The Irish Times
July 17, 1995

The Blade of Guilt
By Anne Dempsey

SARAH vividly remembers the first time she deliberately harmed herself. “I was 19, I was an art student, working at home on a glass mosaic. My parents started a violent argument in the next room. I went in to try to separate them and was told in no uncertain terms to get out. I went back to my room, picked up the glass and cut my wrists. The doctor was called, he panicked and the next thing I knew I was in a psychiatric hospital.

“I was there for four months, filled full of drugs and, because I wanted my art materials brought in, I was diagnosed as an obsessive personality which was not correct.”

What she was, she says, was confused, unhappy and insecure. She and her twin sister were the youngest of a large, middle-class, Dublin family and by the time they were born, the marriage had deteriorated into hitter acrimony.

“I remember tension, anger, fear. My sister and I were caught in the middle and forced to take sides. She handled it differently. She used to lock the two of us in our bedroom to keep out of it but I would be kicking and scratching her to let me down to try to help.

“We lived a very isolated life. We were not allowed out of the garden we didn’t have friends, just each other. As a small child I used to rip the skin at the back of my ears during my sleep and would wake up with blood congealed on my head. It was dealt with only as a physical problem and nobody asked me why I was hurting myself. I was terrified of the dark and at seven was prescribed sleeping pills.”

Once she began to cut herself, Sarah could not stop. Her destructive pattern has lasted over 20 years. Part of her right forearm is numb and her arms, thighs and stomach are criss-crossed with numerous weals and markings, evidence of a lifetime of wounds. Recently she has come to understand the reasons for her actions and is at last beginning to hope it is ending.

“At the beginning, I cut deeply and fairly dangerously,” she recalls. “I used glass, blades or knives. Now I use a scalpel, cutting my arm and wrists and sometimes my thighs and stomach, cutting up to 100 times, though these days not so much and not so deeply.

“I cut for the relief when I could think of nothing else to do. It is a physical expression of the torment going on inside mem have been diagnosed as a histrionic personality and am prone to depression. Things build up: I become disorientated. My head gets tight and finally I cut and there is a huge sense of release. The most important thing is to feel the blood running out, that was why I had to make so many cuts. I look at it draining down and the blood becomes a symbol of the pain running out.

“When I would go to hospital, there would be stitches, bandages and even though the blood was seeping through the bandages and the stitches were dreadfully painful, I would still experience peace and relief and sleep sweetly and stay fairly relaxed so long as still have the bandages then there are the scabs and sears when I’m healing. But as soon as they begin to fade, I can become drawn to cutting again. It is as if I need to see the physical evidence of cutting.”

Self-harm with scratching is quite common, says consultant psychiatrist Dr Patrick McKeon. Using a tool to cut is more rare, “though it does happen. The subjects, he says, tend to be women, coping with unresolved issues “of the past. Some have been sexually abused as children and given “the self-blame and feelings of personal worthlessness that abuse can engender the links between child abuse and adult self-harm can make sense.

Dr McKeon also suggests there may be a biological link in wrist cutting in that the site is heavily supplied with blood vessels where particular tension may he experienced.

“I didn’t like myself,” says Sarah. “I hated myself. I thought was inferior. I felt I didn’t belong in the world. I blamed myself for everything that happened to me and felt it was all my fault.

My sister is very important to me and when we split up at school and later as adults she works abroad I was devastated. It was the dominant twin and studies have shown that after separation, the dominant one suffers most because she is most deprived of her role.

“The way I felt, cutting myself, was the lesser of two evils. The alternative was to commit suicide. I struggle with life every day but actually want to live and cutting has helped. I am usually very pleased after I do it.”

NOW in her early 40s, Sarah lives alone in a small house with the walls full of her work in oils, watercolours, print and design. She has earned her living as a book illustrator and is at pains to point out that women who self-injure are sad but not mad or bad. “Many are leading very normal lives otherwise it’s an intensely personal response to issues.

She accepts the method is not socially acceptable: “I am well known in the casualty department of my local hospital and tend to be treated with censure, indifference and contempt. Most doctors do not allow me talk about my motives for self-injury, as they regard it as attention-seeking. These days I tend not to go to hospital after I cut myself, keep a first a first aid kit at home. I use only a sterilised blade. I have learned to make my own plaster sutures to bring the cut edges together.

Dr McKeon confirms that the aim is not to attract notice: “Some women tend not to present at casualty but conceal their injuries with long sleeves and leather bracelet straps. When asked why they harm themselves they often don’t know. Or they feel it releases pent-up feeling. Some women feel bad, evil, unworthy and feel that in cutting themselves they are cutting out the badness.”

People who self-harm can be helped by psychotherapy and counselling, he says. But if Sarah’s experience is representative, his profession has difficulty facing the issue.

“Recently my doctor told me my behaviour was very childish,” says Sarah. “I said for me it was adult and understandable. My psychiatrist has been very helpful but she never, ever discusses the self-harm, presumably because she too believes that if we talk about it, she is encouraging me. I would have liked to have been able to talk about it, rather than having this conspiracy of silence.

THE SILENCE was broken five years ago when Sarah heard of the Bristol Crisis Service which runs a telephone helpline for women who self-injure. She made contact. “I received gentleness, understanding. My call was answered by a woman who knew what I was talking about. For the first time I began to identify with other people. I was not so alone.

“I have remained in touch with the service. If I know I must cut, I don’t ring them however, if I contact, they are there for me and later the blade seems irrelevant. These days I am cutting myself far less frequently. I believe it is tapering off and now I am beginning a grieving process about what to put in its place. At times when I am struggling to stay from the blade, I find that if I can deal with the pain of wanting to do it, the need does pass.

Sarah is publicising the issue in order to create a climate for dialogue. Ideally, she would like to see the establishment of a self-help group and an Irish crisis phone-line for people who self harm. “We need somewhere where we would be allowed to speak, explain and receive emotional and practical help.

“I am still very sad and disappointed at how my life has turned out. I feel I have missed an awful lot that I will never get back. However, I have insight, I am strong, determined, I have a sense of humour and creative talent.

I am not ashamed of my actions. Before I go to bed. I look at my scars. I stare at them and trace some of them with my fingers. They indicate to me how hard my life has been. If I had my chance again. I would like to have virgin skin. But they are badges of honour. I have had my learning through my scars.”


United Press International
May 6, 1996

Drugs can lessen urge to self-mutilate
By Joyce Cohen

Psychiatrists said Monday that people who cannot resist injuring themselves can get relief through use of available medication. Severe nail-biting, skin picking, which can cause bleeding and scarring, and compulsive hair-pulling—behaviors which were often dismissed as just bad habits—now are seen as psychiatric disorders that sometimes can be controllable with treatment.

Such episodic and repetitive behaviors are “clinically vexing,” said Dr. Armando Favazza of the department of psychiatry at the University of Missouri in Columbia. Favazza said the behavior often starts in adolescence. “Most patients say it just happens, and is extremely difficult to stop,” he said in a presentation at the annual meeting of the Washington-based American Psychiatric Association in New York.

People who bite their nails—often causing them to bleed, for example, say that the injurious behavior relieves tension that build up in them and they say the action gives them some immediate relief. However, they also admit that later on they feel worse—out of control—about their behavior.

Nail-biting (known medically as onychophagia) and skin-picking (called neurotic excoriation) are not yet classified as bona fide psychiatric disorders, says Dr. Daphne Simeon, a research psychiatrist at Mount Sinai Medical Center in New York. In both cases, the antidepressant fluoxetine (Prozac) lessens self-injury compulsions. Prozac, however, has been unsuccessful in treating hair-pulling, known as trichotillomania, which is classified as a psychiatric disorder. Hair-pullers respond better to Anafranil, a drug use to treat obsessive-compulsive disorders. In all three conditions, doctors say they believe there are biological components to the disorders, which may have to do with abnormal glucose metabolism.

“More needs to be known,” said Simeon, noting that only a handful of studies have been published on the problem. Doctors say these self-injurious behaviors and others—such as burning, cutting or sand papering the skin—are not necessarily connected with suicide.

“In fact, it’s the opposite of suicide,” said Favazza. “It makes them feel better. It integrates them back into life. In some cases they say the blood is an old pal.”

Sufferers rarely find the activity painful, said Dr. Robert Grossman, a psychiatrist at Mount Sinai Medical Center. One theory, he said, is their action releases brain chemicals—endogenous opiates—which make them feel better. The disorders haven’t been recognized until recently because patients often are too embarrassed to tell their therapists and doctors. To hide the damage, patients will often wear elaborate hairstyles or wigs; heavy makeup or long-sleeved clothing to cover up skin damage to arms, the most common place for skin-picking.


The Ottawa Citizen
May 25, 1996

Self-destructive woman cuts herself to release the pain
By Shelley Page

Her arms, with their zigzags of white scar tissue, look like a macabre snakes and ladders game. They are exquisite arms really, the way the carved lines and cross hatches slant up, then down. You could stare at them for hours, using your own fingers to trace the pale wells and lines that she herself has carved. If she’d let you.

Just as I reach outward, having glimpsed the cigarette burns, deep finger nail marks, many knife wounds and stitch scars that once held together freshly gashed wrists, she moves her arms behind her back. In spring, as the sun tans her arms, these marks become almost luminescent and people ask her more frequently what happened. She says wearily, “It’s just old wounds.”

Old wounds.

There was a landmark book written about a decade ago, called Women Who Hurt Themselves (Basic Books), detailing the horrific cases of women who mutilate themselves, either by carving themselves up, or through compulsive cosmetic surgeries, eating disorders and other forms of chronic injury to the body. The author, Dusty Miller, will speak here to therapists who help these women, and to the women themselves, most of whom endured severe childhood trauma. The workshops are being hosted by Ottawa’s Centre for Treatment of Sexual Abuse and Childhood Trauma.

The incidence of such cases among women is high but remains a troubling secret. One study estimated that 86 per cent of 136 women at the Grandview School for Girls carved their bodies.

Samantha (the name she has chosen for herself), was an adopted child in a large Ottawa family who says she endured years of mental cruelty, along with physical and sexual abuse.

Before she began carving herself, she used to play chicken with trains, standing on the tracks near Hunt Club and Bank Street. Always the last to jump off, she was the hero among her friends. She could hang on so long because she didn’t care if she died. She eventually stopped playing chicken and started more private rituals. Cuts and burns and suicide attempts. She hanged herself in hospital once. Took massive amounts of pills. In turn she received shock therapy—as recently as six years ago—and was once on 55 different medications.

On a piece of paper she has scrawled an explanation for why she does this. There is unbearable anxiety, anger and sadness about her past. It gets so extreme she enters a trance-like state, which she needs to escape. She begins to hurt herself, which makes her concentrate on the physical pain instead of the emotional pain. There is great relief. This mutilation is her own personal therapy.

When her daughter got older and saw the gashes and cuts, Samantha began to hurt her body in more private places. Once she used a razor blade and slashed her abdomen from ovary to ovary. She used purple thread to sew it up because she didn’t want to go the emergency ward.

It seems like such a female thing to do, this self-injury. It’s such a non-confrontational way to deal with something. Surely there must be men who want to die because of similar childhoods. They must play chicken with things all their lives, Samantha suggests.

Maybe they light themselves on fire and jump across a canyon or climb into a barrel and fall over Niagara Falls.

“People call these guys heroes for what they do,” Samantha says. “But I know what they’re really doing.”

Samantha says she is being gentle with me by not telling me the worst things she has done. She can see how squeamish I am, how when she describes the place of a particular wound I clutch the corresponding part on my body.

My shoulders relax when she tells me she hasn’t done it for months now because, at 45 after years of wrestling, she is finally getting better.

For decades, most therapy focused on stopping the behavior, instead of exploring the reasons for it. The women who do are often just dismissed as manipulative attention seekers.

“Imagine if someone thought we were incredibly brave instead of sick and weird,” says Samantha, who wishes once someone would say to her, “You must have been incredibly strong to cut yourself open like that and then sew yourself back together.”

Literally and figuratively.


Chicago Tribune
November 3, 1996

Helping Those on the Edge; Lemont Facility Reaches Out to Self-Mutilators
By Mary Peterson Kauffold

The inner torment of the three women is palpable as they recount the horror of their childhood sexual abuse and its terrible legacy—years of brutal self-mutilation.

They are clients in the SAFE (Self Abuse Finally Ends) Alternatives Program at Rock Creek Center, Lemont, a private mental health facility that offers inpatient and outpatient services. The 30-day program specializes in treating people who deliberately and repeatedly mutilate themselves.

“I started self-injuring, hitting myself, beating myself up when I was 20, but I didn’t start cutting on my stomach and sometimes on my arms and wrists with razor blades until four years ago,” said Lynda Tyska, 46, of Los Angeles.

“I remember being in grade school, I was about 8, when I stuck my hands in the snow for a really long time, until I thought I had frostbite,” recalled Sally (a pseudonym), 31, of Lombard, who has a history of anorexia and bulimia. Sally doesn’t remember intentionally harming herself again until she was 15. “Then I started cutting my arms with a razor. Later I burned myself with cigarettes and I inserted needles into my skin.”

“The first time I cut myself on purpose was when I was 7. I used a rusty bicycle seat,” said Claudia Ash, 27, of Wichita, Kan. “Off and on growing up, I’d cut myself with razors or sharpened pencils or I’d burn myself with cigarettes or candles or on the gas stove. Everyone just thought I was clumsy. I’d burn or cut about 12 times a month.” There are few words that trigger gut-deep revulsion at their mere mention. Self-mutilation ranks high on the list.

No one understands that better than clinical psychologist Wendy Lader, 44, and mental health researcher Karen Conterio, 38. Lader is the clinical director and Conterio the program director of SAFE Alternatives. Ninety-nine percent of their clients are female, ranging in age from 13 to 65.

“Most of the rest of the world is appalled by this behavior,” said Lader. Even seasoned medical professionals have difficulty dealing with the grisly symptoms of this disorder. “Several years ago, a staff male nurse who had been in Vietnam and worked on burn units got sick to his stomach when he saw that one of our clients had self-injured by injecting feces and urine into her skin,” she related.

Conterio, a self-described maverick and entrepreneur, founded the program in 1985 as an outpatient support group at Hartgrove Hospital, a psychiatric hospital in Chicago. “I saw a problem that was being completely overlooked and decided to do something about it,” she said.

A year later she teamed with Lader, who was then the director of the women’s program at Hartgrove, to develop an inpatient treatment program. Conterio and Lader moved SAFE Alternatives to Rock Creek in May, lured by the center’s offer of a 20-bed hospital unit dedicated exclusively to treating self-mutilation patients.

The program is believed to be the only one of its kind in the country, according to psychologists, psychiatrists and mental health groups interviewed. It’s scheduled to be profiled this fall on ABC’s “20/20” and on the TV magazine “American Journal.” Lader and Conterio have appeared on national TV talk shows, including “The Oprah Winfrey Show,” “Donahue,” “Jenny Jones,” “Geraldo” and “Larry King Live.” Conterio was featured as an expert on adolescent self-mutilation in articles published last summer in Seventeen and Sassy magazines and recently was hired as a script consultant by a TV production company for a movie of the week.

Razor blades and cigarettes are among the most common instruments of self-mutilation, but SAFE Alternatives’ 600-plus case files give testimony to the proficiency of ordinary household utensils (scissors, knives, wires, candles and needles) to puncture, gash, burn and mangle human flesh.

Why do people savagely afflict and disfigure themselves? The short answer is because the act works like an emotional pressure-release valve, experts say.

Self-injury (the term Lader and Conterio prefer to self-mutilation) is driven by an inability to express feelings. “It’s not unusual for clients to enter the program with very little understanding of the reason they self-injure,” Lader explained. “They think self-injury comes out of the blue. They say, ‘I never get angry.’ And I’ll say, ‘Oh really, look at your body! What are you running from? What’s inside you that’s frightening you? What can’t you face?’”

“Many of our clients have endured horrendous emotional deprivation and sadistic abuse,” Conterio said. “The majority, about 80 percent, suffered physical and emotional abuse, and 50 percent were sexually abused. Self-injury lets them vent painful feelings they can’t express.”

“When I cut, I feel like I’m cutting out my shame,” Tyska said.

A phenomenon sometimes associated with self-mutilation is the absence of physical pain during the act. “In many cases, there appears to be an analgesic effect associated with this behavior,” Lader said. “We’re not really sure of the exact biological mechanism, but it’s believed to involve the release of pain-blocking chemicals produced in the brain called beta-endorphins.”

Sally admitted to feeling intense pain but only briefly when she self-mutilates, “then I disassociate from my body.”

The current trend of body modification—by tattooing, scarification (cutting the skin, typically in a pattern, to produce “artistic” scars), body piercing and skin branding—may fall under the category of socially acceptable mutilation, but Lader views it as a mental health red flag.

“It’s becoming more and more mainstream, but that doesn’t mean there isn’t a pathological underpinning to this behavior,” she said. “I believe there’s something very wrong when kids do more and more of this.

“I was on a talk show with several kids who had done a lot of body modification, and at first they insisted that it was simply body art. But I kept pushing. And finally one teen blurted, ‘It’s about the pain.’ And I said, ‘Bingo!’”

Many people believe acts of self-mutilation are suicide attempts, but the experts disagree. “This is not about self-destruction, this is a coping strategy,” Lader said.

“This is a pathological form of self-help behavior,” said Dr. Armando Favazza, professor of psychiatry at the University of Missouri-Columbia. Favazza is recognized internationally as an authority on self-mutilation, according to the American Psychiatric Association, Washington, D.C. “When a person is filled with so much anxiety and anger that they feel like they’re going to explode, the act of cutting is like lancing a boil, all the bad stuff goes out.

“Unfortunately self-mutilation only works for a short period of time, maybe a few hours or a few days, so to achieve the same relief, the behavior is repeated,” he said.

In June, Favazza released the second edition of his book Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry (Johns Hopkins University Press, $17.95). He traces the cultural roots of mutilation from ancient to modern times, describing in graphic detail such practices as Egyptian skull molding, African tribal genital mutilation and Chinese foot binding. He cites numerous documented cases of severe self-mutilation: limb and finger amputation, male and female castration, eye gouging, biting off fingertips and bone breaking.

“Self-mutilators seek what we all seek: an ordered life, spiritual peace—and maybe even salvation—and a healthy mind and body,” he writes. “Their desperate methods are upsetting to those of us who try to achieve these goals in a more tranquil manner, but the methods rest firmly on the dimly perceived bedrock of human experience.”

Favazza and Conterio collaborated in a 1988 study of 240 female habitual self-mutilators. They reported “the typical (self-mutilator) is a 28-year-old Caucasian who first deliberately harmed herself at age 14. Skin cutting is her usual practice, but she has used other methods, such as skin burning and self-hitting, and she has injured herself on at least 50 occasions. . . . She now has or has had an eating disorder and may be concerned about her drinking.”

The study concluded that 750 out of every 100,000 Americans self-mutilate annually, or about 2 million total in the U.S. Favazza said that subsequent investigation suggests the number is closer to 3 million. But the truth is, no one really knows for sure. Statistics on the incidence of self-mutilation are unavailable because of a lack of scientific research on the topic, according to a phone survey of the U.S. National Institutes of Health, the Anxiety Disorders Association of America and the American Psychiatric Association.

SAFE Alternatives takes an unorthodox view of treatment. Patients are not housed in a protective environment where sharp objects and other potentially harmful instruments are absent. They are given a crash course in no-excuses decision-making. Upon admission to the program, a patient must sign a contract with the staff promising not to self-mutilate. Violation of that taboo is grounds for immediate dismissal.

“We don’t infantilize their behavior by taking away sharps and putting them in restraints, which is tantamount to saying, ‘Poor baby, you can’t control this by yourself, can you?’” Conterio said. “I tell them, ‘You can choose to self-injure or not to self-injure.’ The patient will say, ‘I don’t have a choice; I have to injure.’ And my response is, ‘You are choosing to injure, so why don’t you choose to do something else? The bottom line is, you do have a choice.’”

“When people come here, their first impulse is to leave,” said Jerilyn Robinson, a staff social worker. “They realize they will need to talk about their feelings and handle real emotions without having self-injury to fall back on. I tell them, ‘Stick with it. It works.’”

“The ability to achieve success where other more traditional programs have failed is a hallmark of SAFE,” said clinical psychologist Deborah Zwick, who has offices in Chicago and Oak Lawn. She has referred 50 adolescent girls, ages 12 to 19, to the program in the last eight years. “Instead of focusing on past self-injury behavior, SAFE shifts the patient’s attention to finding alternative ways of releasing stress.”

Some of the coping techniques patients are encouraged to try are taking a relaxing bath, calling a friend, writing in a personal journal and exercising. Based on followup interviews with her SAFE Alternatives teenage alumni, Zwick estimates 75 percent have stopped self-mutilating.

Tyska is confident that when her treatment ends, she will not self-mutilate again. “Self-injury definitely does not work, and in fact, it allows your abuser to win,” she said. “My abusers can no longer hurt me, but if I abuse myself, I’m allowing them to win. So the best thing for me to do is to stop hurting myself and have a life.”


Fort Worth Star-Telegram (Texas)
June 15, 1997

Tortured minds; When life—with all of its sharp edges—becomes unbearable, some people cut themselves with a paper clip, a pop-can tab, a kitchen knife. It’s called self-injury, and it’s growing.
By Liz Stevens

Paula Watson was 7 when she began using her body as a canvas for her psychological pain. To the ends of her fingers, the little girl would secretly clamp serrated clips, like the kind that hold children’s mittens to their winter coats or fasten baby blankets. The tighter the clip, the better she would feel.

“I learned when I was really young that hurting myself would take the pain away, make the emotions calm down,” Watson says. “It’s like being in a tornado and everything is spinning faster and faster and all these emotions are pouring out; they’re going everywhere and you can’t control them, you can’t make them stop. And cutting made them stop.”

Broken light bulbs, pop-can tabs, razor blades, knives—Watson, now a 32-year-old Grand Prairie mother of three, has used all of them to relieve her suffering, slashing the backs of her legs and arms, carving demeaning words into her skin. Twenty-five years, numerous hospital stays and dozens of prescriptions later, Watson no longer needs to see herself bleed to feel better.

In terms of public knowledge, self-injury is the new bulimia. Doctors, teachers and peers are seeing more cases of the behavior, especially among teen-agers. And with increasing media attention on self-injuring, or cutting, the medical community is slowly acknowledging that self-abusers require specialized treatment.

An estimated two million people in the United States, mostly women, self-injure. Many of them function in the work world; most, such as Watson, hide their behavior out of fear and shame. Cutting, notes one doctor, “is the loudest scream no one ever hears.”

If that’s true, then Karen Conterio has bionic ears. Conterio is the co-founder of S.A.F.E., or Self-Abuse Finally Ends, at the Rock Creek Center, a mental health complex in Lemont, Ill. The sole program of its kind, S.A.F.E. takes a progressive approach to helping patients understand and control the impulses that lead them to self-injure.

Come fall, the second S.A.F.E. clinic in the country will likely open in Austin at the Brown Schools’ Health Rehabilitation Center.

“I think it is an extraordinary program,” says Jim Dalzell, region chief executive officer for the Brown Schools of Central Texas. Dalzell was CEO at Rock Creek when he brought S.A.F.E. to that facility in 1996.

“This certainly isn’t being done down here,” he adds. ”And there certainly is a demand and a need.” Scarred for life Forty-five minutes west of Chicago, Rock Creek’s award-winning “prairie farmhouse” architecture spreads out over 42 lush acres. A short walk from the center’s admissions office, Keepataw Lodge houses most of S.A.F.E’s clients and staff, as well as patients in other programs. Its two-story atrium has an octagonal seating area, like an indoor gazebo, and a ping pong table at one end.

At any time of the day, several people are usually hanging out in the atrium, any one of them battling bi-polar or borderline personality disorder, severe anxiety or a substance-abuse problem.

But the women in the S.A.F.E. program who live here, about eight, display the most obvious evidence of dysfunction.

Half of them carry visible scars from their injuring, on their hands, arms, legs. Between them, hundreds of slashes, burns and finger-nail-inflicted scrapes line their extremities. Others confess to cutting on their stomachs, necks and genitals and wearing long sleeves, slacks or turtlenecks to hide evidence of any problems.

Like Watson, people who injure themselves, over and over and often severely, do so out of emotional desperation. The majority endured sexual and/or psychological abuse, or experienced severe trauma, in early childhood, though actual injuring usually begins in adolescence. Most adults who exhibit the behavior are Caucasian women from middle-class and upper-class homes.

In conversation, almost all the S.A.F.E clients speak of dysfunctional families in which they were denied the right to express their emotions, denied attention, denied any sense of control.

Evelyn, a 43-year-old cashier from the East Coast, rocks nervously back and forth in her chair as she tells her story. She was a chronic bed wetter as a child. Each day before Evelyn went to school, she says her mother would threaten her with “the beating of a lifetime” when she returned home. Evelyn says she spent all day terrified of the beating she would receive.

“When I would get home from school, I’d be beat, and this fear would be gone,” she explains. “So I would feel better after the beating. Now, when I’m anxious or upset, if I abuse myself, I take the place of my mother and then I feel everything is OK.”

An addictive element

S.A.F.E’s philosophy is to empower patients. They are almost always free to come and go from the Lodge as they please. During breaks from therapy, they walk the verdant campus, crossing limestone bridges over tranquil ponds surrounded by weeping willows. They spend time under the wood-shaded outdoor gazebo or in their comfortably spacious rooms.

“The place looks like a ski resort so it’s really cool,” says 24-year-old Stephanie Heinrich, a S.A.F.E. patient with a prominent trail of dozens of horizontal scars up her left arm. “I was expecting a hospital.”

Heinrich says she came from a nonabusive home, but began cutting her arms as a teen because of other childhood traumas: At 3, she was hit by a car and has since suffered migraines. At 9, she was kidnapped, and though she remembers little from that 24 hours, she says her body showed signs of sexual abuse after the incident.

When she cuts, she says, “I feel like I’m in control, like nobody can hurt me as much as I can hurt myself.”

Heinrich’s scars are like a diary. ”Like, this one right here, I went into an artery,” she notes, pointing to a thick line of raised scar tissue. “This one right here is one when they took me up to the hospital. These ones right here were right before I came. These ones are so old . . .”

Doctors believe that the act of cutting releases endorphins in the body that dampen the pain. Some patients describe feeling a physical “rush” after they self-injure, but Conterio and S.A.F.E. co-founder Dr. Wendy Lader believe the psychological component of self-injury is its truly addictive element.

“There is a fantasy of when they cut themselves it releases something intangible,” explains Conterio, a substance-abuse counselor who trained in group therapy. “It’s a sense of having control over their impulses.”

In the first week of June, the 10 S.A.F.E. clients were all women, ranging in age from 15 to 43 (the program admits 13-year-olds and up, but its limit is 15 patients at a time). By the time they leave, most will have been here about six weeks—including 30 days of inpatient care and a couple of weeks in the day program in which they live on the Rock Creek campus but not in the Lodge.

Treatment consists of one-on-one counseling, group therapy twice a day and a series of writing assignments. S.A.F.E. participants keep logs detailing times they think about self-injuring, where they were at the time and how they were feeling. The program staff also prescribes medications that help patients function better in their daily lives (anti-depressants or drugs to overcome anxiety, for example).

S.A.F.E. does not set out to “cure” people. Its goal is to prepare them to participate in more consistent and helpful outpatient counseling with their therapists back home. Conterio says the program’s success rate is high but less quantifiable than anecdotal. Referrals come mainly from therapists who have had other patients at S.A.F.E. or former patients who tell others about it. Lots of ex-clients keep the staff posted on their progress. “People have to be pretty motivated and dedicated if they want to see results,” Conterio says.

Giving it up

Up until the 1960s, doctors generally diagnosed self-injuring patients with a psychosis and shipped them off to mental hospitals where they were strapped to their beds. Ignorance still runs rampant. Unknowledgeable medical professionals prescribe ineffective or even harmful medications; therapists who fear triggering a patient to self-injure consequently never get to the root of the problem. And many hospitals treat self-injurers as suicidal (which they most often are not), having staff shadow their every move and confiscate anything sharp that patients might have access to.

The message this traditional treatment sends is “you are incapable of taking care of your impulses. We have to take care of you,” Conterio believes. “This infantilizes the individual, and it sets up a power struggle in which the patient is going to prove to everyone that they can hurt themselves.”

Just the opposite happens at S.A.F.E., she says. An act of self-injury is not rewarded with attention or a longer stay in the hospital. In fact, it is not tolerated. Conterio and Lader have flopped the conventional wisdom that giving up this type of behavior takes years. The crux of their philosophy is that self-injuring, like alcoholism, is a choice.

“What drug rehab do you know where they allow people to drink or to do drugs without any consequences?” asks Lader, S.A.F.E’s clinical director. “Karen’s feeling was you have to be able to give it up in order to get better. When you think about it logically it makes total sense. But a lot of people in the mental health field are brainwashed into thinking that it’s totally impossible.”

S.A.F.E. patients must sign a contract promising that they will not self-injure while at Rock Creek. And they cannot discuss in group therapy or with their peers how they self-injure. For one, talking about injuring can provoke it. Plus, banning it from conversation decreases the need for competition, a rampant problem in mental hospitals, where self-abusive patients vie for the attention of the staff by acting out.

“This has become their identity,” Conterio says. ”This is the only way they know how to communicate.”

And yet most self-injurers conceal their behavior, according to a survey by Dr. Jan Hart, a post-doctoral intern from UCLA working at S.A.F.E. After placing a notice on the Internet, Hart spoke with 85 self-injuring respondents, most of whom worked and had average incomes of $40,000. The majority had been in therapy but never told their therapist about their injuring. For more than half, Hart was the first person they had ever spoken with about their behavior.

“This isn’t just a population that is sick and in the hospital,” she notes. “They are out there running around.”

Life with sharp objects

No one in Watson’s small Oklahoma town knew she had started cutting herself, or if they did, no one spoke about it. As a teen-ager, she carved words such as “whore” and “bitch” into her arms. She wore longs sleeves and pants, even in the summer, to conceal the damage she’d done.

Seated on a sofa in her Grand Prairie home, Watson tears the tab off a nearby soda can and demonstrates how she would scrape her skin muntil it bled. Later she admits, “I shouldn’t have shown you what I used to do because it made me want to do it more.”

The same compulsion overcomes her when she sees a certain television commercial for a can opener that claims to leave a smooth edge. In the ad, a person runs the edge of a can top over his wrist to prove it doesn’t cut.

“It’s a freaky commercial,” Watson says. “It reminds me what I used to do and how it felt good to do it.”

At 17, Watson married her high-school sweetheart, had her first child and moved to Texas. It took several years before even David Watson realized his wife’s addiction to sharp objects. At 28, Paula Watson’s mother-in-law admitted her to a hospital in Oklahoma after Watson said she started hearing voices telling her to cut herself.

“They just put me on a bunch of medication and then released me,” she remembers.

During her next crisis, she was sent to Millwood Hospital in Arlington. A half dozen doctors put her on lithium, Wellbutrin, Prozac, “every anti-depressant ever made,” Watson says. But she still acted out; just carrying around a pack of razor blades made her feel better.

Two years ago she finally found a doctor and an anti-psychotic medication, Clocaril, that helped regulate her emotions and resolve a troubled childhood. She stopped cutting herself and hopes to go back to school. David, who attended family therapy with his wife, has stood by her through all of it.

“He’s a wonderful man,” Watson says. ”I’m sure chasing your wife around, making sure she doesn’t pick up stuff to cut with—I’m sure that’s not fun. “

Moving to Texas

Conterio began conducting outpatient therapy sessions for people who self-injure in the mid ’80s. In 1986, she convinced Lader, an expert in women’s issues, to create the first inpatient program for self-abusers at a Chicago hospital.

Lader says she was initially “quite skeptical” about Conterio’s philosophy, but she soon changed her mind and the two women (Lader is 45, Conterio is 39) have been fine-tuning S.A.F.E. ever since. They are extremely protective of the program, probably why they have not considered duplicating it until now.

“It’s my baby,” Conterio says. “I think if it could be duplicated, I’d see it already out there. We take a lot of care and a lot of time for this program. It’s not going to be a Jack in the Box.”

Dalzell, in Austin, emphasizes that any offshoot of S.A.F.E. will involve intensive training by its current directors. The Texas program will consist of a day program rather than inpatient care, with Conterio and Lader visiting “on a regular basis.”

As for the Austin campus, Conterio says its pretty but not quite as lush as Rock Creek. “Certainly we can’t replicate the physical plan,” Dalzell admits. ”But we can replicate the program.”

Finding help

Like most people who self-injure, Watson had no idea S.A.F.E. existed. Most of the nine women in the program in June stumbled onto it. Heinrich was standing in line at the grocery store when a magazine headline caught her eye. The article, about cutting, quoted Lader and gave S.A.F.E.’s toll-free information number (800- DONT-CUT).

Diana Robinson, a 31-year-old from Seattle, discovered the program on the Internet, through a Website on borderline personality disorders. (Information on S.A.F.E. can be found at www.rockcreek-hosp.com.)

“I never thought I would live to be 25,” says Robinson, who was hospitalized for self-injuring so many times that one Veterans Administration hospital banned her from returning.

Susan, Evelyn and Lynda’s therapists knew of no resources for their patients, until the doctors started to do some research and found S.A.F.E. Sharon, a registered nurse, had a colleague who referred her.

A friend of Talli Heintz’s also saw a magazine article about S.A.F.E. and gave the information to the 15-year-old. Heintz was then attending Grapevine High School and had been in and out of the hospital.

Abuse didn’t spur Heintz to cut herself. ”I just didn’t like my feelings,” she says, sitting in a chair on the Lodge’s back deck. “I didn’t get heard, at home, at school. I would have to get out my anger. I was relieved when I was doing it,” she adds, “but I felt bad for messing up my body.”

Conterio catches some sun a few seats away and listens, subtly but protectively, to the conversation. Heintz glances at her often for support while compulsively pushing a gold stud through the ear of a stuffed Beanie Baby monkey. This is the teen-ager’s last day in the program, and she is scared to leave.

“What if I make myself do it again or have a new problem?” she asks. “I don’t want to have to go to another hospital.”

“I think that’s a healthy statement,” Conterio adds from her chair, catching the teen-ager’s eye. ”I think it’s very realistic to be very scared.”


Daily Mail (London)
July 1, 1997

What on Earth Makes a Pretty 16-Year-Old Girl Like This Turn to Self-Mutilation?
By Liz Gill

ANYONE reading the sort of magazine aimed at teenage girls over the past year will have noticed a disturbing and insidious new trend emerging in their advice columns. More and more young people, particularly girls, seem to be confessing that they deliberately harm themselves; either mutilating their bodies with knives and razors, or taking tablets such as painkillers in toxic doses.

One psychiatrist, Alan Cockett, believes that up to one in 50 adolescents hurt themselves badly enough to warrant medical treatment or some form of counselling.

They are the sort of teenagers who, a few years ago, might have starved themselves to the point of anorexia. Now, rather than hunger, they punish themselves with shards of glass, blades, burning cigarettes and pills.

And when it all becomes too much to bear, they pour their hearts out to the agony aunts in teen magazines, like Tricia Kreitman of Mizz. She receives around 200 letters a week. Of these, four or five will mention self-harm.

‘What worries me particularly is that some of them are as young as 13,’ she says. ‘They talk about cutting or burning themselves. It’s usually linked to other problems, such as eating disorders or severe depression.

‘It’s hard to say whether it’s on the increase. Certainly people are coming out and talking about it more. Princess Diana saying that she had tried to harm herself played a big part in that. They write about it very graphically, about how it lets the pain out.’

One said it was like a silent scream.

‘Of course, there’s always the danger that if you talk or write about something there may be copycat acts, but I think we must discuss it responsibly and let people know they can be helped. They are desperate.

‘I also give advice in Chat magazine, and there I get letters from older women who say they started young, then stopped but found themselves doing it again when there was a crisis in later life, such as a marriage under stress or a new baby.’

Consultant psychiatrist Dr Cockett says: ‘Self-harm is the anorexia of the Nineties. Ten or 15 years ago eating disorders were hidden and stigmatised, but then it became okay to admit that you had a problem rather than suffer in silence. In the same way, self-harm is a disorder that is coming out of the closet. People are beginning to say: “I don’t want to be doing this I need help.”

‘It’s hard to estimate numbers, but my guess is that the number of adolescents harming themselves to a degree that warrants specialist help is similar to anorexia—between one and two per cent.

‘GPs and practice nurses need to be aware of it, as do casualty staff. Certain sorts of injuries are unlikely to occur accidentally: more than one cigarette burn, for instance, or cuts on the arm, or cuts in hidden places like the inside of the thigh or the soles of the feet, particularly when there are old scars as well.

‘Friction burns are rarely accidental. Some people who harm themselves rub themselves red raw, often on the back of their hands, on something rough like a carpet. Or, more rarely, they wrap string very tightly around their wrists, so injuries caused by the circulation being cut off should be a warning.

‘If medical staff do suspect something, it’s important to ask the question in the right way, because anything accusatory will just bring a denial.

‘But they could say, in a gentle voice, that what they see suggests the person might have done it to themselves, that the problem needs to be cleared up and that help is available; or that they’ve seen it before, so the person knows they’re not the only one.

‘Most girls who do this want to admit it and want to stop. They just cannot find the way.’ In mild cases, local help with a counsellor or psychiatrist may be appropriate, but the most desperate cases would need the sort of in-patient residential unit which Dr Cockett runs at Orchard House near Taunton in Somerset.

‘This is the end of the road and we make that clear,’ says Dr Cockett. ‘It does make a difference to know that if you don’t get sorted out here, you probably won’t get sorted out at all.’

The approach is to create an emotionally and physically secure environment in which the adolescents can at last begin to talk through the traumatic events in their lives.

‘The self-harm has been their defence against the pain arising from some trauma. It’s been a way of switching off, of dissociating. For some, this is the first time they will ever have felt safe enough to talk about what’s happened.’

The average stay is about five and a half months, during which time they are given the chance to catch up with any schooling they have missed and take part in the Youth Awards Scheme.

More importantly, they learn to recognise what triggers episodes of self-harm and alternatives to it: talking, listening to music, physical exercise or holding imaginary conversations with oneself on the source of the trauma.

Medication plays only an occasional role, but staff do sometimes restrain patients. ‘We had one girl who literally used to try to bash her brains out on the pavement. You get others who have hit their limbs against walls or taken noxious substances.

‘They think about the world in terms of what they can do to harm themselves—and because they’re often very bright, they can always come up with something new.

‘But they don’t want to destroy themselves; they want to be stopped. And I think we have a responsibility to ensure their bodies are preserved, so that when they are better they aren’t all carved up.

‘We try to minimise temptation, so although there are knives, for instance, in the unit, if one has to be used we try to ensure that no one is using it alone.

‘What all self-harmers have in common is the use of physical pain or the sight of blood or the concentration the act requires to switch off unbearable mental processes.

‘We need to be more aware. Parents, for instance, should be suspicious of unexplained injuries or items with blood on them for no good reason.

‘Imitative behaviour is always a bit of a worry when something starts being talked about. But self-harm is not glamorous and a ‘normal’ teenager who tries it will soon discover it hurts like hell.’

It is not just teenagers who are afflicted. Consultant clinical psychologist Gloria Babiker, who works at the Barrow Hospital, Bristol, says: ‘I have two women patients who spend their days in high-powered jobs and who then go home at night and cut themselves. ‘They do it because they’re at the end of their tether. They’ve exhausted their social contacts, they’re isolated and they have no more emotional resources they can draw on. You hear people say: “I haven’t got it in me.” They’re running on empty.’

Lois Arnold, a counsellor who has researched self-harm for the Mental Health Foundation, says: ‘A lot of people don’t go to hospital, so the ones we know about are probably only the tip of the iceberg.’

She says self-harm affects far more women than men, because ‘women tend to turn their feelings in on themselves more. The pain varies according to what you do. Sometimes there isn’t any pain at the time. Sometimes the pain itself is important, because it’s a distraction from the emotional pain inside. A feeling inside may be hard to define, but if you put it outside you’ve somehow got tangible proof. A real injury shows you’re very hurt.

‘The sight of blood can be important, too. A lot of people say the feelings of badness come out with the blood. There’s often this sense of purging.

‘There can also be an element of control; that at least this is one thing in your life you can control. It also gives you a reason to look after yourself because there’s something real to put a bandage on.’

Many self-harmers have been sexually or physically abused; others may have been emotionally neglected or traumatised by an event, such as bereavement, particularly as a child.

‘It’s a response to experience, to perhaps not having enough support or ways of expressing yourself. I don’t think these people are born fragile. Some of us are lucky enough to develop inner resources; others are left foundering. It’s not necessarily anyone’s fault.’

Ms Arnold, who studied 76 cases of self-injury for her research, says: ‘What comes through is that it’s no good giving people drugs or putting them in hospital if you don’t address the causes.

‘If you take away this way of coping without offering those who do it another way of dealing with their problems, they’ll only swap to something else, such as an eating disorder or alcohol abuse.’

JODY’S STORY

JODY WILLIAMS is a pretty 16-year-old from a middle-class home in Grantham, Lincolnshire, who is sitting eight GCSEs and looking forward to a college place in September.

Yet Jody’s right arm is criss-crossed with a network of fine scars, a tangible reminder of the emotional turmoil which less than a year ago caused her to take a piece of glass from a bottle bank and score her own flesh again and again.

She recalls the moment vividly. ‘I was in the park with my boyfriend, who I was very keen on, and he told me that he didn’t want to go out with me any more. Even though I’d been worrying that he was going to finish with me, when he actually said it I just went numb. I felt as if everything had stopped working.

‘As I was walking out of the park, I passed the bottle banks and sat down beside them. I was crying, really distressed. There was all this broken glass on the ground, and I picked up a piece and made about four cuts on my arm. They were each about three inches long. ‘I can’t really explain why I did it, but as I saw the blood flowing and running away, I thought maybe my problems would go the same way.’

Jody was to cut herself again almost every day for the following month, although, she says, after that first episode she never showed her mother.

‘I never did it at home—only at school in the toilets or in the village. I’d just put tissues on the cuts and cover them with my jumper. I never showed anyone. I thought it was my business.

‘I’ve never taken drugs and I never would, because you don’t know what’s in them or the damage they can do. Cutting yourself isn’t as dangerous because it goes no further; you see what’s happening. But it was as addictive as a drug: I felt I had to do it. If I did it with glass it didn’t hurt, but another time I did it with a broken cassette case and that was painful.

‘It was helpful to how I was feeling. I felt relief, as if I’d had a lot of problems and tension all bottled up and they all came flowing out. Cutting myself pushed the problem to one side. But then when it wore off I had to do it again. I was very frightened. I felt I must be the only person doing this.

People were so horrified and shocked that I thought no one had ever heard of it before. That made me more worried than ever.

‘It was always my arm—my right arm, because I’m left-handed. It was a real mess at one stage. The cuts never needed stitches but you can still the scars. They look worse when it’s sunny, because they’re more visible. But I’m not ashamed. If people ask me about them, I tell them. If they’re horrified, then that’s their problem.

‘It all stopped when I began to feel a bit better. I suppose I took off the rose-coloured glasses about this boy and saw he wasn’t worth it. I don’t regret it. It served a purpose and I’m not ashamed. But I wouldn’t advise anyone else to do it.’

Jody, who was prescribed mild tranquillisers and saw a psychotherapist for a while, now seems well. But she cannot be sure she will never feel compelled to do it again. ‘It depends what happens,’ she says.

‘If you want someone to stop then you should leave them alone. If you try to stop them, they’ll do it even more. The best thing that has happened is that I’ve got a job on a casual basis as a waitress at a leisure centre. I really enjoy meeting people. But sometimes I think it might happened again, if history repeated itself or if people were cruel to me or upset me.’

MOTHER’S STORY

ALTHOUGH Jody attributes her self-mutilation to her break-up with her boyfriend, her mother Margaret, 50, believes it had more to do with her grief over the death of her father Ken from a heart attack a few months earlier and the emotional upheaval surrounding her parents’ separation a few months before that.

Jody had remained in the marital home with her father and it was she who discovered his body.

‘She had been through these terrible times,’ says Mrs Williams, who has four other children, all grown up. ‘She’s always been a sensitive child and a great worrier.

‘Jody came into the house and said: “Look.” She was hysterical. Her arms were covered in blood. At the time I didn’t know what on earth had happened, whether she’d been attacked or had had an accident. I got hold of her, sat her down and tried to calm her. There were all these cuts down her forearm.

‘She had always been a bit of a loner and a worrier. She was continually worrying about her father. His own father had had a heart attack at a young age, and if Ken was half an hour late she’d think something tragic had happened.

‘I was rather glad when Jody got a boyfriend because I thought it would take her mind of other things. He meant a lot to her.

‘But I think the cutting was really about her father’s death and everything she had been through. I think she wanted to tell someone how she was feeling. Grieving takes many forms. I think she just wanted to scream and shout and say: “I’m still hurting.”

‘We had no warning of this—no family history of anything like it. I don’t know where she got the idea from. As a parent you feel helpless, but you can’t get angry: that makes things worse.

‘She seems to be coping now. Of course we have our fall-outs, like every mother and daughter, but she knows I love her and I’m here for her. If anything, we probably all kept our emotions too much in check after Ken’s death, and I think this, in the end, was Jody’s way of coping with the trauma and the grief.’

Today, Margaret believes that what Jody needs is patience and plenty of tender loving care. ‘Sometimes I look at her arms and they look angry and I wonder if she’s doing it again. When something like this has happened, you feel you always have to be watchful.’

Language of Injury: Comprehending Self-Mutilation by Gloria Babiker and Lois Arnold will be published later this year by the British Psychological Society. Damage fact sheet is available from PO Box 55, London W12 8UE. Send an SAE to The Basement Project, 82 Colston St, Bristol BSI 5BB for as a booklet on self-harm. The Bristol Crisis Service for Women runs a helpline on Friday and Saturday, 9pm-12.30am, tel. 0117 925 1119.

The burden of carrying a secret shame

SOME girls who harm themselves dare confide only in teenage magazines.

Melissa Roske, agony aunt of Just Seventeen, says self-harm is a regular feature of her postbag.

‘They talk about how it brings relief, how it’s a release from all their anger and suffering. Often it’s something like stabbing their arms with a compass or dragging scissors across their skin. They do it enough to feel pain or draw blood. They never want to kill themselves. But the biggest thing that comes across is fear. They know what the norm is and they know this isn’t right. They might have told their best friend, but usually it’s a secret shame and a very heavy burden for them.

‘They’ve taken a positive step by writing, so I then encourage them to seek further help: to confide in their parents if possible, or a trusted teacher, relative or older friend, and I tell them about places where they can get help.

‘They must also start looking inward and asking themselves what’s going on in their lives that might be causing this. Have their parents split up? Is there a boyfriend problem or trouble at school?

‘It’s not a good idea to blame parents for not knowing it might be happening to their child. If girls can hide entire pregnancies from their families, they can certainly hide this. But if they do see something fishy, they should start talking about it.’


The New York Times
July 27, 1997

The Thin Red Line
By Jennifer Egan

One Saturday night in January, Jill McArdle went to a party some distance from her home in West Beverly, a fiercely Irish enclave on Chicago’s South Side. She was anxious before setting out; she’d been having a hard time in social situations—parties, especially.

At 5 feet 10 inches with long blond hair, green eyes and an underbite that often makes her look as if she’s half-smiling, Jill cuts an imposing figure for 16; she is the sort of girl boys notice instantly and are sometimes afraid of. And the fear is mutual, despite her air of confidence.

Jill’s troubles begin with her own desire to make everyone happy, a guiding principle that yields mixed results in the flirtatious, beer-swilling atmosphere of teen-age parties. “I feel I have to be all cute and sexy for these boys,” she says. “And the next morning when I realize what a fool I looked like, it’s the worst feeling ever.... ‘Oh God, what did I do? Was I flirting with that boy? Is his girlfriend in school tomorrow going to give me a hard time? Are they all going to hate me?’”

Watching Jill in action, you would never guess she was prone to this sort of self-scrutiny. Winner of her cheerleading squad’s coveted Spirit Award last year, she is part of a Catholic-school crowd consisting mostly of fellow cheerleaders and the male athletes they cheer for, clean-cut kids who congregate in basement rec rooms of spare, working-class houses where hockey sticks hang on the walls and a fish tank sometimes bubbles in one corner. Jill is a popular, even dominating presence at these parties; once she introduced a series of guys to me with the phrase, “This is my boy,” her arm slung across the shoulders of some shy youth in a baseball cap, usually shorter than she, whose name invariably seemed to be Kevin or Patrick.

But in truth, the pressures of adolescence have wreaked extraordinary havoc in Jill’s life. “Around my house there’s this park, and there used to be like a hundred kids hanging out up there,” she says, recalling her first year in high school, two years ago. “And the boys would say stuff to me that was so disgusting ... perverted stuff, and I’d just be so embarrassed. But the older girls assumed that I was a slut... They’d give me dirty looks in school.” Blaming herself for having somehow provoked these reactions, Jill began to feel ashamed and isolated. Her unease spiraled into panic in the spring of that year, when a boy she’d trusted began spreading lies about her. “He goes and tells all of his friends that I did all this sexual stuff with him, and I was just blown away. It made me feel dirty, like I was absolutely nothing.”

Jill, then 14, found herself moved to do something she had never done before. “I was in the bathroom going completely crazy, just bawling my eyes out, and I think my mom was wallpapering—there was a wallpaper cutter there. I had so much anxiety, I couldn’t concentrate on anything until I somehow let that out, and not being able to let it out in words, I took the razor and started cutting my leg and I got excited about seeing my blood. It felt good to see the blood coming out, like that was my other pain leaving, too. It felt right and it felt good for me to let it out that way.”

Jill had made a galvanizing discovery: cutting herself could temporarily ease her emotional distress. It became a habit. Once, she left school early, sat in an alley and carved “Life Sucks” into her leg with the point of a compass. Eventually, her friends got wind of her behavior and told her parents, who were frightened and mystified. They took Jill to Children’s Memorial Hospital, where she was treated for depression and put on Prozac, which she took for a few months until she felt better. By last summer she was cutting again in secret and also burning—mostly her upper thighs, where her mother, who by now was anxiously monitoring Jill’s behavior, wouldn’t see the cuts if she emerged from the family bathroom in a towel. Last summer, Jill wore boxers over her bathing suit even to swim. By January, her state was so precarious that one bad night would have the power to devastate her.

No one recognized Jill’s behavior as self-mutilation, as it is clinically known (other names include self-injury, self-harm, self-abuse and the misnomer delicate self-cutting), a disorder that is not new but, because it is finally being properly identified and better understood, is suddenly getting attention. Princess Diana shocked people by admitting that she cut herself during her unhappy marriage. Johnny Depp has publicly revealed that his arms bear scars from self-inflicted wounds. The plot of “Female Perversions,” a recent movie that fictionalized the book of the same name by Louise Kaplan, a psychiatrist, hinges on the discovery of a young girl cutting herself. And Steven Levenkron, a psychotherapist who wrote a bestselling novel in the 1970’s about an anorexic, recently published The Luckiest Girl in the World, about a teen-age self-injurer.

“I’m afraid, here we go again,” Levenkron says, likening the prevalence of self-injury to that of anorexia. “Self-injury is probably a bit epidemic.” Dr. Armando Favazza, a professor of psychiatry at the University of Missouri-Columbia medical school, estimates the number of sufferers at 750 per 100,000 Americans, or close to two million, but suggests that the actual figure may be higher.

Long dismissed by the psychiatric community as merely a symptom of other disorders—notably borderline personality disorder—self-mutilation is generating new interest as a subject of study. Dr. Barbara Stanley of the New York State Psychiatric Institute explains: “Some of us said, maybe we shouldn’t be focusing so much on diagnostic studies. ... Maybe this behavior means something unto itself.”

Indeed it does. Favazza, whose book Bodies Under Siege was the first to comprehensively explore self-mutilation, defines it as “the direct, deliberate destruction or alteration of one’s own body tissue without conscious suicidal intent.” His numbers apply to what he calls “moderate/superficial self-mutilation” like Jill’s, rather than involuntary acts like the head banging of autistic or retarded people, or “coarse” self-mutilations like the eye enucleations and self-castrations that are occasionally performed by psychotics. Moderate self-mutilation can include cutting, burning, plucking hairs from the head and body (known as trichitillomania), bone breaking, head banging, needle poking, skin scratching or rubbing glass into the skin.

The fact that awareness of self-mutilation is growing at a time when tattooing, piercing, scarification and branding are on the rise has not been lost on researchers. While experts disagree on the relationship between the behaviors, the increasing popularity of body modification among teen-agers, coupled with the two million people injuring in secret, begins to make us look like a nation obsessed with cutting. Marilee Strong, who interviewed nearly 100 injurers for her book, A Bright Red Scream, to be published in 1998, calls it “the addiction of the 90s.”

On that Saturday night in January, despite Jill’s anxious resolutions, things at the party ultimately went awry. “It was really late,” she says, “and I was supposed to stay at my best friend’s house, but she left and I didn’t go with her. I was drunk, and it was me down there in the basement with all these boys. ... I’d walk by and they’d grab my butt or something, so I sat on a chair in the corner. And they tipped the chair over and made me fall off of it.”

Realizing she was in a situation she would punish herself for later, Jill went upstairs and tried in vain to get a friend to leave the party with her. She had nowhere to stay—no way to get home without calling her parents—so she ended up at the home of her friend’s brother, who was in his 20s and lived near the party. This proved to be another mistake. “I wake up there the next morning, and these guys were basically dirty 20-year-olds,” she says, “and they tell me: ‘You want a job living here with us? We’ll pay you a hundred bucks if you strip for us once a week.’ ... I was just like: ‘I have to go home! I have to go home!”’

But by now, a cycle of shame and self-blame was already in motion. On finally arriving at the two-story brick house where she lives with her parents and brothers (one older, one younger), Jill learned that she was being grounded for not having called home the night before. Her bedroom, right off the kitchen, is a small, makeshift room with accordion doors that do not seal off the noise from the rest of the house. “All Sunday I just slept and slept, and I was just so depressed, so disgusted with myself. ... I felt like the dirtiest thing ever because of everything that had happened the night before.”

For all her popularity, Jill felt too fragile that morning to ask her friends for reassurance. “I feel really inferior to them, like they’re so much better at everything than me,” she says of the other cheerleaders. “I feel like I have to be the pleaser, and I can never do anything wrong. When I fail to make other people happy, I get so angry with myself.”

That Sunday, no one was happy with Jill: her parents, the friend whose house she hadn’t slept at and, in her fearful imagination, countless older girls who by now had heard of her sloppy conduct at the party and were waiting to pounce. “Monday morning came and I was scared to death to have to go to school and see people,” she says. “I started cutting myself. First I used a knife—I was in the bathroom doing it and then I told my mom because I was scared. She was like, ‘Why the hell are you doing this? You’re going to give me and your father a heart attack.’ ... She took the knife away. So then I took a candle holder and went outside and cracked it against the ground and took a piece of glass and started cutting myself with that, and then I took fingernail clippers and was trying to dig at my skin and like pull it off, but it didn’t help anymore, it wasn’t working. ... That night, I was like, ‘My mom is so mad at me, she doesn’t even care that I was doing this,’ so that’s when I took all the aspirin.”

Jill isn’t sure how many aspirin she took, but estimates it was around 30. “That night was like the scariest night in my life,” she says. “I was puking and sweating and had ringing in my ears and I couldn’t focus on anything.” Still, she slept through a second day before telling her parents what was really ailing her. They rushed her to a hospital, where she wound up in intensive care for three days with arrhythmia while IV’s flushed out her system, and she was lucky not to have permanently damaged her liver.

“That was very shocking, to think that she was going through so much pain without us being aware of it,” says her father, Jim McArdle, a ruddy-faced police lieutenant with a soft voice, who chooses his words carefully. “There’s a ton of denial,” he admits. “It’s like: ‘It happened once, it’s never going to happen again. It happened twice, it’s not going to happen three times.’ The third time you’re like. ...” He trails off helplessly.

Self-injury rarely stops after two or three incidents. According to the only large-scale survey ever taken of self-injurers (240 American females), in 1989, the average practitioner begins at 14—as Jill did—and continues injuring, often with increasing severity into her late 20’s. Generally white, she is also likely to suffer from other compulsive disorders like bulimia or alcoholism. Dr. Jan Hart, who surveyed 87 high-functioning self-injurers for her 1996 doctoral dissertation at U.C.L.A., found their most common professions to be teacher and nurse, followed by manager.

The notion of teachers, nurses and high-school students like Jill seeking out ways to hurt themselves in a culture where the avoidance of pain and discomfort is a virtual obsession may seem paradoxical. But it isn’t. People harm themselves because it makes them feel better; they use physical pain to obfuscate a deeper, more intolerable psychic pain associated with feelings of anger, sadness or abandonment. Often, the injury is used to relieve the pressure or hysteria these emotions can cause, as it did for Jill; it can also jolt people out of states of numbness and emptiness—it can make them feel alive.

These mood-regulating effects, along with a certain addictive quality (over time, the injurer usually must hurt herself more frequently and more violently to achieve the same degree of relief), have prompted many clinicians to speculate that cutting, for example, releases the body’s own opiates, known as beta-endorphins. According to Lisa Cross, a New Haven psychotherapist who has treated self-injurers, patients have for centuries described the sensation of being bled in the same terms of relief and release as she hears from self-injurers. And people who have been professionally scarred or pierced sometimes describe feeling high from the experience.

Women seeking treatment for self-injury far outnumber men. There are many speculations as to why this might be, the most common of which is that women are more likely to turn their anger inward. Dusty Miller, author of Women Who Hurt Themselves, believes that self-injury reflects a culturally sanctioned antagonism between women and their bodies: “Our bodies are always too fat, our breasts are too small. ... The body becomes the object of our own violence.”

But the fact that few men are treated for self-injury doesn’t mean they aren’t hurting themselves, too. Among adolescent injurers, the ratio of boys to girls is near equal, and cutting is rampant among both male and female prisoners. Self-Mutilators Anonymous, a New York support group, was initiated 11 years ago by two men, one of whom, Sheldon Goldberg, 59, gouged his face with cuticle scissors, “deep digging” to remove ingrown hairs. “I would have so many bandages on my face from cutting that I would sit on the subway all dressed up to go to work,” says Goldberg, a former advertising art director, “and people would look at me and I would realize a wound had opened up and I was bleeding all over my shirt.” Now, five reconstructive operations later, the lower half of Goldberg’s face is solid scar tissue. “But men can get away with it,” he says. “When people ask me what happened, I say: ‘I was in the war. I was in a fire.’ Men can use all the macho stuff.”

It’s February, and a frigid midwestern wind thumps at the windows of Keepataw Lodge at the Rock Creek Center, a general psychiatric institution in Lemont, Ill. It is the home of the SAFE (Self-Abuse Finally Ends) Alternatives Program, the nation’s only in-patient treatment center for self-injurers, started in 1985. Jill, in jeans, hiking boots and a Pucci-style shirt, lounges on an upholstered banquette in the lodge’s skylighted atrium. She has been here 10 days, spending her mornings in the hospital’s adolescent program completing assignments her school has faxed in, dividing her afternoons between individual and group therapy.

She’s ebullient—partly from sheer relief at being surrounded by people with her same problem. “It’s really weird how many people in the group have my same kind of thinking,” she says, repeatedly removing and replacing a pen cap with hands scarred by cigarette-lighter burns. “How they grew up feeling like they didn’t deserve to feel their feelings, like they had to keep people happy. ... I don’t even know who I am anymore, because everything I do depends on what other people want.”

Her cheerleading friends have visited, bearing get-well cards and magazines, but Jill finds playing hostess on the grounds of a mental hospital a tall order. “I’d make up things like, ‘Oh, I have a group in 10 minutes, so you guys better leave,’ because I couldn’t take it to have them sitting there and me not knowing how to make them happy in such a weird environment,” she says.

Her parents arrive to meet with her doctor and then take Jill home after her group therapy; for insurance reasons, she must continue the 30-day SAFE program from home as an outpatient. (Blue Cross refused to cover her hospitalization costs before SAFE because her problem was “self-inflicted”; the family is appealing.) Jim and Nancy McArdle are warm, open people who seem a little shellshocked by their sudden immersion in the mental-health system. Jim, who in happier times likes to kid and joke, sits tentatively at a table with his hands folded. Jill is the most animated of the three. “I’ll just turn it off, like I never even knew what that was,” she says of the behavior that landed her in the hospital only three weeks ago. An anxious glance from her mother, an attractive woman with reddish brown hair who works as a respiratory therapist, gives Jill pause. “Last time we thought it was going to be fine too,” she reflects. “But then eventually it just all fell back even worse than it was before. It’s scary to think about. I don’t want to spend my life in hospitals.”

This is a reasonable fear. Most of Jill’s fellow patients at SAFE are women in their late 20s and early 30s, many of whom have been hospitalized repeatedly since their teen-age years, some of whom have children. (SAFE accepts men, but its clientele is 99 percent female.) In free moments during the program’s highly structured day, many of these patients can be found on the outdoor smoking deck, perched on white lawn chairs under an overhead heating lamp beside a thicket of spiky trees. (Unlike many psychiatric wards, SAFE does not lock its doors.) The deck’s cynosure is a white plastic bucket clogged with what look to be thousands of cigarette butts; even when the deck is empty of smokers, the air reeks.

“Hi! What’s your diagnosis?” Jane C., a Southerner in her early 30s, cheerfully queries a patient who has just arrived. “Bipolar? Me, too! Although that can mean a lot of different things. What’re your symptoms?” Jane, who insisted her last name not be used, is one of those people who can’t bear to see anyone left out. She has olive skin, an animated, birdlike face and wide, dark eyes like those in Byzantine paintings. She smiles even while she’s talking.

The patient bums a cigarette from her, and Jane lights it. “Cheers,” she says, and the two women touch cigarettes as if they were wine glasses.

Jane once made a list called Reasons for Cutting, and the reasons numbered more than 30. But the word she uses most often is power. Like many self-injurers (65 percent according to the 1989 survey; some believe it is much higher), Jane reports a history of sexual abuse that began when she was 7. Shortly thereafter, she raked a hairbrush across her face. By age 10, she was in her parents’ bathroom making her own discovery of the razor blade. “I cut right in the fold of a finger,” she says. “It was so sharp and so smooth and so well hidden, and yet there was some sense of empowerment. If somebody else is hurting me or making me bleed, then I take that instrument away and I make me bleed. It says: ‘You can’t hurt me anymore. I’m in charge of that.’”

Sometimes Jane pounds her head repeatedly against a wall. “When my head’s spinning, when I’m near hysteria, it’s like a slap in the face,” she says. “I’ve had multitudes of concussions—it’s amazing I have any sense at all.” It is virtually impossible to imagine this polished, friendly young woman doing any of these things. Much like Jill, Jane, herself a former cheerleader, masks her vulnerabilities with an assertive and jovial persona.

“She’s created this face to the world that’s totally in control when there’s really chaos going on underneath,” says Dr. Wendy Friedman Lader, SAFE’s clinical director. “There’s something very adaptive about that, but it’s a surreal kind of existence.” Even Jane’s many scars are well hidden, thanks to what she calls her “scar-erasing technique,” which sounds something like dermabrasion.

Like many victims of early trauma, Jane is plagued by episodes of dissociation, when she feels numb or dead or separate from her body. Cross, the New Haven psychotherapist, explains the genesis of dissociation this way: “When you are abused, the natural thing to do is to take yourself out of your body. Your body becomes the bad part of you that’s being punished, and you, the intact, positive part, are far away.” But what begins as a crucial self-protective device can become an inadvertent response to any kind of stress or fear. “There have been times when I don’t even feel like I’m alive,” Jane says. “I’ll do something to feel—anything. And that’s usually cutting. Just seeing blood. . . . I don’t know why.”

At SAFE, Jane C. is often in the company of Jamie Matthews, 20, a quiet, watchful young woman with pale skin and long brown hair who seems to bask in her friend’s overabundant energy. Cutting herself, Jamie says, is a way of coping with her rage. “I would get so angry and upset and so tense, so all I could think about was the physical pain, doing it harder and doing it more. And then afterwards it was a relief ... sometimes I would sleep.”

As a student at a small college in upstate New York, Jamie lived in a dormitory, so privacy was a major preoccupation. “I would lie in bed at school—that was the best place for me to do it because if my roommate walked in, she would think I was sleeping—and I would lay on my back with the knife underneath me, and then pull it out the side, across my back.” Jamie already completed the SAFE program once, last summer, but relapsed back at school. The last time she injured herself, she says, was when it felt best. “It was actually pleasureful. It gave me chills; it was that kind of feeling. I sat there smiling, watching myself bleed.” Descriptions like these, along with the intimate rituals that accompany some people’s injuring—candles, incense, special instruments—have led some clinicians to compare self-injury to masturbation.

Jamie’s self-injury has caused her a multitude of problems, yet there is almost a tenderness in her voice when she speaks of her self-harming acts. “It’s all mine,” she says. “It’s nothing that anybody can experience with me or take from me. I guess it’s like my little secret. I’ve got physical scars. ... It shows that my life isn’t easy. I can look at different scars and think, yeah, I know when that happened, so it tells a story. I’m afraid of them fading.”

Self-injury can appear, at first, to be a viable coping mechanism; the wounds are superficial, no one else is getting hurt and the injurer feels in control of her life. But what begins as an occasional shallow cut can progress to sliced veins and repeated visits to the emergency room. As with any compulsion, the struggle to resist one’s urges can eclipse all other thoughts and interests, and despair over the inability to control the behavior can even lead to suicide attempts. “It’s like a cancer,” says Cross. “It just seems to start eating into more and more of your life.”

Jane C. managed to hide her problems for many years. She was married and had a successful career as a sales executive at a medical-supply company, whose wares she frequently used to suture and bandage her self-inflicted wounds. Eventually, despite her vigilant secrecy, Jane got caught—her mother appeared at her house unexpectedly and found her in the bathroom, drenched in blood. Weakened by her emotional turmoil and a severe eating disorder, Jane ultimately almost passed out on the highway while driving home from a sales call, and finally left her job three and a half years ago. “I went on disability, which was really hard on my pride,” she says. “I’ve never not worked in my whole life.”

Jane C.’s discovery by her mother is a fairly routine step in the life cycle of self-injury—for all the secrecy surrounding it, it is finally a graphic nonverbal message. “I think that there’s a wish implicit in the injury that someone else will notice and ask about it,” says Christine Sterkel, a psychologist with SAFE. This was clearly true in Jill’s case; after burning her hands, she covered the wounds with band-aids until Christmas morning, then appeared before her family without them. “In the park, she cracked a bottle and cut both her wrists,” a friend of Jill’s told me. “Everyone gathered around her, and I think that’s what she wanted. She was crying and I’d be hugging her and stuff and then she’d raise her head and be laughing.”

Later in the afternoon, Jill, Jane C., Jamie and the other SAFE patients settle on couches and chairs for one of the many focused group therapy sessions they participate in throughout the week. Patients must sign a “no-harm contract” before entering the program; group therapy is a forum for grappling with the flood of feelings they would normally be numbing through self-injury. It is not, as I had envisioned, an occasion for trading gruesome tales of the injuring itself. Karen Conterio, SAFE’s founder, has treated thousands of patients and rejects the public confessional that is a staple of 12-step programs. “Self-mutilation is a behavior, it’s not an identity,” she says, and encourages patients to save their war stories for individual therapy.

Beyond that caveat, Conterio, 39, a lithe, athletic woman with short blond hair, lets her patients set the agenda. Today, Jill and the others discuss their feelings of shame—shame they repressed by injuring, shame over the injuring itself. At emergency rooms, their wounds were often mistaken for suicide attempts, which in most states requires that a patient be locked up in a psychiatric ward, often in physical restraints.

Later, in a small office adorned with mementos given to her by former patients—a knit blanket, a papier-mache mask—Conterio tells me that she’s less concerned with guiding patients toward a specific cause for their self-injury than with helping them learn to tolerate their feelings and express them verbally—in other words, begin functioning as adults. Still, revisiting one’s past is a key step in this process. As Maureen Ford, a psychologist at SAFE, puts it: “Self-injury is a kind of violence. So how is it that violence has entered their life in some way previously?”

In Jill McArdle’s case, the answer isn’t obvious. She is part of an intact, supportive family; as far as she knows, she has never been sexually abused. But there were problems. Jill’s brother, a year older than she, was born with health troubles that cost him one kidney and left him only partial use of the other. Today he is well, but, Nancy McArdle says: “It was three, four years of just not knowing from one day to the next how he was going to do, in the hospital all the time. ... Jill picked up on it right away and tried to make everything easy on us where she was concerned.” (Jamie Matthews also grew up with a chronically ill sibling.) Beyond worrying constantly about her ill son, Nancy McArdle, whose own childhood was marked by alcoholism in her family, admits to feeling a general sense of impending catastrophe while her children were young. “I wouldn’t drive on expressways—I’d take a different route,” she says. “If I saw a storm coming, I’d think it was a tornado.” Giggling at the memory, Jill says: “She’d make us all go into the basement with pillows and blankets. I’ve been petrified of storms ever since then.”

Nancy McArdle has since been given a diagnosis of obsessive-compulsive disorder and is on Prozac, and she and Jill can now laugh about those old fears. But it’s easy to see how Jill, as a child with a terrified mother, a chronically ill sibling and a father who kept a certain distance from the emotional upheavals in the household, might have felt isolated and imperiled. She quickly developed an unusual tolerance for pain. “I’d fall and I’d never cry. ... I never felt any pain, really. It was there, but I pushed it back.” Triumphing over physical pain was something she could excel at—distinguishing herself from her physically weak older brother, while at the same time reassuring her mother that she, anyway, would always be strong.

This mix of toughness and a hypervigilant desire to please is still the engine of Jill’s social persona, which mingles easy affection with an opacity that seals off her real thoughts. “She never tells anybody how she feels—ever,” Nancy McArdle says.

Jill agrees: “I turn it all inside. I just think I have to help myself, it all has to be up to me.” But paradoxically, the child who feels that she must be completely self-sufficient, that no one can help her or that she doesn’t deserve help is uniquely ill equipped for the independence she seeks. Terrified to express emotions like sadness or rage for fear of driving everyone away from her, such a person becomes more easily overwhelmed by those feelings and turns them on herself.

“I and my razors and my pieces of glass and the pins and the needles are the only things I can trust to bring relief,” paraphrases Dr. Kaplan, author of Female Perversions. “These are their care givers. These have the power to soothe and bring relief of the tension building up inside. ... They don’t expect the environment to hold them.” Tending to their own wounds, which many injurers do solicitously, is the final part of the experience. In a sense, self-injury becomes a perverse ritual of self-caretaking in which the injurer assumes all roles of an abusive relationship: the abuser, the victim and the comforting presence who soothes her afterward.

In someone like Jane C., whose childhood was severely traumatic, physiology may be partly to blame; trauma can cause lasting neurological changes, especially if it occurs while the central nervous system is still developing. Dr. Bessel van der Kolk, a professor of psychiatry at Boston University who specializes in trauma, explains: “The shock absorbers of the brain are shot. If everything is running smoothly, if it crawls along just fine—as it does in nobody’s life—you’re fine. But the moment you get hurt, jealous, upset, fall in love, fall out of love, your reaction becomes much stronger.”

The Toronto Star
October 10, 1997

Kids who cut: Something’s gone wrong in their lives and they take knives or razor blades or lit cigarettes to their bodies.
By Janice Turner

They are young people who have experienced trauma, witnessed tragedy or been abused. They feel anxious, angry, alone, worthless.

They are emotionally numb. Empty. And in order to feel again, they mar their own flesh. Using a paper clip, safety pin, a knife, razor blade or bits of glass, a cigarette or flame, they seek relief, leaving a trail or patchwork of scars.

They’re self-mutilators. Kids who cut. And the people who work with youth say they’re seeing more of them.

How many teens and young adults cut or burn their own bodies? The experts contend they don’t have any meaningful numbers. All they can say with any accuracy is that more young people are coming forward.

“It’s not a new phenomenon, but we are seeing more of it,” says Bettina Federspiel, clinical coordinator at Delisle Youth Services. “I can only guess people feel more comfortable” seeking help, frequently encouraged by a trusted adult—a guidance counsellor, teacher or social worker.

Kids are doing it more, talking about it more, and mental health professionals are asking about it more, observes Marshall Korenblum, psychiatrist and director of the adolescent out-patient team at the Hincks Centre for Children’s Mental Health. “It’s where eating disorders were maybe 10 years ago,” he says.

About 20 per cent of Delisle clients have harmed themselves by cutting. That includes those who have done it once or twice and are frightened by it, and those who have been disfiguring themselves for years.

Disturbed street kids, you say? Try public school, separate school, private school kids—and, yeah, street kids, too.

“We absolutely do not see this as more of a problem with one (socio-economic) group than another,” says Federspiel.

Not all of these kids are from homes from hell, she stresses. Some of them are from reasonably stable families and may be doing well academically. Certainly, affluence is no guarantee that a young person won’t self-abuse.

Higher-income families have “an ability to hide behind a mask of properness,” she says. “The problems are there, but there’s much more secrecy and, therefore, the problem is often more severe by the time we get involved.”

The most common form of self-injury is cutting, and the most common places are wrists, upper arms and legs, according to Shelley Levitz, a supervisor with Kids Help Phone. Other forms of self-punishment include scratching, needle poking, head banging and rubbing glass into the skin.

There can be an addictive quality to these acts—“soothing” and “hypnotic,” self-injurers report.

“You see the scars in the older kids, but you see the fresh mutilation in the younger kids,” observes Ruth Ewert, health centre program coordinator at Evergreen, a drop-in centre on Yonge St. for street kids aged 16 to 24.

Self-injurious acts are generally not perceived as botched or manipulative suicide attempts. Most of these youths do not intend to die as a result of the behaviour. Federspiel cautions against criticizing people who self-harm.

“We have to be careful not to judge each other for how we cope,” she says. “Life is pretty darn hard. Some people are lucky, they’re equipped to get through the tough stuff. Others are less resistant. We don’t always understand why.”

Many more females seem to self-abuse than males. Most begin in their mid-teens and stop by their mid-20s. All of them are turning inward in order to get by.

“Self-harming is a response to life experiences. It can be abuse, sexual abuse, but it’s not always. It can be loneliness and isolation or trauma,” Federspiel says.

“When we ask why (they do it), the typical response is, ‘It makes me feel like I’m here, it grounds me.’ Others say it takes them away from the here and now. Some say it’s a way to remind themselves that things aren’t right and to remind others. For others, nobody knows about it, and they’ve been doing it for years.”

Although much of society is repulsed by it, self-injury is “a very common response to trauma, and trauma has been existing in society for centuries,” Federspiel says.

Adolescent boys tend to act out in other ways—they drink, abuse drugs and are more likely to break the law than girls. Adolescent girls who are in despair may self-mutilate, abuse drugs, deprive themselves of food, punish themselves through extreme exercise or have unprotected sex.

Self-mutilators may be responding to an immediate issue or abuse from the past. They often come from families where expressing emotions is difficult. No doubt some, but not all, of these kids have a serious mental disorder, says Leigh Solomon, a psychiatrist and a consultant at North York General Hospital’s teen clinic since 1990.

“It doesn’t mean that they don’t, on the outside, do well,” cautions Levitz, at Kids Help Phone. “It’s on the inside that they’re not doing well. They need help in making connections to other people and to their feelings.”

But haven’t youths always faced pressures? Federspiel maintains things are different these days.

“Young people are under incredible influences that dictate who they’re supposed to be, and those influences have more power now,” she says. “The pressures are of a different nature. They’re unrealistic, confining and unrelenting.”

In many cases, the young person doesn’t have a trusted adult to lean on, somebody to talk to who is stable and strong. If a friend is doing it, it may be seen to be an acceptable thing to do.

Self-cutting is often associated with shame and guilt, but curiously enough, not pain. At least not initially.

“They report no pain at the time,” says Bob Stein, director of the psychotherapy youth division at Sunnybrook Health Science Centre. “The mental pain is usually so extreme, (the self-injury) gets rid of it, and it stings maybe a half hour later.”

“You really have to be open-minded,” insists Federspiel. “They don’t see themselves necessarily as self-harmers. When you’re so confused or feel out of touch with reality, the cutting brings you back. The external scars are a reflection of the internal scars.” This is not, for the most part, attention-grabbing behaviour.

The kids who show up at Delisle “are not proud of it. There’s a stigma attached.” Some cases can be dramatic—and horrifying. In some of the more severe cases, the cutting literally covers the body, extending from the neck, along the arms, across the abdomen and down the legs.

“But you have to react calmly,” Federspiel says. “With assistance, many, as they move into adulthood, can develop different ways of coping. They need to be connected to persons and communities. We help them to develop supportive relationships.” Treatment focuses on underlying issues, not the self-injury.

Self-mutilation is a symptom, not a syndrome, emphasizes Korenblum of the Hincks. It encompasses a “huge variety of behaviour,” and treatment—including counselling and medication—can vary greatly.

Federspiel believes that in many instances, these type of acts can be prevented.

“We have enough knowledge,” she says. “We know what hurts, and hurtful experiences for children can create difficult lives.”