Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis

by Montross, Christine

  We had all internalized Lauren’s discomfort and now wanted to push it—and her—away. And therein lies the maladaptive truth of projective identification: It can spark a self-fulfilling prophecy. Fears that infidelity will breach the marital walls cause a partner to cheat. Lauren’s fears of rejection, abandonment, and aggression lead to behavior that brings about rejection, abandonment, and aggression. Lauren’s uncle or sister falls ill, she fights with a neighbor, she swallows rusty scissor blades. We prepare to discharge her from the hospital (yet another form of abandonment and rejection in Lauren’s eyes), and she eats chips of wood from the window frame. Soon we all feel angry at Lauren and want her to leave the hospital and never come back.

  • • •

  People who hurt themselves on purpose tend to explain their actions with a shared, if paradoxical, refrain: In situations of extreme stress, self-injury can provide a release. But how does this coping mechanism work? How can physical pain relieve psychic pain? How could shedding one’s own blood or purging be comforting? How could swallowing a potentially lethal object make a person feel safer?

  To attempt to answer these questions—and therefore to be better able to treat Lauren and other patients like her—I needed to examine both what has happened to self-injurers in their lives to lead them to harm themselves and what happens to them when they do.

  It is, of course, impossible to make general statements that apply to an entire population. Nonetheless, psychiatrists and their colleagues have identified that trauma, abuse, and neglect can predispose people to self-harm.

  Dr. Bessel van der Kolk, a psychiatrist and preeminent researcher on the effects of trauma, has repeatedly found that the brain can be structurally and chemically altered by severe trauma. If these changes happen at an early-enough age, the resulting damage may be permanent. Similarly, in their 2000 paper entitled “Repetitive Self-Injurious Behavior: A Neuropsychiatric Perspective and Review of Pharmacologic Treatments,” Brown University psychiatrists Rendueles Villalba and Colin Harrington write, “Numerous animal and human studies associate early psychological trauma with subsequent development of repetitive self-injurious behavior.” Villalba and Harrington elaborate on some specific neurological effects of trauma and support van der Kolk’s assertion that the brain is changed: “Overt abuse (especially of a sexual nature), as well as severe neglect, may produce profoundly toxic . . . effects on neuropsychologic development.” They cite nonhuman primate research that found that “early social isolation frequently leads to repetitive self-injurious behavior” and that primates who were deprived of social contact and support not only hurt themselves but also exhibited changes in both the structure and function of their brains.

  These findings hark back to a famous set of experiments with rhesus and macaque monkeys, conducted from the 1950s to the 1970s by Margaret and Harry Harlow. In a series of heartrending studies, the Harlows separated infant monkeys from their mothers, sometimes keeping them in isolation chambers for up to two years. The experiments yielded some of the most durable scientific findings on the psychological and behavioral consequences of social isolation in primates and prompted a radical reexamination of the importance of parent-infant bonding. (They also, unsurprisingly, contributed to the rise of the animal-rights movement.)

  The isolated Harlow monkeys were subjected to a variety of environments and stressors, and their responses were dutifully recorded and analyzed. Through their experimentation, the Harlows found that baby monkeys who were isolated differed in many ways from their nonisolated counterparts. “Total isolation . . . for at least the first six months of life,” Harry Harlow writes, “consistently produces severe deficits in virtually every aspect of social behavior.” Monkeys who had been isolated “were grossly incompetent” in their social interactions. “As infants and adolescents,” Harlow writes, “they failed to initiate or reciprocate the play and grooming behaviors characteristic of their peers.” As adults these monkeys did not engage in normal sexual behavior. They showed abnormal levels of aggression. And the females who had been isolated subsequently made terrible mothers, ignoring or behaving violently toward their offspring. Monkeys who had been isolated for six months “demonstrated limited social recovery” when reintegrated with a primate community. In monkeys who had spent their entire first year of life in total social isolation, no recovery whatsoever was shown. Harry Harlow’s discussion of this finding is appropriately grim: “The effects of six months of total social isolation were so devastating and debilitating that we had assumed initially that twelve months of isolation would not produce any additional decrement. This assumption proved to be false; twelve months of isolation almost obliterated the animals socially.”

  Many of the baby monkeys who were separated from their mothers exhibited self-injurious behavior when afraid. Some banged their heads against their cages. Others hit themselves. Still others bit their own extremities, sometimes to the point of near amputation. As these monkeys were subjected to increasingly stressful situations and stimuli, some hurt themselves so badly that they had to be euthanized. The responses the primates had to the self-harm were particularly striking in that they mirrored the sequence of emotions described by humans who intentionally inflict injury upon themselves: When the monkeys began hurting themselves, they were agitated and visibly distressed. As their self-injury progressed, they became calmer and calmer.

  So what is it about self-mutilation that has the power to produce calm in a certain cohort of human and nonhuman primates alike?

  From a scientific standpoint, self-injurious behavior is difficult to study. The ethics of scientific research prevent studies from being conducted in which human subjects are knowingly harmed, and rightly so. However, this means that we cannot, for example, observe cutters as they are cutting themselves in order to assess the physiological and psychological responses their actions evoke. Instead researchers must rely on patients’ self-reporting—a notoriously inexact source of data—or devise experiments that attempt to replicate the effects of cutting without in fact causing harm.

  In 1995 the Journal of Abnormal Psychology published a paper by Janet Haines and her colleagues entitled “The Psychophysiology of Self-Mutilation,” which aimed to do precisely that. In the paper, Haines lists the reported factors that give rise to the negative emotions that most commonly prompt self-injury as “interpersonal conflict, rejection, separation, or abandonment,” which may be “threatened, real, or imagined.” Indeed, nearly all of Lauren’s admissions cited predisposing events that could be interpreted through this lens. A terminally ill uncle or a sister’s hepatitis diagnosis could signal pending abandonment via illness or death. A fight with a neighbor raised the specter of both interpersonal conflict and personal rejection. Similarly, when Lauren’s doctors and nurses grew frustrated by her behavior and impatient with her care, she would perceive this as yet another rejection. In the self-fulfilling prophecy of projective identification, her own actions poured fuel on the fire of her worst fears.

  Haines describes a generalized sequence of events that typically occur before, during, and after self-injury. This sequence has been repeatedly described by self-injurers and their clinicians, and it begins with the rise of negative emotions. As the emotions swell, they reach a point where the self-injurer can no longer tolerate the intensity of the feelings. It is at this point that a phenomenon called dissociation is thought to occur. Haines writes that as the negative feelings become increasingly intolerable, “many self-mutilators report feeling numb, withdrawn, and unreal” and begin to engage in the act of harming themselves. As the wound is inflicted, it typically does not cause pain until “minutes, hours, or even days after the injury,” regardless of its severity. Haines postulates that this anesthesia is likely a physiological one, “mediated by an increase in endogenous opiates . . . caused by the extreme stress reaction prior to cutting.” In other words, according to her theory, the body may release its own morphinelike substances tw
ice: first in response to the stress and then in response to the injury. Not only would this double response mute pain, it also could contribute to the addictive properties of self-injury, reinforcing the impulse to turn to self-harm in moments of distress.

  Haines wanted to explore exactly what happens in the body and mind during episodes of self-injury. In order to do this, she gathered groups of “mutilators” and “nonmutilators” and read them personalized scripts of various events they had experienced and described, including one event, such as an argument with a significant other, that was meant to evoke a degree of psychic distress. Then both groups were read a script that guided them through images of self-harm. Various physiological measurements associated with tension, such as pulse and respiratory rate, were taken throughout the experiments. The results showed that the subjects with a history of self-injurious behavior became calmer—both by their own self-assessment and by the measured bodily responses—during the self-mutilation imagery. Essentially, the mere act of imagining they were hurting themselves calmed the “mutilators” down. No such results were evoked from the “nonmutilator” subject group.

  Months after I encountered Lauren, I treated a woman who, in the context of her husband’s moving out, had cut her wrists with a razor blade. “I felt so empty, so separate from myself, I didn’t even really notice I was doing it,” she recounted to me, her thin forearms wrapped in gauze. “Or I noticed, but it was more like I was watching it happen from above, not participating in it. At some point I saw something glistening white, and that kind of snapped me out of it. I remember thinking, ‘What are those white lines interrupting the red?’ and then I realized they were my tendons, and then I saw how much blood was all around me. That’s the only time I got scared. Not because it hurt—it didn’t, it hadn’t—but because I suddenly realized that I was going to have to go to the hospital.” She paused. “I knew that my sister would be really upset. I guess I only freaked out because I realized what a mess I had made and how badly I had screwed up.”

  This numbness and disconnection that my patient described help elucidate the phenomenon of dissociation. The self becomes an outsider who observes the body from afar, who does not participate in its actions and does not feel its feelings, be they emotional or physical. Foreign body.

  To a certain degree, dissociation can be a normal part of our everyday lives. I may feed the dog, brush my teeth, empty the dishwasher, yet on any given day have no recollection of the steps I took in the process of each of these mundane, everyday occurrences. I had the attention to complete these tasks but not the conscious awareness of doing so. “Highway hypnosis” is another common form of dissociation in which people may drive for long distances without clear recollections of shifting gears or maneuvering in traffic, without an awareness of having navigated turns and off-ramps on their way to their destination.

  Trauma is understood to cause a spectrum of more serious dissociative symptoms. A mild form of dissociation may occur in the midst of grief when, after the death of a loved one, we feel as if we are floating above ourselves or wading through a thick emotional fog, unable to connect with others or respond to our lives in the ways we normally do. After the September 11 attacks, hordes of New York City residents reported uncharacteristic feelings of detachment and disconnectedness. Scientific research has linked high levels of dissociative symptoms to the aftermaths of war, of earthquakes, of torture, of firestorms. Studies have demonstrated that people are far more likely to embody a dissociative state after they have witnessed an execution. The psychiatrist Glen Gabbard, a renowned psychoanalytic scholar, explains these occurrences succinctly. “Dissociation,” he writes, “allows individuals to retain an illusion of psychological control when they experience a sense of helplessness and loss of control over their bodies.” The type of dissociation that permits self-harm, however, is obviously less benign than that which results from inattention, or even from grief.

  Not all people who endure trauma—or even all those who exhibit dissociative symptoms in its wake—engage in self-injurious behavior. In her illuminating 1998 book on self-injury, A Bright Red Scream, the journalist Marilee Strong turns to attachment theory to explain why this is so. Attachment theory postulates that a child’s ability to develop into a psychically healthy individual is largely dependent upon whether there has been a stable emotional bond between the child and an adult who cares for him. A secure attachment bond assures the child that he is safe and that he will survive. Strong writes, “Research has confirmed that a single secure attachment bond is the most powerful protection against traumatization. Emotional attachment makes a child feel connected and supported, not alone and helpless. . . . Abused and neglected children never learn from their parents how to soothe themselves and cannot trust others to help them do so. So they may turn to cutting and other forms of self-injury as a means of self-soothing and reestablishing, at least temporarily, biological and psychological equilibrium.” Strong goes on to quote the psychologist David Frankel. “Usually kids internalize a sense of a parent they can call up from inside themselves for comfort in times of distress,” says Frankel. “These kids don’t have that—or what they call up is a Mom who wishes they were dead and a Dad who wants to sleep with them.”

  Dr. Diana Lidofsky, a psychologist and the director of psychotherapy training at Brown, elaborates upon Frankel’s assertion. Abusive parents who are intentionally malevolent certainly exist and may give rise to children who harm themselves, she agrees. Still, she believes that the parental failures that predispose a child to self-injurious behavior are more commonly based in deep neglect. Lidofsky characterizes this neglect as “chronic and toxic misattunement.” These parents, she asserts, may not physically or sexually abuse their children but may instead be “catastrophically absent, inadequate, and disturbed.”

  In people who deliberately hurt themselves, dissociation has often taken root as a coping mechanism in the midst of trauma. When a child is beaten or neglected or sexually abused, she may dissociate in order to distance herself from the experience. If she cannot physically get away from her abuse or neglect, she finds psychic ways to do so. If a person has to dissociate frequently, she may eventually shift into a state in which she perpetually feels disconnected and numb.

  Self-injury, then, with its flood of sensation, pierces this feeling of unreality and deadness. A razor blade splits flesh, and bright red blood pours forth and stains everything in its path. The hot metal rim of a lighter presses into skin, and smoke issues forth, carrying with it a jarring, searing smell of burn. Hair is torn from the scalp, tangling fingers in knotted tresses. A cold scissor blade slides down Lauren’s throat, and it is gripped and held by esophagus, sphincter, stomach; an ache persists, locatable, its cause known.

  • • •

  One day during Lauren’s hospitalization, I realized I didn’t know anything about her childhood or her family, and I decided to ask her. She was so furious with me that she would not even speak. Though she was choosing not to engage in her treatment, I didn’t want to do the same. So I returned to Lauren’s lengthy charts, in which I had first found a record of all she had ingested and all the ways in which the objects had been removed. Lauren was such a familiar patient to everyone else who worked in the hospital that I had picked up her care in the present moment, as if her history were as well known to me as it was to the doctors who had cared for her so many times before. I went back to Lauren’s earliest records to treat her like a brand-new patient, in the hope that I could find something we were all overlooking that could actually help her. I wanted to let go of all the behavioral plans and baggage that accompanied Lauren the minute she arrived in the ER; I wanted to let go of my own frustration and release the feelings of ineptitude she gave rise to in me.

  The psychiatric and medical and surgical notes of Lauren’s current admission no longer contained the detailed descriptions that might have characterized a first, second, or even third hospitalization. Ins
tead the notes were full of shorthand phrases that summarized her years of treatment as a chronic patient. She was a “well-known” patient with a “long history of intentional ingestions.” A patient who had “failed multiple medication trials,” for whom an established care plan was immediately put in place. I had come to know her this way, as a prepackaged, well-known patient with a huge reputation. A chronic patient. A patient who had consistently failed to be cured.

  I laboriously paged through Lauren’s charts. I did not come away with a treatment plan I hoped would save her. Yet I did find, back in her earliest admissions, a deeper understanding of her past.

  Lauren’s father was murdered when she was a baby. She never knew her mother for reasons that are not clear. Her aunt, who took her in after her father died, was a heroin addict and died from an accidental overdose when Lauren was six. From that time on, Lauren lived in a series of group homes and foster homes. She used drugs and sometimes stole or prostituted herself to get them. Her psychiatric admissions started when she was in elementary school and never stopped. She had given birth to two children, both of whom were immediately taken into protective custody and never returned to her. They would have now been eleven and six, born when Lauren was fourteen and nineteen, respectively.

  I didn’t have to know about rhesus monkeys in isolation or the intricacies of attachment theory to imagine that a person with Lauren’s history might be acutely sensitive to abandonment. Whether or not trauma had brought about physical changes in her brain that I could not see, I could believe that she’d had experiences during which it was better to be numb, distant, floating.

  • • •

  Even if we understand why Lauren and others may chronically hurt themselves and why the behavior is helpful to them (if only partially and temporarily so), the challenges of how to treat these patients within our current health-care system do not fade.