Boy this is a tough one. The first thing I would do is get a psychiatric consult. There might be some impairment of reality testing here. Moreover, you have a fairly dangerous health situation, with her weight that low. Do you have access to an eating disorder clinic/specialist? You can use her writing skills to help her. You could have her journal, do self-dialogues, dream journal, whatever just to get the information flowing. I have a bias toward family therapy in eating disorder cases, but you have to decide if that's best for your individual client. The wounds you describe seem to be in excess of what I've seen with Borderlines, although that's still a possibility. I agree that self-mutilation can be an attempt to master/control psychological pain that seems overwhelming. For myself, I do not believe body piercing is self-mutilation. This is a pretty complicated case. I hope you have a good support network, access to other disciplines, and good supervision/consultation.
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