by Dusty Miller
Basic Books, 1994
Review by Joy Ikelman on Jan 5th 2000
There is a very personal language used by those who hurt or abuse themselves. It involves grief and rage, and it is usually related to the abuse they experienced earlier in their lives. Dusty Millers Women Who Hurt Themselves, A Book of Hope and Understanding, explores this language and puts it into a new perspective.
Miller calls her theory Traumatic Reenactment Syndrome (TRS). Her definition of TRS behaviors include eating disorders, cutting, burning, sexual acting out, substance abuse, and any hurtful behaviors that may be metaphors for earlier trauma or abuse. Miller chooses to write about women, although she acknowledges that men may also present these behaviors. She explains that men are socialized to act out their aggression or rage, or repeat the abuse on others. Women are more likely to inflict pain upon themselves.
Miller organizes her material into two sections. The first is an in-depth look at the cause/effect of women who hurt themselves. The second section covers treatment methods which may be useful for clients.
The premise of TRS is that some women "reenact the harm done to them as children and reinforce their belief that they are incapable of protecting themselves, because they were not protected as children" (p. 8). The self injuring behavior is a survival skill used to control intense inner emotions, while at the same time, helping the individual to feel more alive.
The trauma may have involved sexual or physical abuse, parental neglect, invasive caretaking, or chronic childhood illness. The individual may dissociate, or split, the experience from the conscious mind, substituting other behaviors that take the place of the abuse. Miller calls this a fragmentation of the Triadic Self: "The Abuser harms the Victim and cannot be stopped because the Nonprotecting Bystander is incapable of intervening" (p. 32).
Dissociation may involve analgesia (physical or emotional numbing) or amnesia (completely blocked memory) or occluded memory about the childhood abuse. Denial, confusion, self-devaluation, depersonalization, and identity fragmentation may also occur (Chapter 4). The goal of recovery is to reintegrate the individual.
Miller mentions the detrimental nature of labeling an individual solely as obsessive-compulsive, narcissistic, histrionic, borderline, multiple personalities, depressed, alcoholic, or psychotic. Medical treatment should address any primary diagnosis, and also examine any overlapping TRS behavior.
Miller suggests three phases of therapy--the Outer Circle, the Middle Circle, and the Inner Circle. The first goal is to create a safe place so the work may proceed. From there, an exploration of family dynamics is important to the delineation of symptoms. Support of a protective other (therapist, spouse, 12-step group, other support group) is useful at this time. The Inner Circle, the core of the therapy, involves "facing the truth of what happened to the child" (p. 235). This brings transformation in self-definition and relationships. Most importantly, the inner "Protective Presence" is developed, and its limitations tested.
The book is written in an uneven style, from mostly scholarly wording to occasional first person client accounts. The accounts and their interpretation may be disturbing to some readers. The book, unfortunately, does not soothe the hopelessness that women who hurt themselves experience. Women who cut, for example, have basic questions about their compulsive self injuring. Why do I do it? Why do I do it this way? How do I stop? Will it ever stop? Miller presents the map, but gives no compass.
Women Who Hurt Themselves does not really contribute new material or theories regarding self injurious behavior, other than presenting an expanded definition of Post Traumatic Stress Disorder (PTSD). However, the book is recommended for therapists working with clients who display self destructive behavior, as an adjunct to other materials on PTSD.
This book is not recommended for the client, unless she has proceeded far along in her therapy. There are enough "triggering" stories in here which could bring a client to a panic state, compelling her to self injure. There are also plenty of unresolved questions in the book which might cause severe anxiety in a client.
Note from the reviewer: If you need answers and direction regarding self injury, do some searching on the Web. One excellent site is Self-Injury. There is basic information here, resources for help, and plenty of links. It is also the starting point for those wishing to join Bodies-Under-Siege (BUS), an email discussion group about self injury. When reading these Web pages, I noted that men were very well represented among those who self injure. Hopefully, writers such as Miller will be more gender-inclusive in future contributions to the literature.
Joy Ikelman has worked as a scientific writer and editor for more than twenty years. She has a B.S. from Concordia College, Nebraska, with additional coursework from the University of Colorado. She is published in the fields of geophysics and the history of science. Joy has also written newsletters, book reviews, and press releases while participating in various community organizations. Her favorite activity is enjoying quiet time with Ike, her sweetheart of 21 years. Her interest in mental health preceded her own diagnosis with bipolar disorder. Philosophically, Joy believes that knowledge is power, and that a patient with any illness has a fundamental right to question, learn, and contribute.