The psychotherapist whose books (including the novel The Best Little Girl in the World) have illuminated the nature and treatment of obsessive-compulsive disorder (OCD), anorexia nervosa and bulimia now shines the spotlight on another misunderstood behavioral disorder: self-mutilation. Levenkron begins by advising desensitization to the disturbing wounds, scars and blood-letting patients inflict upon themselves, redirecting focus toward the underlying issues. He likens cutting to OCD in that it is a compulsive act meant to relieve unbearable emotional pain, and to eating disorders in that it is a method of seizing control. Like anorexics, most cutters are girls, unable to express anger toward others, instead turning it against themselves. Levenkron is careful to explain that cutting is not the same as body piercing or tattooing, which reflect "adolescent trendiness," and that cutters are not suicidal, their wounds life-threatening only rarely and accidentally. Cutting is done secretly, "usually in a trancelike state," and "the act of creating pain... or drawing blood, is in itself the goal." Cutters then develop an "addiction" to this method of exchanging physical pain for emotional pain. With many examples from his practice, Levenkron provides clear and comprehensive information on the causes and effective treatments of this mysterious disorder, specific advice for therapists and an encouraging sense of hope for patients and their families.
Copyright 1998 Reed Business Information, Inc.
--This text refers to an out of print or unavailable edition of this title.
Self-mutilation, most commonly by cutting or burning, frequently begins in adolescence and may continue for a lifetime if the behavior is left untreated. It can cause permanent scarring, blood loss, infection (including human immunodeficiency virus infection), and even death. It is also psychologically dangerous.
Self-mutilation can be visually shocking -- imagine a crosshatching of ugly red gashes on an adolescent's arms and legs -- and eerily silent, a dramatic symbol that takes the place of words. It has the power to move not only psychiatrists and other mental health workers, but also the members of the emergency room staff, who bind and stitch the wounds of "cutters" and assess the likelihood that such persons will commit suicide; plastic surgeons, who are asked to remove the scars but often find their questions unanswered about how the wounds that caused them occurred; and youth workers in all areas -- hospitals, schools, and juvenile and residential facilities -- who may be struggling with more than one child who cuts, often in recognition of and in competition with each other.
Levenkron understands the need for sharing basic information about this taboo subject as well as strategies for treatment. As a therapist who has worked with this problem for more than 20 years, he has much to offer. Levenkron is also a gifted writer who, with this book, adds to the growing genre of creative nonfiction in which personal narratives and many of the other devices used in fiction attract the reader's attention, and engrossing stories provide information about a complex subject in a medical or scientific field. Stories are one of the oldest means by which we pass along information. I believe that today, physicians are hungry for stories. Most of our journals are filled with extensive research studies, and the case reports -- our stories -- are rapidly disappearing.
Levenkron fills his book with stories. The lives of Kessa, Annika, and Dina, for example, are described in spellbinding detail. I first heard about the book from two of my adolescent patients, one a girl who regularly cuts her arms and another who mostly restricts her food intake but will cut herself occasionally. These patients liked the book but had some questions about it. They felt that the lives and problems of the people Levenkron describes paralleled their own and validated their struggles with cutting. Moreover, they grasped Levenkron's well-articulated and repeated message that getting better requires replacing cutting with a trusting attachment to an understanding person.
They were puzzled, however, by some of his comments about medications, which he suggests are merely agents to stabilize hereditary chemical problems. My patients, both of whom had used medications that resulted in less frequent cutting, understood that their problems were a complex mix of many factors and that medication, individual therapy, and family therapy were all working together to help them get better. They knew that their depression was more than a biochemical imbalance and that their cutting behavior was more than a problem with attachment.
I liked much about this book. The writing is strong, and Levenkron addresses many aspects of cutting that heretofore have been taboo and does not look away. He has a clear message for those who cut -- in order to get better, you have to develop a trusting attachment to another person -- and repeats it over and over again, interspersing supporting comments, and so, as in many self-help books, seems to say to the reader, "You, too, can do this."
What troubles me is that this book is not written solely for people struggling with this problem, but also for a wider audience -- health professionals, therapists, friends, and parents -- and for these readers its main goal is to define good treatment of self-mutilating behavior. Here there are problems, and Levenkron's perspective is limited. From my own 20 years of experience with such patients and their families, I know that developing a trusting relationship with a qualified, knowledgeable person is an important part of the work. But there are other aspects of treatment to consider: the way medication can work with therapy to decrease symptoms, the way various life stresses can aggravate the condition, and the roles of individual, family, group, and cognitive therapies. The treatment of self-mutilation is complex, as are the factors that contribute to the behavior and the coexisting disorders and symptoms that present with the behavior. And for people who cut, as for anyone, not all depression merely reflects a hereditary chemical imbalance.
As a psychiatrist, I am disinclined to become involved in turf wars with psychologists and other mental health professionals. It has often been my experience that psychologists can describe and capture what psychiatry is and what it does better than psychiatrists can. But Levenkron's perspective seems biased. When he tells the story of the family of a girl who is referred to a psychiatrist because the previous therapist is overwhelmed by the serious nature of the girl's behavior, he says that the referral leaves both the parents and the child feeling "rejected, lost, and hopeless about obtaining successful treatment." Levenkron goes on to note that patients who are referred to psychiatrists feel that their problems are overwhelming to their initial therapists and too severe.
Yet Levenkron makes no recommendations for how to work with such fear. He does not suggest, for example, that a psychiatrist and therapist could work collaboratively on a case or that a patient could be referred to a psychiatrist and not be led to feel that his or her situation was hopeless. Instead, he reinforces the viewpoint that an adolescent will see himself or herself as a "psychiatric freak" if such a referral is made. Certainly not all patients who mutilate themselves need to see a psychiatrist, but psychiatrists are uniquely trained to work with patients with severe problems in which psychological, biologic, and social issues play a part.
I must recommend this book with caution. It is well written and engaging, and it educates the reader about a subject on which too little has been written. However, it does not provide a fully integrated perspective on treating self-mutilation, nor does it describe the many problems that frequently accompany this behavior.
Reviewed by Lynn Ponton, M.D.
--This text refers to an out of print or unavailable edition of this title.