Academic journal article American Journal of Psychotherapy

Girls Who Cut: Treatment in an Outpatient Psychodynamic Psychotherapy Practice with Adolescent Girls and Young Adult Women

Academic journal article American Journal of Psychotherapy

Girls Who Cut: Treatment in an Outpatient Psychodynamic Psychotherapy Practice with Adolescent Girls and Young Adult Women

Article excerpt

The observation of deficits in the capacity for mature emotional self-regulation in girls who cut is noted in the literature (Daldin, 1990; Novick & Novick, 1991; Nock et al., 2008). The acquisition of the ability to respond in a healthy manner to stress and challenge, either from outside or inside the self, is one of the most important tasks of early development; girls who cut have not accomplished this developmental task or are seriously compromised in their efforts to do so. The connection between this observation, the psychosexual developmental antecedents of this deficit, and psychodynamic approaches to treatment are explored in the literature and in case reviews.

KEYWORDS: cutting, non-suicidal self-injury, self-abuse, self-regulation, skin


In adolescence the risk of engaging in nonsuicidal self-injury (NSSI) ranges from about 13.0% to 23.2% (Jacobson and Gould, 2007), which is even higher than it is in adults (estimated to be 4% by Briere & Gil, 1998). Given that the 12 -month prevalence of NSSI is as high as 2.5% to 12.5% (Muehlenkamp & Gutiérrez, 2007 as referenced in Miller, 2007, as many as 2.1 million teens self-abuse (Miller et al., 2007). Deeply disturbing are the statistics on the relationship of NSSI in teens and suicide attempts; in a recent study, 70% of teens who had engaged in recent NSSI reported having made, at a minimum, one suicide attempt. And 55% reported two or more such attempts (Nock et al., 2007). The average age of onset of NSSI is usually between ages 12 and 14 years (Muehlenkamp and Gutierrez, 2004), with an even higher risk for young adults between 18 and 25 (Whitlock et al., 2006), which may reflect the potential for contagion in "nontreatment" groups, such as college students (Muehlenkamp et al., 2008). There is literature emerging that reports on behavioral subtypes of adolescents who cut, and that while most engage in only a few episodes of cutting (Nock et al, 2006; Whitlock et al., 2006), Whitlock and colleagues (2008) find that gender, number of episodes, and severity of damage vary in different subsets, and this may affect assessment strategy and treatment.

Having a psychiatric disorder is associated with nonsuicidal self-injury in teenagers. A study evaluating adolescent psychiatric inpatients who had engaged in NSSI during the year prior to admission found higher rates of internalizing disorders (including major depression and post-traumatic stress disorder), externalizing disorders (including conduct disorder and oppositional defiant disorder), and elevated substance abuse compared to youth that do not self-mutilate (Nock et al., 2006). The association between self-injury and borderline personality disorder is well known in both adults and adolescents with NSSI (Shearer, 1988, 1994; Stanley & Brodsky, 2005; Nock et al., 2006). In a controlled study of a group of self-destructive teens with NSSI and suicidal behavior, only bipolar disorder distinguished adolescents with NSSI from those that were not selfdestructive (Jacobson et al., 2008). A recent study of adults (Foote et. al, 2008) points to the association between dissociative disorder, self-harm and suicidality, and though the symptom of dissociation is reported (Kisiel & Lyons, 2001; Miller et al., 2007), the relationship of a dissociative disorder to NSSI has not been studied in adolescents to date.

The most serious aspect of concern in these cases is co-occurrence with suicidal behavior and the risk of completed suicide (Miller et al., 2007), and authors note that patients with both NSSI and suicidality represent a more disturbed, at-risk group (Cloutier et al., 2010). Within a group that self-injures, the statistics do not differ on whether boys or girls are more likely to attempt suicide (Jacobson et al., 2008). Miller et al. suggest that because the motivations of the adolescent who cuts to manage her dysfunctional emotional state differ from the patient who is suicidal and wants to die, treatment approaches need to be specific (2007). …

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