CALIFORNIA STA'IE UNIVF...RSITY, NORTHRII:GE
'IWO STUDIES IN SELF-MUTilATION:
\)
ANALYSIS AND REVIEW
A thesis s~tted in partial satisfaction of the requirements for the degree of Master of Arts in
Education,
Educational Psychology,
Connseling
&
Guidance by
Terrence I.Duis Rearick
Jnne, 1979

-::The :-Thesis of Terrence Louis Rearick is approved:
-Dick -Theil
~california State University, Northridge i

TABLE OF CONTENTS
INTRODUCI'ION
REVIEW OF THE LITERATURE a. Etiology b. Treabnent
.METHOOOI..CGY
CASE HIS'IDRIES
ANALYSIS
RECCM1ENDATIONS
BIBLIOORAPHY
Page
15
16
24
27
31
1
6 i i

ABSTRACI'
'IWO STUDIES IN SELF-MUTILATION:
ANALYSIS AND REVIEW by
Terrence IDuis Rearick
Master of Arts in Education
Self-mutilation, although rare, is a devastating sort of psychopathology. Seen primarily in an institutional setting, the impulse to ignore it must be resisted.
Presented here, is a review of the literature. There has been an att.errpt to organize the infonnation in tenus of causation and treabnent.
Additionally there has been an effort to :point out and give credit to those schools of thought that have contributed to the l::ody of knowledge.
Also included are two case studies of self-mutilative clients and an analysis of these cases and recommendations for further study regarding causation and treatment. iii

INTRODUCI'ION
Self-mutilation or self-injury, (both terms will be used here), is perhaps the rrost shocking, and certainly one of the rrost extreme fo:rms of human psychopathology. Although incidents of selfmutilation comprise only a sma.ll part of the total spectrum of abnonnal behavior, there has been a great deal of study in this area.
This is probably due to the life threatening nature of the disorder and the barriers i t poses to nonnal social and intellectual development.
In the following paper we will atterrpt to analyze selfmutilative behavior through a revia-1 of the literature and the use of two case studies. We will study self-mutilation and it's relation to suicide, sado-masochism and guilt. Also we will explore the connections between self-mutilation and· manipulation, sensory deprivation, anj sexual aberration.
Throughout the literature two schools of thought seem to emerge as advancing a majority of ideas and theories regarding this phenomena. The psychoanalysts and the behaviorists have had the most success in this field and they stand out most often. We will atterrpt to delineate some of these ideas and point out differences or similarities whenever possible.
The study of self-mutilation is limited in many ways. The greatest and perhaps the rrost obvious is that the investigation of such behavior is lirni ted alrrost entirely to the institution. This would sean to follow logically in that rrost cases of self-mutilation require the type of close supervision found in this type of a setting.
1

2
Ironically, however, it is just the atnosphere that these institutions provide which may bring on and foster this behavior.
Self~mutilation although repelling at times, has captured the interest of man throughout history. Literature is filled with examples of self~mutilation. The Bible provides us with one example in the phrase, "If thine eye offends thee, pluck it out." (6)
Another example which comes to mind is that of Oedipus and how he
·blinded himself by gouging out his own eyes. So self-mutilation, while abhorrent, has provided us with some main themes in literature.
Characteristic of the ambiguity of self-mutilation is that it may l:e observed in many cultures in somewhat tolerable or even socially desirable for:ms. In the Western ~rld this is examplified by bitten nails, pierced ears, and in some instances body tatooing. In many primitive cultures self-mutilation may be used as a fonn of body enhancement. Tribal scarring, comtonly found in many tribes in Africa, is an example of this. (17) A rather Irore subtle fonn of selfmutilation, found in our culture, is derronstrated by the chronic surgical patient. This individual consistently seeks surgery when not necessary. Perhaps this can be generalized to include those patients who o::mtinually undergo plastic surgery to alter their appearance. {2)
Self-mutilation is a disorder behavior which is often a component of a larger or rrore complex disorder. Autistic patients are corrmonly self-injurious, exhibiting such behaviors as head banging, biting, and eye :r;oking. Such behavior is at times so serious that the patient must be physically restrained from injuring himself. (1) The severely retarded also exhibit self-mutilative behavior frequently. These

3 cases of autistic and retarded patients probably make up the majority of the cases recorded concerning self-mutilative behavior. While they may be of some interest to us, in te:rms of treatment methods and some specific forms of self-mutilation, t~y are not the primary interest in this paper. The major concern of this paper will be those patients who, while institutionalized, seem able to function in many or all spheres of no.rrnal life. These patients are cormonly perceived as psychotic, or borderline schizophrenics. (2,3) They are often diagnosed as paranoid or severely depressed. It is in these individuals that this behavior is at times rrost inappropriate and unfathomable.
There are some consistent characteristics concerning the selfmutilative patient that appear throughout the literature. The typical self-injurer is described as having had a turbulent fami.ly background.
Included in this category are those children who have been the victims of beatings, rejections or very ofte"'}, sexual abuse by a member of the inmediate family. (3, 7 ,8,17 ,20,23) Frequently the subject is fran a single parent home. The typical self-mutilating individual is described as aggressive and often hostile. (2,3,8,23,25) This aggression or hostility, while present, is not necessarily manifested in traditional ways. (2,3,7,20) Mbst studies have indicated that the ~ female is more commonly self-mutilative than the male. (1,8,10,18,27,
29) Wrist cutting or slashing is the most corrrron type of injury.
(1,10,16,27) While this is true, there are a number of other selfmutilative behaviors which are
COTill'Dil..
These include head banging, tongue biting, eye pJking, and slashing or cutting on various parts of

4
·the body. (7 ,8,18)
Another type of self-injurious behavior that is often seen is
:seJ:f-.inflicted burns. (14) This is not to :be confused with those burns or injuries resulting from a11 attempt to prove endurance. 'Ihis frequently occurs in institutional settings in the form of games of the
11 Chicken" variety. Such w::mnds resulting from these types of games
·.o£ten result in the "hash marks" or scarring so often found in mental wards or prisons. Such v;ounds or scars, in fact, may lend a degree of
:status to the patient or inmate who bears them. (23)
:Head banging is probably the rrost dangerous fonn of self-
:mu:tilative behavior. It has the potential of leading to rrore serious and permanent damage. Concussions, blindness, brain daroage and permanent physical disfigurement may result from such behavior. (11, l3,33)
Self--mutilation is often seen as a fonn of sado-rrasochism. This would seem to be an inaccurate assumption. Self-mutilative acts, as defined here, are typically, described as or perfonned in the absence of pain. (1,7,10,12,14,15,17,18,22,23,28,31,31) Also reported is that there is no merrory of the event as it tCX)k place. Without the incidence of pain i t would appear that self-mutilation bears little or no relation to sado-masochistic behavior.
Self-mutilations are often confused with, or may appear to be the result of unsuccessful attempts at suicide. (24) One study goes so
£ar as to describe self-mutilative incidents as a series of "little suicides". (17) Self-mutilation may often resemble attempted suicide
..in that it is often exhibited in order to avoid an unpleasant

5 situation. Clients are often known to have banned themselves in order to avoid class, therapy, \OC>rk details or just the day's routine. ( 9, 22)
Clients exhibiting self-mutilative behavior describe the act as an escape from pressure or a release of tension. (22) Release from this tension is usually immediate and patients remark on the satisfaction in seeing their own blood flow. Self-mutilation also resembles suicide in another way in that it makes it possible to get a sort of revenge. It is rather like corrrnitting suicide and being able to see the reactions of those left behind. Although self-mutilation does bear all these relationships to suicide, we do not wish to concern ourselves with those injuries resulting from legitimate attempts at suicide. Such injuries do not fall into the definition of selfmutilation used in this study. Such injuries are resultant of an attempt to end ones life and are not conmitted purely for the sake of injury. (17)

REVIEW OF THE LITERATURE
RI'IOICGY
The causes underlying self-mutilation are many and varied. Ideas regarding causation not only differ fran case to case, but from researcher to researcher. Theories regarding the origins of selfmutilative behavior are often described in terms of the particular school of thought that the researcher subscribes to. Throughout the literature the tM:> schools of thought that seem to stand out are the analysts and the behaviorists.
THE PSYCHOANALYSTS
Analytical explanations of the disorder are usually expressed in tenns of ego differentiation or as part of a sexual aberration.
(7 ,8)
Many analytical researchers feel that the act of self-mutilation represents an attempt to establish the self as a separate entity from the rest of the v.orld. (8,14) It would appear that the goal of the self-mutilating patient is often to feel something
1 even pain
1 in an attempt to establish boundaries between the self and the outer world. (14) In at least one instance in the literature it was reported by a patient that the ability to feel pain represented a return to reality. (14)
Self-mutilation has also been explained as a psychosexual disorder along the lines of kleptomania or pyromania. (30) other theories involving sexual explanations sometimes appear to contradict
6

7 one another. '1'his is especially true in reference to the sex of the self-mutilator.
In studies of male self-mutilators it is thought that the act of self-mutilation represents a form of self-castration. (22,31) In performing this syml::olic castration, patients report an escape fran tension. Also reported is the satisfaction of a "powerful force" whlch overcomes them. (8, 31) In contrast, when studying the act of wrist cUtting in women, the self-mutilative act is considered to represent sexual penetration. (28) Also along these lines it is thought that the resulting wounds re?resent tiny genitalia or miniature vaginas. (30) As in males these acts accomplish a great release of tension. Psychoanalytic t.h.eory often relates this to an alleviation of some generalized or c::rildhood guilt. (7 ,8,17) Release from th.is ter1sion is usually irnmedi2te and subjects express their relief or satisfaction in seeing their ow.n blood flow. (28)
Analytic schools of thought des,:;ribe the self-mutilator as an individual of very low self-esteem. Such patients seet'Tt to be saying,
"I might as w"E'll do it to myself be:::'-.Jre someone does it to me."· (13,14,
23) It is also thought that self-rnctilation may be an attempt to do it to oneself before one does it to ancther. (7,8,9) In such cases much weight is given to theories which e.'\:? lain the behavior as a form of rage turned inward. Many self-muti:3.ting patients exhibit a tranendous arrount of sexual confusicn. This confusion is often in regard to their own sexuality as well as the reasons for their choices.
Often such patients have had a trau;::atic sexual experience in the past or as a cr.ild. (2,8,18) Many times what could be referred to as horro-

8 sexual panic can be observed in such patients. . The patient is often unsure of his or her own sexuality and displays an aversion or fear of harosexuality. Self-mutilation is also frequently seen by analytical researchers as a form of campensation for early parental rejection. This would again, possibly relate to a sense of guilt.
THE BEHAVIORISTS
The behavioristic point of view regarding self-mutilation explains the behavior as a learned operant :rraintained by both positive and negative social reinforcerrent. As such, self-mutilative behavior may be maintained by both the positive and negative reinforcers as well as aversive conditioning and reinforcers which are not readily apparent to the researcher or observer. · ( 8 ).
In a study by Bacaman et al, it has been shown that selfmutilating behavior often occurs as a response to sensoxy deprivation.
In others it has been sho~Nn that the combination of boredom, inactivity and anxiety, conditions which are inherent to institutional settings
1 are just the conditions which may precipitate this kind of behavior.
(3,8,10
1
14
1
20,23) In one study of twenty juveniles (20) it was shown that these conditions
1 combined with peer pressure
1 rurrour
1 depression and status seeking behavior, led to an epidemic of self-mutilating behavior. !1~1 patients involved in the epidemic reported these things to be a factor in harming themselves.
Many ·times
1 however
1 the reasons behind self-mutilation may be far less complex. Often a patient will be attempting to manipulate

9 staff members with such behavior. As we have mentioned before, such manipulation may represent an attempt to avoid a specific situation.
(17) The patient may be malingering in order to avoid something else unpleasant. Often such acts may be rnanipulati ve in tenus of the patient's needs for attention. Frequently the patient will approach, and perhaps
1 in an indirect manner, hint that he is about to ham himself or that he already has. In this threat versus action situation, it is apparent that the patient may
1 indeed, be struggling with a
"powerful force". (14
1
28,30)
Patients have been known to turn over harmful material to a staff manber only to be found slashing their wrists rroments later. This is ccmronly interpreted as borderline behavior. The patient seans to be drifting in and out of reality, experiencing only brief periods of sanity. (14) This conjecture is considered unlikely by some in that it is unlikely that all self-mutilating patients are in the borderline category. A somewhat more plausible explanation is that the patient tries to involve another patient or staff member in order to avoid total responsibility for his actions. (15) When a self-mutilative patient does manage to involve a staff member in the behavior he fonns what is known as a "co-conspirital dyad". (15) In fanning this dyad the patient seems to feel that he has shifted a certain amount of responsibility for his actions to the staff member. New staff members should be aware of this phenomena in order to avoid problans in regard to conflicting loyalties.
Both visual and auditory hallucinations have been reported by patients. (3,14) It is interesting to note that audio hallucinations

10 usually involve the voices of people who are known to the patient.
Pat:ients usually report the voice of a parent telling them to do something to themselves. (2,3) In cases where the voices are of people not. known to the patient, self-mutilation often occurs in order to escape the voices. (14) Visual hallucinations take many fo:rrns and seldom seem to represent figures known to the patient. These figures typ.ically, are described as being god-like or very mysterious. ( 3 ,14,
23) These hallucinations are usually reported by patients who exhibit
rore severe types of pathology.
F:inally, it would seem that there is a progressive aspect to this
-type o£ behavior. (3,14) The self-mutilating patient will typically
-begin by making small lacerations on the ann, wrist or sometimes the abdomen. As the syndrome develops however, the seriousness of the
·wounds increases. Studies have shown also that the type of self-
::injuty often changes. The patient often "progresses" from wrist rul::ti:ng to burns or head banging. (23)
Jhjuty tYPe of ritualistic behavior at an early age. (8,12,17,31)
SUCh behavior is represented by the child who continual! y rocks back
:forth or possibly, picks at himself on a continual basis.
·-'Pi:"eabnent of this disorder, again, is varied and depends in a
~l:arge
on ·the orientation of the therapist. The nost common type of -treabnent for self-mutilative patients would seem to be cherro-

11 therapy. This is true because of the management problems that the self-injurious patient presents. Self-injurers are rrost often treated with psychotropic depressants. Arrong the rrore comronly used drugs are haldol, parnate, thorazine, stellazine and mellaril. {9 ,26) The results of this type of treatment do not constitute what could be oonsidered a riddance of syndrome. They do however, reduce the occurrence of such behavior. The objective in such cases is to alleviate pressures which are thought to bring on the incidents of self-nmtilati ve behavior. The dynamics of the behavior are put aside at tili.s point and the consideration is with the halting of the behavior itself. {14,26)
One study reported successful diminuation of a patient 1 s selfinjuring behavior through the use of several psychotherapeutic techniques used in conjunction with each other. (26) It should be noted that another study indicated that the use of reasoned argument, i.e., statements regarding the seriousness of injuring oneself, were of little value. (20)
In a study by IDvaas et al {1965) , it was derronstrated that techniques for alleviating guilt were often effective in reducing self-mutilative behavior in schiz~phrenic children. Alleviation of guilt was achieved by making what were considered to be guilt alleviating statements. Such statements consisted of saying things like,
"I don 1 t think that you're a bad child. " , in response to selfinjurious gestures. It should be noted however, that after a time the self-injurious behavior seemed to increase in response to such stat.e-
IlE1ts. This phenorrena led researchers to believe that such soothing

12 remarks were actually eliciting the unwanted behavior from patients.
In other words, the patients v.Duld hann thernsel ves in order to hear the statements made by the researchers. In this case the guilt alleviating statements were considered to be positive social reinforcers.
~training patients in how to deal with anger and frustration has been a ve:ry successful way to deal with these patients. Studies have combined several teclmiques to deal with this problem. (26)
Patients were shown or nodeled appropriate responses to anger. In addition they were continually encouraged to think alx>ut and label their errotions. Role playing was also used in this training and the combination of these
types of training seemed to lessen incidents of self-mutilation for some t.ime. Sane patients have been trained in assertiveness and this appears to have eliminated another source of tension. Also included as treabnent in this study were psychodrama, therapy groups and a system of behavior nodification based on withholding of privileges.
Behavior nodification has been a ve:ry successful method of treabnent for this disorder in the past. (1) Patients have been introduced to token economies to alleviate the behavior. These pa.tients have been seen as markedly irrproved over short periods of time. (24)
In one study simple reinforcers such as the word "good" or a favorite blanket or extra foods proved to be powerful incentive in alleviating or eliminating the occurrences of self-mutilative behavior. (24) Several studies have established the use of physical

13 contact as a reinforcer. (32) In this particular case subjects were rewarded for correct responses, {i.e., specific periods of non-hannful behavior) , by holding or embracing. This type of behavior appeared especially effective in reducing the number of self-injurious incidents.
In a study by Bergman, (1975), it was shown that behavioral contracting was possible with this type of patient. Several schizophrenic patients were simply told that it was possible for them to attain certain privileges, (free time, make-up, mirrors, etc.) in return for not hanning themselves. This seemed to help patients elinri..nate the behavior in themselves.
Another study was successful in eliminating self-Imltilating behavior in patients by canbining reinforcement for incompatible behavior and overccmpensation.
Nearly all behavior :rrodification methods have enjoyed some neasure of success in this area and aside from cherrotherapy behavior m:xlification seems to be the rrost effective way of dealing with this disorder.
Electro-shock therapy has also been used in this area with shock being used as an aversive stimulus. (32) In one instance a special device was designed, (a helmet apparatus with a control causing autoinduced shocks) , to control head banging behavior. This device administered a shock to the subject whenever he began to bang his head. (33) As a reducer of head banging this device was very effective, but it's limitations were to specific behavior.
In a study by Ball et al, (1975) , another :rrechanism was devised that reduced self-injurious behavior in assaultive and self-destructive

14 retardates. This device was a jacket with many electrical connections which were activated by any sudden or violent IIDvements on the part of the wearer. This allowed control of a much wider range of selfmutilative behavior than the previous helmet device.
In one rather interesting study of rats the power of electric shock, as an aversive conditioner is derronstrated quite vividly. (19)
'!his study shrnved tP..at the rats v.uuld often subject themselves to a shock in order to avoid another, IIDre :powerful shock. This was done to avoid a shock. The interesting ramification of this study is that, although eventually the shocks given on the grid were greater than the shock the rats were trying to avoid, they continued to run across it.

METHOOOI.CGY
The case studies presented here were done in a large detention facility for juveniles. These studies involve minors housed in a special section or, "unit", in this facility. This unit was designed to house, "problem", juveniles. The population of this unit included
' many kinds of problems. Housed here were minors thought psychotic, suicidal, homosexual or physically handicapped. Essentially, this unit housed those juveniles thought incapable of functioning in a nonnal living unit. The unit was staffed with a licensed psychiatrist, psychologist, and several well qualified counselors. All staff were available to any client at any time. Diagnostic impressions of the minors were the result of input by all staff and several conferences were held each week. It was as a result of these conferences that treatment plans were developed and results of these plans were discussed.
Additionally, much of what is presented here is the result of impressions, diagnoses, a11.d ideas of others previously written. In this particular setting it was the policy for staff to review the histories of all clients and add to these histories themselves.
Creating a type of "log" or journal of behavior and resulting irnpressions for every client. A review of these logs vJas partially responsible for development of these case studies.
Both of these studies are considered to be extreme. They are ooncerned with clients housed in the same unit at the same time. There is no doubt that their interaction had an effect on their behavior and this inte..raction will be discussed later.
15

CASE HIS'IORIES
'llle first client, for purpJses of this study we shall refer to him as Tom, to be considered was a 17 year old Caucasian with a long history of delinquency and problems at home. 'llle client's father died when he was only three years old. His rrother, (herself once hospitalized for an attempted suicide), was considered to be extremely depressed. He had tvK> younger sisters, however there is little informa.tion regarding them. He had an older brother with whom he was very close and with whom he initially became involved in petty crime.
His rrother remarried and the stepfather proved to be extrernel y abusive to the client and his older brother. He administered frequent l:Jeatings and it was as· a result of this that the client began a pattern of running away from home.
Eventually the client became involved with juvenile authorities as a result of his running away from home. He was placed in a series of foster homes and homes for boys. He was described at this time as being responsive to treabnent regarding his anti-social behavior and as doing very well in relationships with staff in these settings. He did, however, continue his pattern of running away, the difference being that now he ran back horne.
When the client was 16 years old his rrother was diagnosed as a tenninal cancer patient and was given only a few rronths to live. At this point Tam's early life would appear to be consistent with existing theory, in that, his childhood was turbulent and that he had been exposed to periods of physical violence at an early age. It was at this ti..rne that Tan became involved in rrore serious criminal activity
16

17 placed in a juvenile detention center.
!:n:i.t_.i<::l.lly the client was described as errotionally "flat". He was
~\!gl'lt tQ be paranoid in regard to loss of impulse control and lacking
He admittedly felt the need for attention and affect,.i,QI1 <:¥1d had a very low opinion of himself. This type of attitude is
~ns.:j,stent with the findings of Bacaman presented in 1972.
~~!c;l,:t.i,QI1ShiP between the client and a staff member. The objective in qt ~~lt..,esteem. This was to be combined with use of peer group
WJ;tJ.EmCe.
I~.itia.lly his self-mutilative behavior was manifested in a series
Qf: qqq.:j,dents and minor scratches observed on his arms and h?nds. Tom's
QQilQ.it_ion worsened however, and the mutilations became rrore overt. He
put staples into his hands and forehead. He also developed qr1 a.t:t:,i.tude, often verba.lized, that "If anyone cared about me they
't J,.et me hurt rcyself like this. " This attitude was seen as an a.t:t_ernpt
gather strength from those around him and to confinn his
~~l_f..,vx:>rth.. A study by Offer and Barlow in 1960 observed an identical lt was thought necessary to medicate the client in order to lessen
Ghance of self-injury through this behavior. As in both behaviori$t.iG and analytic treatments the medication of the client consisted rro~tly of the psychotropic drugs such as thorazine, and continued t:bt':ol.lghout his stay in the nnit. At one point Tam was receiving as much as 1000 mgs. of thorazine a day.

18
His self--mutilative behavior continued despite medication and he
experience roth visual and audial hallucinations. 'Ibm
Eiescribed the audial hallucinations as a voice belonging to his now
~eaa oother. Visually he related the appearance of a m:m in a white
who urged him to jump out the window. 'Ihis particular phenomena
~s related exactly throughout the literature in regard to types of
-ha!l:ucihations.
·At ·this time a quite cormon phenanena, described by Lester as
Thstib.itional, occurred in the unit. 'Ibm began to relate to another
:Self;;;..muti-lati ve client in the unit. Interestingly, both of their behaviors became m.::>re bizarre and severe at this time. Self-mutilative
~inCluded slashing himself on the anus and wrists, jurnping off his
-bed head -first and head banging. Another fonn of self-mutilation that
.The cl-ient began to engage in was the insertion of foreign objects into hls ·penis and ears. It is possible that this last behavior contained
:irtarii:pulative aspect in that it invariably resulted in a trip to the
--riOspital.
-1-\t :this ·point staff came to the conclusion that much of 'Ibm's
had become manipulative in tenns of receiving affection and cavofdance of responsibilities. It was thought that this manipulative
and achievement of high status in the peer group might be
~even ·rore probable when staff considered m:my of these acts to be in
:COn-petition with those of the other self-mutilative individual (Bill)
:in the unit.
A type of behavioral contracting based on the withdrawal of

19 privileges in response to self-mutilative acts was designed by staff.
··Whenever the client would harm himself he would be required to remain in :sight of staff at all times. He was not allowed to go to his roan
<Dr be :alone during the day and when retiring he was required to rerrove all.hut his mattress from his room. 'Ihis proved effective for short
±erms_hut did not fully rid Tom of the behavior.
Psychiatric diagnoses at that tiire described 'Ibm as having a chysterical element to his personality and lacking in socialization.
:Interestingly it was also noted at this time that he was suffering
:from a deep sense of guilt regarding his rrother' s death. Although there .appears to be little reason for considering it as such, ana-
~ytical theory sees this guilt as a factor in etiology.
As :a last resort, isolation from the unit was used as a treatment
:nE:I::hod, the rationale being that perhaps Tom's behavior was in response to rewards or reinforcement from his peer group. Rerroval from the unit was also thought to provide incentive to eliminate or reduce incidents of :self-:hann. At the same time medication was continued and attempts to increase Tom's self-esteem were reinstituted. Again, in a type of
.behavioral contracting, the client was allowed to return to the unit
:for .brief "visits" as a reward for periods of non-harmful behavior.
It was at this time that the self-mutilative incidents lessened
:and eventually ceased, apparently in response to this approach.
"The client was seen tM:> years later, and although his criminal
· :activit'.! had continued, there had been no further episodes of self-
'Irnltilation.

20
'J.'h~ p~nd case to be considered was that of a client we shall refer to as Bill. His case was a rather notorious one. Bill was also l7 yeqJ::p 9;Ld and caucasian. He had been in and out of this particular insti t::gt:i,.on for several years and was 'i\rell known to all staff.
:e:iJ.:J,.
1 s nother had been a heroin addict and had died of an overdose when he was 6 years old. The remaining family consisted of a stepfather, two older sisters and an adopted brother. Again there is eviden~e gf a chaotic childhood and JXlSsible rejection by the stepfather.
~qqrdjng to his family, the client had always felt responsible for his nother 1 s death. On the norning of her death the client had noticed t,hat she did not seem to "feel well". Apparently this was the beginning of the overdose. · He asked his nother if she wanted him to stay hQme to take care of her, but his rtother instead, sent him off to school. On his return from school Bill found her dead himself. This was, to say the least, a traurratic experience for any 6 year old boy.
He stated several times then, and laber in life, that had he stayed hane to take care of her as was his intention perhaps he could have saved her. Here we can see a nore observable and perhaps a nore realistic foundation for later fe~lings of guilt.
After his nother 1 s death, Bill t€gan to run away from home and wound up in a series of foster homes. At the age of 15 he came to the attention of the local health departrnen± as a victim in a series of
"accidents". This was cc:mronly thought to be the beginning of his self-mutilative behavior.
At the same time b.,.e client began to have nore and nore frequent

21 contacts with law enforcement agencies and as a consequence came to the detention center.
Ipitially, the client was seen as a rather impulsive young man.
An analytic description in an early report saw him as being infantile, regressive and somewhat manipulative. His level of self-esteem was descrjbed as low and seemed to be begging for external controls. It
~uld appear that a low level of self-esteem was a consistent factor in these cases and throughout the literature.
~ill's self-mutilative behavior was far more frequent and severe than witnessed in most cases of this sort. Such behavior also seemed
take on more bizarre forms. In one instance Bill shoved a pencil up his nose and broke it off. He was also extremely prone to overdosing on any drugs that he could steal.
As the rate of self-mutilative incidents increased so did t.he severity of the acts. He was seen as approaching a psychotic break and to be suffering from severe lower level rorderline personality organization.
Medication was started a.lrrost .imnediatel y in this case and consisted of thorazine, stelazine and haldol. The object here, being to reduce roth the rate and severity of the client's behavior.
Treatment was behavioristically oriented and was aimed at raising the client's level of self-esteem, alleviating some of the guilt feelings that he was experiencing, and teaching him to control and appropriate! y express his anger. This was to be accomplished through role m:xleling, contracting for privileges, and consistent verbal reinforcement.

22
When angry, Bill v.uuld often insert wires and needles subdennall y into his hands and veins. In a rather analytic explanation, this was seen as indicating identification with his m::>ther who had died by inserting a need.le into her ann.
In one instance the client inserted a wire through his abdominal wall. Interestingly however, although the client allowed himself to be discovered, it was necessary to physically restrain him to rerrove the wire from his abdomen. This was similar to the behavior described by Grunebaum in 1967, regarding co-conspirital dyads.
These incidents were seen, in many instances, to be inappropriate responses to his anger and rage. He was thought to be turning his anger inward as a preferable alternative to striking at others. This is a carnron theory found throughout the literature.
Bill was described at one point to be using self-nrutilation as a means to gather aid and feel attachment from those around him. This was an attitude that was often verbalized as a feeling of helplessness and a need to have someone to talk to.
Although this client did not experience hallucinations he did suffer from ro.any nightmares. These nightmares had a psychotic flavor to them in which the client was both the nrutilator and the one being mutilated.
Treabnent for Bill followed nruch the same lines as the treabuent for Tom, but nothing seemed to work. The only method which seemed to enjoy any measure of success was in regard to raising self-esteem. In such cases the client was given positions of responsibility in the unit and left to do things his own way. Afterward he v.uuld be paired with a

23
5taff member who would discuss his feelings and ideas concerning such responsibilities. Any gains by this treabnent method, however; were
~hort tenn and the client invariably returned to his fanner behavior.
A1 though ·this client showed very little improvement while in this unit, a follow-up study-prov-ided-some- interesting observations.
The client had been transferred to another institution rather prematurely. When he returned, a year later, it was noted that all selfmutilative behavior had disappeared when he was transferred.
Additionally, there were no reoccurrences of the behavior and this continued until his eventual release a year later. This could be an indication that the self-mutilations represented a stress reaction as described by Ba.ch-Y-Rita. (2, 3)
In conclusion i t can be said that l:oth Bill and Tom were in dire need of acceptance. An interesting aspect that was apparent in both cases was that each client had adopted the style and mannerisms of what could be typically described as a "gang member". Each claimed affiliation with a particular gang known to inhabit their neighl:orhcx:x'ls. They cla:imed to be gang members to the death. The reality, in each case, however, was that the gangs wanted nothing to do with them.
They had been rejected even at this level.
In surrrnary it could be said that both clients were lacking in self-esteem, suffering from strong feelings of guilt, had experienced a greater than average anount of rejection and were unable to handle or express their rage and anger in an appropriate manner. Both were described as psychotic or near psychotic but this issue may have been clouded due to their lack of socialization.

ANALYSIS
In each case rather obviously, the client emerges from what is seen to be a turbulent childhood. Early experience with death, loneliness, and rejection provides a common link for each of the clients.
Exposure to physical violence, also may have been a factor in the develop:nent of the disorder. All these conditions, cited in the literature as contributors to causation of this type of disorder, are interesting, but do not, in thernsel ves, appear to provide a sufficient explanation in terms of,etiology. It is noted that many psychological problems may be the result of a turbulent childhood or the raising of an individual in a single parent home. It is also noted that these are not tmcom:ron circumstances in growing up and do not always result in a self-mutilative individual.
In both cases, 'Ibm and Bill were diagnosed in similar ways. They were seen as deficient in socialization and as fearful of loss of irrq;>ulse control. Additionally both were seen by themselves, as well as others, to be suffering from an extreme sense of guilt. These factors, combined with the very low level of self-esteem that each was credited with, may have resulted in a type of self-punishment which was expressed as self-mutilation.
While this is a possibility, we must remember that these studies were done in a detention facility. Many· of the observations regarding socialization, fear, and loss of control, are not only common to many of those housed there, but at times may be appropriate responses to incarceration.
In both clients the level of self-esteem was extremely low. Tfris
24

25 is . seen as a significant factor in the pattern of self-mutilation.
COmbined with the deep feelings of guilt that each of these elients experienced, this low level of self-esteem provides us with a possible explanation of causation of the disorder.
eilch case the clients are seen as having trouble in the areas
dealing with anger or rage. As presented in theory throughout the
~-=n:era-=tlire, ·this could be a possible indication as to the cause of the
in these individuals. Staterrents made by the clients, reqarding the actions of others and themselves would appear to lend
such a theory. It was also apparent through brief and
%poradic outbursts of temper that each client did have some arrotmt of
or ·anger to deal With. Again, the low level of self-esteem in
-t:.h'e'se ·cases might have inhibited them in tenns of outlets or opporttlrii~1es to express such anger.
=-tn :.:simlnary it could be said that in each case the client appeared to
-from a somewhat turbulent or chaotic childhood.
:Ariother ·aspect which must be addressed in each of these cases is
·of -m:inipulation. It must be remembered that each of the clients
=·sUffered an extraordinary arrount of rejection in a rather short
~periOd
time. Such self-mutilative behavior could be seen in te:rms
=of :an ·attempt to gain attention and syrrpathy. Certainly, this was a
::factor in each case, however, when considering this as a contribut.ing
:factor in causation, one must consider to what extent the desire for
'atte.11tion functioned as such. It would appear that, on the lY.J.sis of
?ability --to control the behavior, Tom, who was far rrore able to cor:.trol his self-mutilative behavior, was :rrore likely to have used it as a

26 form of manipulation. This, however, remains speculation.
It is strongly suspected that a large portion of this type of behavior is the result of self-hypnosis of a type. It is noted that such behavior ·usually occurs in the absence of others. Perhaps this is as a response to loneliness or roredom.

RECOMMENDATIONS
~cific questions for further research in this area came readily t9 ~d.
is the absence of pain so often reported in these cases? As prevj..()l,lSly noted, a possible explanation of this phenomena may concern
§lelf,.,-hypnosis. The absence of pain is mentioned in the literature
Qn}y tn terms of ego establishment. {1,7,12,14) Perhaps the absence
Qf ~' to g. type of self-hypnosis on the part of the client. Additionally, selfhypnol:):i.S could provide an explanation in regard to the manipulative
~pect of this disorder. Without pain, self-mutilation as a means of
.;:tvoiclj,ng responsibility becomes even rrore plausible.
~e relationship between self-mutilation and suicide although
Qften ~tioned in the literature, does not appear to have beeri fully expl()red. The possibility remains, despite theories to the contrary, that §lelf-mutilation represents merely a step towards self-destruction.
This is a CO!l'plex issue and deserves rrore attention. The problem
QQuld be addressed through interviews with self-mutilative patients or by ~eviewing studies concerning suicidal individuals. Apparently this hgs pever been done.
regard to the hallucinatory experiences of some self-mutilative patients, it is interesting to note the differences experienced. Why is i t t:hat when the hallucination is auditory the voices are known to the c;:.:l,:i.ent, while in visual hallucinations the figures are unknortm and
••mysterious"? Additionally, there is also some question as to why, when the hallucinatory figure is known to the client, the self-
27

28 nru.tilati ve gesture is in response to a camnand. This is opposed to when the figure is unknown to the client. In these instances the act of self-nru.tilation is described as an attempt to escape the figure.
Another area which has been neglected is in regard to the specific type of self-mutilation itself. Why does one became a wrist-cutter as opposed to a head banger? What are the differences? 1rlhy does the behavior take the particular fo:rm that it does? Also a possible area not Irentioned in the literature concerns what might be referred to as involuntary self-mutilation. Does an ulcer constitute self-mutilation of an unconscious level? By the same token perhaps many of the
"psychamatic disorders" fall into this category.
The rrost widely ignored area in regard to this disorder however
1 is in regard to treatment. As stated previously
1 the rrost COITII'IDnly used treabnent today is through chemotherapy. While such treabnent may be effective in reducing or eliminating the behavior
1 it does not address itself to etiology. Additionally the treabnent is effective only as long as one is receiving medication. A rrore comprehensive type of treatment is needed.
The use of groups has been alrrost totally ignored in this field.
In the literature there are few references to group methods in treatment of this type of disorder. However
1 in treatment of those cases presented in this study
1 group proved to be an effective tool. The use of peer pressure applied in group sessions proved to be significant in reducing self-mutilating behavior in these clients.
"Ms would appear to be due primarily to a loss of status which became apparent when the entire group was allowed to explore the

29 behavior together. The senselessness of this type of behavior was rrore apparent to the client when seen through the eyes of his peers.
Hypnosis as a method of treatment has been totally ignored also.
Treatment alorig this line would provide for a more thorough examination of subconscious rrotivation. Additionally it could provide answers in regard to theories which include self-hypnosis in terms of etiology.
Finally, as in so :many illnesses and disorders, what is needed is a means of detecting the self-mutilating individual at an early stage.
There are already methods by which this can be accomplished. In the literature there is mention of early "ritualistic" behaviors which are sometimes indicative of future self-mutilative behavior. More of these early signs need to be identified. In developing such a method of early detection we can acob.mplish two goals.
Primarily we can expedite treatment of the disorder at an early stage. In doing so the behavior rray be hal ted before it becomes so learned or ingrained that it cannot be treated. Additionally, by identifying the disorder at an early stage we ma.y be able to observe the dynamics at an early stage. It is possible that infonnation obtained at such an early stage rray be nore pertinent. The client himself, may have a nore accurate ·impression of the dynamics. There may be insight to be gained regarding etiology and personal feelings at this stage.
In surrroa...ry i t -would seem that while much research has indeed been done in this area, much :nore is needed. Specifically, there has been little research done in the field of causation. Most of the literature seems to address itself to what the disorder is and how it is mani-

30 fested rather than etiology. What is needed in this area is a rrore imaginative approach to investigation of causation and possibly a m::>re in.-depth study of those patients engaged in such behavior. Consistent factors found throughout the literature which seem to warrant exploration are guilt, self-esteem, and rejection and the need for acceptance. Treatment also, is in need of a rrore cornprehensi ve theory. In reading the literature and in "WOrking with the cases presented here, it is felt that the rrost effective means of dealing
self-mutilative individuals is behavior modification. A behavioristicall y oriented method of treatment seems to have the longest lasting effect. It "WOuld seem that a multi-faceted approach along these lines including some type of behavioral contracting, peer pressure, and reinforcement for desired behavior can prove very effective.

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