the next, I suggest that you answer the workbook questions. Take your time. In doing so, you'll find that you are discovering a tremendous amount about yourself. I also suggest that you keep a journal while reading this book.

Each of our lives contains a sacred purpose. In the midst of the hustle and bustle of day to day living, it's easy to get so caught up in the details that we completely lose touch with the meaning and purpose of our lives. Birthquake will assist you in uncovering aspects of yourself that have become hidden. It will also provide you with important tools that will enable you to identify your needs and guide you in developing a plan to most effectively meet them.

Most importantly, Birthquake offers you an opportunity to discover the value and significance of your own unique journey.

Virginia's Journey

In a small coastal village in eastern Maine, there lives a woman who is as at peace with her life as anyone I've ever met. She is slender and delicately boned with innocent eyes and long gray hair. Her home is a small, weathered, gray cottage with big windows that look out over the Atlantic Ocean. I see her now in my mind's eye, standing in her sunlit kitchen. She's just taken molasses muffins out of the oven, and the water is warming on the old stove for tea. Music is playing softly in the background. There are wild flowers on her table and potted herbs on the sideboard beside the tomatoes she's picked from her garden. From the kitchen, I can see the book- lined walls of her sitting room and her old dog snoozing on the faded Oriental rug. There are sculptures scattered here and there of whales and dolphins; of the wolf and coyote; of the eagle and the crow. Hanging plants grace the corners of the room, and a huge yucca tree stretches up towards the skylight. It is a home that contains one human being and a multitude of other living things. It's a place that once entered, becomes difficult to leave.

She first came to coastal Maine in her early forties, when her hair was deep brown and her shoulders stooped. She has remained here walking straight and tall for the past 22 years. She felt defeated when she first arrived. She had lost her only child to a fatal automobile accident, her breasts to cancer, and her husband four years later to another woman. She confided that she'd come here to die and had learned, instead, how to live.

When she first arrived, she hadn't slept a whole night through since the death of her daughter. She would pace the floors, watch television, and read until two or three in the morning when her sleeping pills finally took effect. Then she would rest at last until lunchtime. Her life felt meaningless, each day and night just another test of her endurance. "I felt like a worthless lump of cells and blood and bone, just wasting space," she remembers. Her only promise of deliverance was the stash of pills that she kept tucked away in her top drawer. She planned to swallow them at summer's end. With all of the violence of her life, she would at least die in a gentle season.

"I would walk on the beach every day. I'd stand in the frigid ocean water and concentrate on the pain in my feet; eventually, they'd go numb and wouldn't hurt anymore. I wondered why there was nothing in the world that would numb my heart. I put on a lot of miles that summer, and I saw how beautiful the world still was. That just made me more bitter at first. How dare it be so beautiful, when life could be so ugly. I thought it was a cruel joke -- that it could be so beautiful and yet so terrible here at the same time. I hated a great deal then. Just about everybody and everything was abhorrent to me.

I remember sitting on the rocks one day and along came a mother with a small child. The little girl was so precious; she reminded me of my daughter. She was dancing around and around and talking a mile a minute. Her mother seemed to be distracted and wasn't really paying attention. There it was, the bitterness again. I resented this woman who had this beautiful child and had the indecency to ignore her. (I was very quick to judge back then.) Anyway, I watched the little girl playing and I began to cry and cry. My eyes were running, and my nose was running, and there I sat. I was a little surprised. I had thought I'd used up all of my tears years ago. I hadn't wept in years. Thought I was all dried up and out. Here they were though, and they began to feel good. I just let them come and they came and came.

I started meeting people. I didn't really want to because I still hated everybody. These villagers are an interesting lot though, awfully hard to hate. They're plain and simple- talking people and they just sort of reel you in without even seeming to pull at your line. I started to receive invitations to this and that, and finally I accepted one to attend a potluck supper. I found myself laughing for the first time in years at a man who seemed to love to make fun of himself. Maybe it was the mean streak I still had, laughing at him, but I don't think so. I think I was charmed by his attitude. He made so many of his trials seem humorous.

---

I went to church the following Sunday. I sat there and waited to get angry as I heard this fat man with soft hands talking about God. What did he know of heaven or of hell? And yet, I didn't get mad. I started to feel kind of peaceful as I listened to him. He spoke of Ruth. Now I knew very little about the Bible, and this was the first time I had heard about Ruth. Ruth had suffered greatly. She had lost her husband and left behind her homeland. She was poor and worked very hard gathering fallen grain in the fields of Bethlehem to feed herself and her mother-in-law. She was a young woman with a very strong faith for which she was rewarded. I had no faith and no rewards. I longed to believe in the goodness and existence of God, but how could I? What kind of a God would allow such terrible things to happen? It seemed simpler to accept that there was no God. Still, I kept going to church. Not because I believed. I just liked to listen to the stories that were told in such a gentle voice by the minister. I liked the singing, too. Most of all, I appreciated the peacefulness I felt there. I began to read the Bible and other spiritual works. I found so many of them to be filled with wisdom. I didn't like the Old Testament; I still don't. Too much violence and punishment for my taste, but I loved the Psalms and the Songs of Solomon. I found great comfort in the teachings of the Buddha, too. I began to meditate and to chant. Summer had led to fall, and I was still here, my pills safely hidden away. I still planned to use them, but I wasn't in such a hurry.

I had lived most of my life in the southwest where the changing of seasons is a very subtle thing compared to the transformations that take place in the northeast. I told myself that I would live to watch the seasons unfold before departing from this earth. Knowing I would die soon enough (and when I chose) brought me some comfort. It also inspired me to look very closely at things I had been oblivious to for so long. I watched the heavy snowfalls for the first time, believing that this would also be my last, as I would not be here to see them the next winter. I had always had such beautiful and elegant clothes (I had been raised in an upper middle-class family where appearances were of the utmost importance). I cast them off in exchange for the comfort and warmth of wool, flannel and cotton. I began to move about in the snow more easily now and found my blood invigorated by the cold. My body grew stronger as I shoveled snow. I began sleeping deeply and well at night and was able to throw my sleeping pills away (not my deadly stash though).

I met a very bossy woman who insisted that I help her with her various humanitarian projects. She taught me to knit for the poor children as we sat in her delicious smelling kitchen surrounded often by her own 'grandbabies'. She scolded me into accompanying her to the nursing home where she read and ran errands for the elderly. She arrived one day at my home armed with a mountain of wrapping paper and demanded that I help her wrap gifts for the needy. I usually felt angry and invaded by her. Whenever I could, I pretended at first not to be at home when she came calling. One day I lost my temper and called her a busybody and stormed out of the house. A few days later she was back in my dooryard. When I opened my door, she plopped down at the table, told me to make her a cup of coffee, and behaved as if nothing had happened. We never did speak of my temper tantrum in all of our years together.

We became the best of friends, and it was during that first year that she rooted herself into my heart, that I began to come alive. I absorbed the blessings that came from serving others, just as my skin had gratefully absorbed the healing bag of balm I had been given by my friend. I began to rise early in the morning. All of the sudden, I had much to do in this life. I watched the sunrise, feeling privileged and imagining myself to the one of the first to see it appear as a resident now in this northern land of the rising sun.

I found God here. I don't know what his or her name is, and I don't really care. I only know that there is a magnificent presence in our universe and in the next one and the next after that. My life has a purpose now. It's to serve and to experience pleasure - it"s to grow, and to learn and to rest and to work and to play. Each day is a gift to me, and I enjoy them all (some certainly less than others) in the company of people whom I've come to love at times, and at other times in solitude. I recall a verse I read somewhere. It says, 'Two men look out through the same bars: one sees mud, and one the stars.' I choose to gaze at the stars now, and I see them everywhere, not only in the darkness but in the daylight too. I threw out the pills that I was going to use to do myself in long ago. They'd turned all powdery anyway. I will live as long and as well as I am permitted to, and I will be thankful for every moment I am on this earth."

I carry this woman in my heart wherever I go now. She offers me great comfort and hope. I would dearly love to possess the wisdom, strength and peace which she has acquired during her lifetime. We walked, she and I, on the beach three summers ago. I felt such wonder and contentment at her side. When it was time for me to return home, I glanced down and noticed how our footprints had converged in the sand. I hold that image within me still; of our two separate sets of footprints united for all time in my memory.

Get the BirthQuake: A Journey To Wholeness printed version.

next: Virginia's Journey

Study into cutting behavior and suicidality found that exposure to physical or sexual abuse or neglect during childhood, were reliable predictors of self-injury.

Past trauma/invalidation as an antecedent
Van der Kolk, Perry, and Herman (1991) conducted a study of patients who exhibited cutting behavior and suicidality. They found that exposure to physical abuse or sexual abuse, physical or emotional neglect, and chaotic family conditions during childhood, latency and adolescence were reliable predictors of the amount and severity of cutting. The earlier the abuse began, the more likely the subjects were to cut and the more severe their cutting was. Sexual abuse victims were most likely of all to cut. They summarize, ...

neglect [was] the most powerful predictor of self-destructive behavior. This implies that although childhood trauma contributes heavily to the initiation of self-destructive behavior, lack of secure attachments maintains it. Those ... who could not remember feeling special or loved by anyone as children were least able to ...control their self-destructive behavior.

In this same paper, van der Kolk et al. note that dissociation and frequency of dissociative experiences appear to be related to the presence of self-injurious behavior. Dissociation in adulthood has also been positively linked to abuse, neglect, or trauma as a child.

More support for the theory that physical or sexual abuse or trauma is an important antecedent to this behavior comes from a 1989 article in the American Journal of Psychiatry. Greenspan and Samuel present three cases in which women who seemed to have no prior psychopathology presented as self-cutters following a traumatic rape.

Invalidation independent of abuse

Although sexual and physical abuse and neglect can seemingly precipitate self-injurious behavior, the converse does not hold: many of those who hurt themselves have suffered no childhood abuse. A 1994 study by Zweig-Frank et al. showed no relationship at all between abuse, dissociation, and self-injury among patients diagnosed with borderline personality disorder. A follow-up study by Brodsky, et al. (1995) also showed that abuse as a child is not a marker for dissociation and self-injury as an adult. Because of these and other studies as well as personal observations, it's become obvious to me that there is some basic characteristic present in people who self-injure that is not present in those who don't, and that the factor is something more subtle than abuse as a child. Reading Linehan's work provides a good idea of what the factor is.

Linehan (1993a) talks about people who SI having grown up in "invalidating environments." While an abusive home certainly qualifies as invalidating, so do other, "normal," situations. She says:

An invalidating environment is one in which communication of private experiences is met by erratic, inappropriate, or extreme responses. In other words, the expression of private experiences is not validated; instead it is often punished and/or trivialized. the experience of painful emotions [is] disregarded. The individual's interpretations of her own behavior, including the experience of the intents and motivations of the behavior, are dismissed...

Invalidation has two primary characteristics. First, it tells the individual that she is wrong in both her description and her analyses of her own experiences, particularly in her views of what is causing her own emotions, beliefs, and actions. Second, it attributes her experiences to socially unacceptable characteristics or personality traits.

This invalidation can take many forms:

• "You're angry but you just won't admit it."
• "You say no but you mean yes, I know."
• "You really did do (something you in truth hadn't). Stop lying."
• "You're being hypersensitive."
• "You're just lazy." "
• I won't let you manipulate me like that."
• "Cheer up. Snap out of it. You can get over this."
• "If you'd just look on the bright side and stop being a pessimist..."
• "You're just not trying hard enough."
• "I'll give you something to cry about!"

Everyone experiences invalidations like these at some time or another, but for people brought up in invalidating environments, these messages are constantly received. Parents may mean well but be too uncomfortable with negative emotion to allow their children to express it, and the result is unintentional invalidation. Chronic invalidation can lead to almost subconscious self-invalidation and self-distrust, and to the "I never mattered" feelings van der Kolk et al. describe.

Biological Considerations and Neurochemistry

It has been demonstrated (Carlson, 1986) that reduced levels of serotonin lead to increased aggressive behavior in mice. In this study, serotonin inhibitors produced increased aggression and serotonin exciters decreased aggression in mice. Since serotonin levels have also been linked to depression, and depression has been positively identified as one of the long-term consequences of childhood physical abuse (Malinosky-Rummell and Hansen, 1993), this could explain why self-injurious behaviors are seen more frequently among those abused as children than among the general population (Malinosky-Rummel and Hansen, 1993). Apparently, the most promising line of investigation in this area is the hypothesis that self-harm may result from decreases in necessary brain neurotransmitters.

This view is supported by the evidence presented in Winchel and Stanley (1991) that although the opiate and dopaminergic systems don't seem to be implicated in self-harm, the serotonin system does. Drugs that are serotonin precursors or that block the reuptake of serotonin (thus making more available to the brain) seem to have some effect on self-harming behavior. Winchel and Staley hypothesize a relationship between this fact and the clinical similarities between obsessive-compulsive disorder (known to be helped by serotonin-enhancing drugs) and self-injuring behavior. They also note that some mood-stabilizing drugs can stabilize this sort of behavior.

Serotonin

Coccaro and colleagues have done much to advance the hypothesis that a deficit in the serotonin system is implicated in self-injurious behavior. They found (1997c) that irritability is the core behavioral correlate of serotonin function, and the exact type of aggressive behavior shown in response to irritation seems to be dependent on levels of serotonin -- if they are normal, irritability may be expressed by screaming, throwing things, etc. If serotonin levels are low, aggression increases and responses to irritation escalate into self-injury, suicide, and/or attacks on others.

Simeon et al. (1992) found that self-injurious behavior was significantly negatively correlated with number of platelet imipramine binding sites (self-injurers have fewer platelet imipramine binding sites, a level of serotonin activity) and note that this "may reflect central serotonergic dysfunction with reduced presynaptic serotonin release. . . . Serotonergic dysfunction may facilitate self-mutilation."

When these results are considered in light of work such as that by Stoff et al. (1987) and Birmaher et al. (1990), which links reduced numbers of platelet imipramine binding sites to impulsivity and aggression, it appears that the most appropriate classification for self-injurious behavior might be as an impulse-control disorder similar to trichotillomania, kleptomania, or compulsive gambling.

Herpertz (Herpertz et al, 1995; Herpertz and Favazza, 1997) has investigated how blood levels of prolactin respond to doses of d-fenfluramine in self-injuring and control subjects. The prolactin response in self-injuring subjects was blunted, which is "suggestive of a deficit in overall and primarily pre-synaptic central 5-HT (serotonin) function." Stein et al. (1996) found a similar blunting of prolactin response on fenfluramine challenge in subjects with compulsive personality disorder, and Coccaro et al. (1997c) found prolactin response varied inversely with scores on the Life History of Aggression scale.

It is not clear whether these abnormalities are caused by the trauma/abuse/invalidating experiences or whether some individuals with these kinds of brain abnormalities have traumatic life experiences that prevent their learning effective ways to cope with distress and that cause them to feel they have little control over what happens in their lives and subsequently resort to self-injury as a way of coping.

Knowing when to stop -- pain doesn't seem to be a factor

Most of those who self-mutilate can't quite explain it, but they know when to stop a session. After a certain amount of injury, the need is somehow satisfied and the abuser feels peaceful, calm, soothed. Only 10% of respondents to Conterio and Favazza's 1986 survey reported feeling "great pain"; 23 percent reported moderate pain and 67% reported feeling little or no pain at all. Naloxone, a drug that reverses the effects of opioids (including endorphins, the body's natural painkillers), was given to self-mutilators in one study but did not prove effective (see Richardson and Zaleski, 1986). These findings are intriguing in light of Haines et al. (1995), a study that found that reduction of psychophysiological tension may be the primary purpose of self-injury. It may be that when a certain level of physiological calm is reached, the self-injurer no longer feels an urgent need to inflict harm on his/her body. The lack of pain may be due to dissociation in some self-injurers, and to the way in which self-injury serves as a focusing behavior for others.

Behavioralist explanations

NOTE: most of this applies mainly to stereotypical self-injury, such as that seen in retarded and autistic clients.

Much work has been done in behavioral psychology in an attempt to explain the etiology of self-injurious behavior. In a 1990 review, Belfiore and Dattilio examine three possible explanations. They quote Phillips and Muzaffer (1961) in describing self-injury as "measures carried out by an individual upon him/herself which tend to 'cut off, to remove, to maim, to destroy, to render imperfect' some part of the body." This study also found that frequency of self-injury was higher in females but severity tended to be more extreme in males. Belfiore and Dattilio also point out that the terms "self-injury" and "self-mutilation" are deceiving; the description given above does not speak to the intent of the behavior.

Operant Conditioning

It should be noted that explanations involving operant conditioning are generally more useful when dealing with stereotypic self-injury and less useful with episodic/repetitive behavior.

Two paradigms are put forth by those who wish to explain self-injury in terms of operant conditioning. One is that individuals who self-injure are positively reinforced by getting attention and thus tend to repeat the self-harming acts. Another implication of this theory is that the sensory stimulation associated with self-harm could serve as a positive reinforcer and thus a stimulus for further self-abuse.

The other posits that individuals self-injure in order to remove some aversive stimulus or unpleasant condition (emotional, physical, whatever). This negative reinforcement paradigm is supported by research showing that the intensity of self-injury can be increased by increasing the "demand" of a situation. In effect, self-harm is a way to escape otherwise intolerable emotional pain.

Sensory Contingencies

One hypothesis long held has been that self-injurers are attempting to mediate levels of sensory arousal. Self-injury can increase sensory arousal (many respondents to the internet survey said it made them feel more real) or decrease it by masking sensory input that is even more distressing than the self-harm. This seems related to what Haines and Williams (1997) found: self-injury provides a quick and dramatic release of physiological tension/arousal. Cataldo and Harris (1982) concluded that theories of arousal, though satisfying in their parsimony, need to take into consideration the biological bases of these factors.

What kind of person would cut or burn themselves? It turns out there are some common traits amongst self-injurers.

Most self-injures are women and they seem to have some psychological characteristics in common. They are people who:

• strongly dislike/invalidate themselves
• are hypersensitive to rejection
• are chronically angry, usually at themselves tend to suppress their anger have high levels of aggressive feelings, which they disapprove of strongly and often suppress or direct inward
• are more impulsive and more lacking in impulse control tend to act in accordance with their mood of the moment
• tend not to plan for the future
• are depressed and suicidal / self-destructive
• suffer chronic anxiety
• tend toward irritability
• do not see themselves as skilled at coping
• do not have a flexible repertoire of coping skills
• do not think they have much control over how/whether they cope with life
• tend to be avoidant
• do not see themselves as empowered

People who self-injure tend not to be able to regulate their emotions well, and there seems to be a biologically-based impulsivity. They tend to be somewhat aggressive and their mood at the time of the injurious acts is likely to be a greatly intensified version of a longstanding underlying mood, according to Herpertz (1995). Similar findings appear in Simeon et al. (1992); they found that two major emotional states most commonly present in self-injurers at the time of injury -- anger and anxiety -- also appeared as longstanding personality traits. Linehan (1993a) found that most self-injurers exhibit mood-dependent behavior, acting in accordance with the demands of their current feeling state rather than considering long-term desires and goals. In another study, Herpertz et al. (1995) found, in addition to the poor affect regulation, impulsivity, and aggression noted earlier, disordered affect, a great deal of suppressed anger, high levels of self-directed hostility, and a lack of planning among self-injurers:

We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors. (p. 70). And Dulit et al. (1994) found several common characteristics in self-injuring subjects with borderline personality disorder (as opposed to non-SI BPD subjects): more likely to be in psychotherapy or on medications more likely to have additional diagnoses of depression or bulimia more acute and chronic suicidality more lifetime suicide attempts less sexual interest and activity In a study of bulimics who self-injure (Favaro and Santonastaso, 1998), subjects whose SIB was partially or mostly impulsive had higher scores on measures of obsession-compulsion, somatization, depression, anxiety, and hostility.

Simeon et al. (1992) found that the tendency to self-injure increased as levels of impulsivity, chronic anger, and somatic anxiety increased. The higher the level of chronic inappropriate anger, the more severe the degree of self-injury. They also found a combination of high aggression and poor impulse control. Haines and Williams (1995) found that people engaging in SIB tended to use problem avoidance as a coping mechanism and perceived themselves as having less control over their coping. In addition, they had low self-esteem and low optimism about life.

Demographics Conterio and Favazza estimate that 750 per 100,000 population exhibit self-injurious behavior (more recent estimates are that 1000 per 100,000, or 1%, of Americans self-injure). In their 1986 survey, they found that 97% of respondents were female, and they compiled a "portrait" of the typical self-injurer. She is female, in her mid-20s to early 30s, and has been hurting herself since her teens. She tends to be middle- or upper-middle-class, intelligent, well-educated, and from a background of physical and/or sexual abuse or from a home with at least one alcoholic parent. Eating disorders were often reported. Types of self-injurious behavior reported were as follows:

• Cutting: 72%
• Burning: 35%
• Self-hitting: 30%
• Interference w/wound healing: 22%
• Hair pulling: 10%
• Bone breaking: 8%
• Multiple methods: 78% (includes all the above)

On average, respondents admitted to 50 acts of self-mutilation; two-thirds admitted to having performed an act within the past month. It's worth noting that 57 percent had taken a drug overdose, half of those had overdosed at least four times, and a full third of the complete sample expected to be dead within five years. Half the sample had been hospitalized for the problem (the median number of days was 105 and the mean 240). Only 14% said the hospitalization had helped a lot (44 percent said it helped a little and 42 percent not at all). Outpatient therapy (75 sessions was the median, 60 the mean) had been tried by 64 percent of the sample, with 29 percent of those saying it helped a lot, 47 percent a little, and 24 percent not at all. Thirty-eight percent had been to a hospital emergency room for treatment of self-inflicted injuries (the median number of visits was 3, the mean 9.5).

Why Are Most Self-Injurers Women?

Although the results of an informal net survey and the composition of an e-mail support mailing list for self-injurers don't show quite as strong a female bias as Conterio's numbers do (the survey population turned out to be about 85/15 percent female, and the list is closer to 67/34 percent), it is clear that women tend to resort to this behavior more often than men do. Miller (1994) is undoubtedly onto something with her theories about how women are socialized to internalize anger and men to externalize it. It is also possible that because men are socialized to repress emotion, they may have less trouble keeping things inside when overwhelmed by emotion or externalizing it in seemingly unrelated violence. As early as 1985, Barnes recognized that gender role expectations played a significant role in how self-injurious patients were treated. Her study showed only two statistically significant diagnoses among self-harmers who were seen at a general hospital in Toronto: women were much more likely to receive a diagnosis of "transient situational disturbance" and men were more likely to be diagnosed as substance abusers. Overall, about a quarter of both men and women in this study were diagnosed with personality disorder.

Barnes suggests that men who self-injure get taken more "seriously" by physicians; only 3.4 percent of the men in the study were considered to have transient and situational problems, as compared to 11.8 percent of the women.

Source:

• Secret Shame website

More info: Self-Injury and Associated Mental Health Conditions

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next:   Psychological and Medical Treatment of Self-Injury

Many children with ADHD have problems with self-esteem. Why? And how can you improve your child's self-esteem?

What is Self-esteem?

There are so many definitions bandied around. We like to think of it simply as being comfortable in your own skin. In children, we like to see it as a kind of protective covering that protects them from the sometimes harshness of life making more able to weather the storm, more able to cope with conflict in life, more realistic and more optimistic too. And as parents, we play a crucial role in determining how our kids see themselves.

Self-esteem is about self-value. It's not about being bigheaded or bragging. It is about how we see ourselves, our personal achievements and our sense of worth.

Self-esteem is important because it helps children feel proud of who they are and what they do.

It gives them the power to believe in their abilities and the courage to try new things. It helps them develop respect for themselves, which in turn leads to being respected by other people.

We can all get some comfort from knowing that there are no absolute right or wrongs in parenting, no expert can give advice about our own particular situation, as every parent and child is totally unique, it would be impossible to know accurately what each individual situation was like and therefore impossible for any expert to have THE answer.

The thing about nourishing self-esteem in our children is that it starts with us as the parent and our own self-esteem. As the quote goes:

'Worry not so much what you say to your child but what you do when you're around them'

Our children notice how we are all the time, which is why we promote the concept of being great role models to our kids and 'being the behaviour you want to see'

So as we move on we must all start off by recognising that we are all doing the best we can for our children and therefore we need to start by giving ourselves a pat on the back for what we are doing well. We need to celebrate our successes with our child and if there are things we read, we would like to have a go at or like to do more of, then make a mental note and start practicing in small steps. We must also celebrate our progress along the way and be kind to ourselves if we get it wrong or fall down along the way.

How is Self-esteem Affected by ADHD?

Your child's self-esteem is shaped by:

• how s/he thinks
• what s/he expects of his/herself
• how other people (family, friends, teachers) think and feel about him/her

Many children with ADHD have problems in school and with teachers and sometimes have difficulties at home. They find it difficult to make and keep friends.

People often don't understand their behaviour and judge them because of it. They disrupt situations, often gaining punishments, so they may find it easier not to bother trying to fit in or do work at school.

All this means children with ADHD often feel bad about themselves. They might think they're stupid, naughty, bad or a failure. Not surprisingly, their self-esteem takes a battering and they find it hard to think anything positive or good about themselves.

The Problem of Exclusion

Hyperactive, disruptive behaviour is a key factor of ADHD. Children with ADHD can't help behaving this way, but teachers trying to cope with a disruptive child may deal with it by excluding her from the classroom.

Birthday parties and social events are a natural part of growing up, but other parents may not want to invite a child who is known to have bad behaviour. Again, this can lead to a child with ADHD being excluded.

Exclusion only adds to your child's negative feelings and reinforces the idea that they are naughty.

How Can You Improve Your Child's Self-esteem?

If your child is lacking in self-esteem, there are things you can do to help.

Praise and reward: you need to make your child feel positive about them self, so try and give praise wherever possible. This can be for large or small actions - for example, if they have tried hard at school or helped clear up after a meal. As well as verbal praise, giving small rewards can highlight accomplishments. Get them to exercise their own judgment and praise themselves.

Love and trust: don't attach conditions to your love. Your child needs to know you love her no matter how she behaves. Tell your child she's special and let her know you trust and respect her.

Goals: set goals that are easily achieved and watch your child's confidence grow.

Sports and hobbies: joining a club or having a hobby can build self-esteem. Depending on your child's interests, the activity could be swimming, dancing, martial arts, crafts or cooking. No matter what the hobby, your child will gain new skills to be proud of - and for you to praise. Sometimes children with ADHD will go off their activity, so be prepared to come up with new ideas.

Focus on the positive: get your child to write a list of everything they like about them self, such as their good characteristics and things they can do. Stick it on their bedroom wall or in the kitchen, so they see it every day. Encourage your child to add to it regularly.

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How Can We Promote Self Esteem in Our Children

Allow your children some opportunities to be themselves, letting them choose an activity: remember the story about the parent who went to the zoo and let their child explore the zoo on their agenda. It was so frustrating for the parent who wanted the child to see as much as possible and so rewarding for the child who wanted to spend 2 hours with the penguins!

• Help them develop their own tools for problem-solving, resist the temptation to solve for them, and offer support instead.
• Involve your children in discussions, if they are old enough, about what to do if they misbehave, ask them what they could do to prevent it happening again, and what support, if any, do they need from you. Avoid labeling or name calling, even in your mind.
• Remain firm, fair and consistent with discipline.
• To be consistent takes resources, so spend time doing what you need to do to stay calm and patient.
• Listen to your child, pay full attention, with lips shut to show them that what they say really matters to you.
• Use the language of self-esteem, 'decide', 'choice', and stress the consequences of choices with your child.
• Make it safe to fail, for you and for them, remember it's OK to apologise if you get it wrong.
• Respect is a 2-way thing - we cannot expect a child to learn to respect others if we do not show them respect from which they can learn this from.
• Become a positive role model, if you are excessively harsh on yourself; pessimistic or unrealistic about your abilities your child may eventually mirror you. In contrast, if you nurture your own self-esteem your child will have a great role model.
• Show your love to your child.

Remember just like us, children do not acquire self-esteem at once, nor do they always feel good about themselves in every situation. If your child is feeling down you could try this small exercise. You could help them to write a letter to a make-believe child who is also having a bad day, let your child advise the make-believe child on how to feel good about themselves.

Getting and Giving Criticism

There are times when criticism is necessary, but children with low self-esteem aren't good at accepting criticism - or giving it nicely.

How you give criticism is important. Criticism is the other part of making your child feel loved: sarcastic, negative comments can undo all your hard work to be encouraging. So is there such a thing as good criticism?

If you want to teach your child how to accept criticism, you need to give it in a constructive way.

This means being calm, not angry, and focusing on the behaviour you want to change instead of criticising the person. It also helps if you can find positive things to say to balance the criticism. Using 'I' tends to be less aggressive than 'you'.

So if your child is struggling with a piece of school work, don't say 'you're stupid', but 'I loved the way you read the first page. It's only a couple of words you're stumbling on. That word is...'

All these things apply when your child gives criticism. For example, 'I like playing with you, but it's too cold to play outside today.'

Dealing with Criticism

The best way for your child to deal with criticism is to:

• listen to what's being said. Don't interrupt to contradict or make excuses.
• agree with it, where possible.
• ask questions if unsure about anything.
• admit mistakes and apologise.
• calmly disagree if it's unfair, e.g. by politely saying, 'I don't agree with you'.

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Learn about mental health conditions associated with self-injury and the types of self-harm.

Self-injurious behavior is common in the following conditions:

• Borderline Personality Disorder
• Mood Disorders
• Eating Disorders
• Obsessive-Compulsive Disorder
• Posttraumatic Stress Disorder
• Dissociative Disorders
• Anxiety Disorders and/or Panic Disorder
• Impulse-control Disorder Not Otherwise Specified
• Self-injury as a diagnosis

Self-injury Itself as a Diagnosis

Favazza and Rosenthal, in a 1993 article in Hospital and Community Psychiatry, suggest defining self-injury as a disease and not merely a symptom. They created a diagnostic category called Repetitive Self-Harm Syndrome.

The diagnostic criteria for Repetitive Self-Harm Syndrome include: preoccupation with physically harming oneself repeated failure to resist impulses to destroy or alter one's body tissue increasing tension right before, and a sense of relief after, self-harm no association between suicidal intent and the act of self-harm not a response to mental retardation, delusion, hallucination

Miller (1994) suggests that many self-harmers suffer from what she calls Trauma Reenactment Syndrome.

As described in Women Who Hurt Themselves, TRS sufferers have four common characteristics:

1. a sense of being at war with their bodies ("my body, my enemy")
2. excessive secrecy as a guiding principle of life
3. inability to self-protect
4. fragmentation of self, and relationships dominated by a struggle for control.

Miller proposes that women who've been traumatized suffer a sort of internal split of consciousness; when they go into a self-harming episode, their conscious and subconscious minds take on three roles:

1. the abuser (the one who harms)
2. the victim
3. the non-protecting bystander

Favazza, Alderman, Herman (1992) and Miller suggest that, contrary to popular therapeutic opinion, there is hope for those who self-injure. Whether self-injury occurs in tandem with another disorder or alone, there are effective ways of treating those who harm themselves and helping them find more productive ways of coping.

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Types of Self-Harm

Self-injury is separated by Favazza (1986) into three types. Major self-mutilation (including such things as castration, amputation of limbs, enucleation of eyes, etc) is fairly rare and usually associated with psychotic states. Stereotypic self-injury comprises the sort of rhythmic head-banging, etc, seen in autistic, mentally retarded, and psychotic people. The most common forms of self-mutilation include:

• cutting
• burning
• scratching
• skin-picking
• hair-pulling
• bone-breaking
• hitting
• deliberate overuse injuries
• interference with wound healing
• and virtually any other method of inflicting damage on oneself

Compulsive Self-harm

Favazza (1996) further breaks down superficial/moderate self-injury into three types: compulsive, episodic, and repetitive. Compulsive self-injury differs in character from the other two types and is more closely associated with obsessive-compulsive disorder (OCD). Compulsive self-harm comprises hair-pulling (trichotillomania), skin picking, and excoriation when it is done to remove perceived faults or blemishes in the skin. These acts may be part of an OCD ritual involving obsessional thoughts; the person tries to relieve tension and prevent some bad thing from happening by engaging in these self-harm behaviors. Compulsive self-harm has a somewhat different nature and different roots from the impulsive (episodic and repetitive types).

Impulsive Self-harm

Both episodic and repetitive self-harm are impulsive acts, and the difference between them seems to be a matter of degree. Episodic self-harm is self-injurious behavior engaged in every so often by people who don't think about it otherwise and don't see themselves as "self-injurers." It generally is a symptom of some other psychological disorder.

What begins as episodic self-harm can escalate into repetitive self-harm, which many practitioners (Favazza and Rosenthal, 1993; Kahan and Pattison, 1984; Miller, 1994; among others) believe should be classified as a separate Axis I impulse-control disorder.

Repetitive self-harm is marked by a shift toward ruminating on self-injury even when not actually doing it and self-identification as a self-injurer (Favazza, 1996). Episodic self-harm becomes repetitive when what was formerly a symptom becomes a disease in itself. It is impulsive in nature and often becomes a reflex response to any sort of stress, positive or negative.

Should self-injurious acts be considered botched or manipulative suicide attempts?

Favazza (1998) states, quite definitively, that self-mutilation is distinct from suicide. Major reviews have upheld this distinction. A basic understanding is that a person who truly attempts suicide seeks to end all feelings whereas a person who self-mutilates seeks to feel better. Although these behaviors are sometimes referred to as parasuicide most researchers recognize that the self-injurer generally does not intend to die as a result of his/her acts. Many professionals continue to define acts of self-harm as merely and totally being symptomatic of borderline personality disorder instead of considering that they may well be disorders in their own right.

Many of those who injure themselves are strongly aware of the fine line they walk but are also resentful of doctors and mental health professionals who define their incidents of self-harm as suicide attempts instead of seeing them as the desperate attempts to release the pain that needs to be released in order to not end up suicidal.