I begin to work with a twenty-three year old woman who has a history of depression and cutting herself. Maria comes because she is very concerned about her inability to control herself. She has tried for years to stop, succeeds for a while and then eventually starts again. She has tried psychiatrists, counsellors, hypnotherapists and a wide variety of practitioners of alternative therapies. The best Maria has ever achieved was short-term symptom relief. The medication that the psychiatrist prescribed did help, but Maria felt that she was crazy if she saw a shrink and so stopped attending as well as stopping her medication.
She lives at home with her parents and has drifted into a job in the advertising world. Work mates don’t know about her self-harming, while her parents do. Maria has had many boyfriends, and will do anything to please them, usually having sex on the first date. She feels very depressed when her relationships end and can cut herself at these times. She gets involved in another relationship as quickly as she can. She currently has withdrawn from her social activities.
Her parents are really worried about her, but for different reasons. Mum is scared of her suiciding, while Dad sees her cutting herself as a sign of her unhappiness with her work life and social life.
They have lots of arguments about Maria. Mum is constantly on edge, scared that she will find Maria dead in bed one morning. Mum begs her daughter not to hurt herself and tries to constantly talk to her about all the positives in Maria’s life. The more she talks, the more Maria switches off and zones out. The more she zones out, the more Mum worries. Their conversations seem to be constantly involving discussions about cutting.
Dad thinks that Mum is too worried and should show more self-control and not nag Maria so much. He is devoted to his work and tries to push Maria to be a success at her work. He believes that advertising is not really a good career and that she should get involved with something more serious. They mainly talk about career paths on the occasions when they might have a conversation. Dad often has mentioned to Maria that he doesn’t like being at home much because of all the arguments he has with her Mum.
Mum and Dad only talk about Maria, and independently, both have told her that they worry about what their life together will be like after Maria moves out.
Maria knows rationally that cutting herself is not good for her and that she is at risk of damaging her body if she keeps on like this. In fact, her cuts have sometimes become infected. She knows she should stop, but can’t. When I ask her how not being able to stop affects her, she answers with “I don’t know”.
In fact that is a common answer for her. Maria is very aware of her behaviours, but has very little awareness of how she feels in response to her behaviours, or to the behaviour of others. She can describe the many occasions in which she feels flat, but can’t talk about other feelings. She prefers to be in situations where she doesn’t feel much, preferring the company of the plasma screen TV in the lounge room.
We talk about her cutting herself. She thinks that she is not suicidal when she does it, but knows very little else. So I ask her about the last occasion in which she cut herself. That was after a boyfriend sent her an SMS dumping her. As she described the end of the relationship she was able to remember how deeply upset she had been at that time.
I then asked Maria about the time before that when she had cut herself. Her parents had been yelling at each other viciously, arguing about what to do about Maria. As Maria recounted details of the fight she remembered how she got increasingly angry with her mother for causing the fight. She also got angry with herself for causing her parents so much trouble. While saying this, she was also able to remember how angry she was with herself after receiving that SMS. Maria was unable to work out who she had been most angry with – her ex, her mother or herself.
I then asked Maria how she felt after she had cut herself. On each occasion, she remembers feeling better, that the physical pain had been better than her strong feelings, and that she felt calmer. It was in the hours after cutting herself that she became depressed. I waited. She thought about what she said. After a few moments, she said “I’m not crazy! I’m doing this to help myself feel better!” She thought some more, and seemed to relax into herself. The last thing she said at the end of the session was “I knew I was right. I wasn’t suicidal!”
At the start of the next session, Maria came in and stared intently at me for a few seconds while she sat down. It seemed that she was looking at me for a reason, one that I could only guess at.. She sat, and I waited for her to collect her thoughts and begin. She started to tell me brief stories of what had happened at home and at work since we last met. She recounted an angry argument between her parents the previous night. When I asked her about the effect on her of the argument, Maria said “I don’t know”. What she did know was that she went to her room and sat on the floor staring into space, with no energy to do anything. Today, she felt the same all day while at work.
I asked Maria to replay the argument between her parents that she heard the previous night. As she talked about the details, she started to energise and was no longer talking in her flat voice. She talked louder and quicker. She stopped and then out it poured – her anger with her mother and her anger with her father. Why was she so interfering? Why was he never home? Why didn’t they leave her alone? Why were they always fighting? Her anger escalated, and then she suddenly stopped. Her energy level dropped, and she slouched in her seat. When she didn’t talk for a few moments, I asked her where she was at. She said that she realised that their fighting was her fault and that she was to blame for their problems. She continued to withdrew into herself.
I spoke to her and she did not respond. The session ended and she slunk out the door. Her mother was in the waiting room waiting to give her a lift and looked at me questioningly. I looked back at her. Maria’s Mum knew that she was withdrawn and depressed and together they left.
We have now been working together for months. The sessions have a forwards and then stationary pattern. During some sessions, Maria develops insight and an ability to be more comfortable with her feelings. In other sessions, she is angry or depressed or both, and hating herself for feeling like that. As she becomes more able to be angry and depressed, she does not need to try so hard to escape from those feelings. Her cutting of herself is reducing in frequency, and she is beginning to feel more positive about improving her ability to manage her emotions.
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