It is rare to encounter a work on an important topic that would be of interest to clinicians, patients and their families, and to the general public. Books aimed at the later often tend to sensationalize their subject matter, and books aimed at patients and their families tend to be "dumbed down" to an almost embarrassing extent, rendering them useless to the clinician. But Plante achieves this seemingly impossible balance in Bleeding to Ease the Pain and has produced a work that I would recommend strongly to colleagues, patients, and anyone concerned about the lives of today's adolescents.
Adolescent cutting and intentional self-injury is a widespread phenomenon, affecting at least 1% of American teenagers. Plante offers plausible, if not always data-driven, explanations as to why these disconcerting behaviors appear to be increasing in prevalence. She includes a compelling chapter on the developmental challenges faced by adolescents, and suggests that the trend toward earlier onset of puberty and the negative effects this can have for female adolescents contributes to cutting. It remains to be empirically demonstrated that early puberty is a risk factor for cutting behavior in adolescence, but Plante's hypotheses, generated from her apparently extensive clinical experience, could launch a multitude of research programs in this area.
Plante strives to "de-pathologize" cutting, describing it primarily as a means of communication ("What part of this bloody wound don't you understand?") and distress relief. She also notes the connections among cutting, borderline personality disorder, and childhood sexual abuse. She is mindful of suicide risk and rightly insists that careful suicide risk assessment is paramount in the treatment of these patients, but she also notes that most cutters never attempt suicide. That said, is important to note -- as Plante does -- that up to two-thirds of adolescent suicide completers have a history of cutting. I was a little concerned by the faith she appears to place in suicide "no-harm" contracts, which have little or no evidence to support their use. In fact, the most likely outcome of such contracts is to lull the treating clinician into a false sense of security.
Dozens of vivid case histories are situated throughout the book, nicely illustrating critical themes. I imagine that these brief vignettes will be the sections of the book that resonate most with patients and their parents. For parents, these vignettes should inspire recognition ("That's just what my daughter is like"), normalization ("She's not the only one like this"), and increased empathy ("I had no idea how much she has been suffering"). Plante's book also serves as an excellent introduction to mental health treatment, explaining clearly the various treatment modalities, the varied types of mental health professionals, and, most importantly, the responsibilities of the patient in her own treatment. This focus on the patient's responsibilities is refreshing, as is Plante's suggestion that, in order to foster a sense of autonomy and agency, that the adolescent patient be allowed to select her therapist, after "interviewing" two or more. She also rightly emphasizes the importance of the therapeutic alliance and warns that therapy won't be successful if you don't like your therapist. Curiously, however, she gives much less attention to the negative countertransferential feelings that therapists often harbor for these challenging patients.
Summary: A concise, excellent introduction to adolescent cutting from a clinician's perspective. Valuable for clinicians, patients, parents, and the interested general reader.
© 2008 Glenn Sullivan
Glenn Sullivan is an assistant professor of psychology at the Virginia Military Institute and a licensed clinical psychologist practicing in Lexington, Virginia. His areas of research and clinical interest include suicidal behavior, PTSD, psychological assessment, and psychotherapy with men.