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Book Review   |    
A Bright Red Scream: Self-Mutilation and the Language of Pain • Cutting: Understanding and Overcoming Self-Mutilation
Charles R. Swenson, M.D.
Psychiatric Services 1999; doi:
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by Marilee Strong; New York City, Viking, 1998, 232 pages, $24.95 • by Steven Levenkron; New York City, W. W. Norton, 1998, 269 pages, $25 hardcover, $13 softcover

In this section . . .

Self-mutilation, which is receiving much attention from both mental health professionals and the public, is the topic of the lead review. Following it are reviews of several books involving various forms of storytelling about people: fictionalized stories by a psychoanalyst about early experiences that mark people for life, a biography of a Nobel-prize-winning economist with schizophrenia, a book exploring autobiography and how it reflects society, and autobiographical accounts of alcohol abusers and their families. Books on trauma and other topics round out the section.

The largest subgroup of the more than two million Americans who mutilate themselves are those who do it deliberately, episodically, and repetitively, generally followed by a brief respite from turmoil. Usually diagnosed as having a cluster B personality disorder, dissociative disorder, posttraumatic stress disorder (PTSD), substance abuse, an eating disorder, or more than one of these disorders, they are most frequently women between ages 13 and 40.

Their behaviors can be frightening, disturbing, and refractory to treatment, resulting in immense frustration for patients, families, friends, and therapists. Princess Diana's 1993 disclosure of her self-cutting behaviors catalyzed a trajectory of increased public exposure of this previously secretive topic. The two trade books reviewed here, one by a journalist and one by a psychotherapist, attempt to continue this trajectory.

Marilee Strong, a journalist who has previously reported on victims of war, trauma, and neglect, has written an illuminating and compassionate book, A Bright Red Scream: Self-Mutilation and the Language of Pain. She extensively interviewed more than 50 individuals who self-mutilate and tells their stories in a manner that is at once credible, compelling, and instructive. She has woven in summaries of related research, commentary from clinical experts, and explorations of the historical and cultural contexts of self-mutilation. A dominant theme is that self-mutilation gives voice to unmetabolized childhood trauma.

The greatest strength of this book is journalistic. Strong vividly portrays the clients and the place of self-mutilation in their lives, capturing the multiple functions and meanings of the behavior. Individuals who hurt themselves will find themselves in this book, and therapists will find their patients. There are those for whom self-injury replaces chaos with control, agony with relief. Others do it to feel more real, or to punish themselves, or to keep from killing themselves. Some cut to communicate pain, and others do it in the service of revenge. Some individuals learn of the "benefits" of self-injury by accident, others by imitation.

The behavior acquires an addictive momentum. For the patient on the road to recovery, Strong captures the poignancy and the power of the yearning for the "good old days," when self-mutilation solved everything.

The author is at her eloquent best in describing links between childhood traumata and adult self-mutilation. Effectively spotlighting the work of Frank Putnam (1) on childhood sexual abuse and Bessel van der Kolk (2) on the profound and long-lasting biological effects of trauma, she makes very complex matters read like a good story, weaving in case vignettes and interviews with the authors. Unfortunately, Strong's focus on trauma benignly neglects the nearly 50 percent of self-mutilating individuals who do not report trauma histories. Many therapists have taken their patients on destructive wild goose chases looking for trauma histories.

Surveying the history of self-mutilation in American psychiatry, she moves from case reports of the 1800s to Karl Menninger's classic Man Against Himself (3) to the empirical approaches that began in the 1960s. She nicely highlights the role that self-injury can play in managing dissociation, loss of control, and numbness. In her jarring account of body piercing, tattooing, and other "non-pathological" types of self-mutilation, it is to her credit that she can see connections, but also important distinctions, between these and "pathological" types.

In her discussion of treatment approaches, Strong highlights the immediate necessity to learn to cope without self-injury and the long-term necessity of dealing with underlying PTSD. She walks the reader quickly through various approaches—medications, psychotherapies, skills, expressive therapies, and eye movement desensitization and reprocessing—always emphasizing pragmatism and combinations of therapies. She provides a reasonable summary of dialectical behavior therapy, the only psychosocial treatment that has been empirically demonstrated to reduce self-mutilation for borderline patients, although she fails to grasp that it is a long-term model with a depth psychotherapy that addresses PTSD in detail. She presents several credible case vignettes with successful outcomes, offering the reader realistic hope. As far as I am aware, this book has no peer at the moment as an informative, compelling read that gets across the suffering and plight of those who self-mutilate while offering accurate, up-to-date information and realistic hope for recovery.

On the other hand, I was immediately put off by the front cover of the hardcover edition of Steven Levenkron's Cutting: Understanding and Overcoming Self-Mutilation. An attractive young woman is leaning forward toward the camera. She is wearing very short shorts and the very obvious centerpiece of the cover is her crotch. Just below her crotch, her forearm with scars from recent cutting is placed on her knee. The cover is seductive, sexualized, and entirely inappropriate for a book that proposes to shed light on a hidden topic, bringing compassion and reducing stigma.

Levenkron is a private-practice psychotherapist who recently wrote a popular book on eating disorders, The Luckiest Girl in the World (4). Like Strong, he weaves case vignettes with commentary on the understanding and treatment of self-mutilation. His cases are from his practice. His commentary is almost entirely his own personal perspective, without meaningful reference to the research or clinical work of others. As this is not made explicit, the uninformed person could finish the book with the impression that Levenkron is presenting consensus thinking on the topic.

His writing style is conversational, confident, familiar, even comforting. Unfortunately, the author leaps from one formulaic oversimplification to another, as if his readership is unsophisticated. For example, "As children, we are incapable of making judgments about the adults in our lives and how they treat us." Or, "Self-mutilators rarely allow others to achieve emotional closeness to them." The dialogues between himself and his patients sound condensed and a bit unrealistic, and they almost always portray a therapist who can quickly elicit cooperation from even the most noncollaborative client. Although Levenkron may be an excellent therapist for these patients, his dialogues lack credibility.

Even though the offensive cover, the exclusion of other perspectives, the oversimplifications, and the unrealistic dialogues each are misleading in different ways, one can find merit in this book. For instance, one can tell that Levenkron has indeed worked to understand a good number of these patients and has grappled with a therapeutic approach. His approach is an extension of the basic stance he has taken with patients with eating disorders, and he does his best writing about self-mutilating individuals who also have eating disorders. His recommendations for doing psychotherapy with the self-injurious patient echo those of experts in the field. He always takes self-cutting very seriously. He counters secrecy with an insistence on disclosure. When necessary, he takes an active structuring role that can be very much needed by these patients. He works to interrupt self-cutting before addressing trauma in depth. He is sensitive to the prominent role that shame plays in self-mutilation. And he insists that a strong, trusting attachment to the therapist is central to all else.

These are two very different books primarily targeting a lay audience, designed to shed light on a painful and often misunderstood subject. One book readably synthesizes an enormous amount of information with credible personal accounts. I will recommend it to patients, their families and friends, and professionals. The other book, while it reflects considerable experience and provides useful recommendations, is misleading and at times offensive. I would recommend leaving it on the shelf.

Dr. Swenson is associate professor of clinical psychiatry at the University of Massachusetts Medical School in Worcester and area medical director of the Massachusetts Department of Mental Health.

Putnam FW: Dissociation in Children and Adolescents: A Developmental Perspective. New York, Guilford, 1997
Van der Kolk BA, McFarlane AC, Weisath L (eds): Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, Guilford, 1996
Menninger KA: Man Against Himself. New York, Harcourt, Brace, & World, 1938
Levenkron S: The Luckiest Girl in the World. New York City, Penguin, 1998


Putnam FW: Dissociation in Children and Adolescents: A Developmental Perspective. New York, Guilford, 1997
Van der Kolk BA, McFarlane AC, Weisath L (eds): Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, Guilford, 1996
Menninger KA: Man Against Himself. New York, Harcourt, Brace, & World, 1938
Levenkron S: The Luckiest Girl in the World. New York City, Penguin, 1998

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