The Toronto Star
March 27, 1998

Self-mutilator needs a plastic surgeon; Scars are daily reminders of her self-abusive past
By Janice Turner

Casey Smith has been able to put her self-abusive past behind her—emotionally.

But each day she has to confront the physical reminders—the patchwork of 50 or so white scars that line her left forearm; the thick, bumpy pink scars on her left upper arm; the dozen or so thick white scars on the upper inside of her right arm.

“I want to carry on with my life, but it’s really hard to start off new when you have your past mapped out on your body,” she says.

Smith, a pseudonym, was a self-mutilator for more than a decade. She was able to stop the behaviour about a year ago, at age 23.

At first, she used small objects—pins, little bits of rocks—then started using blades, carpet cutters and dollar store knives.

“At first I cut because I was just so angry,” she says. “I couldn’t speak to anyone and the only way I could release myself was by hurting myself. Sometimes it was every day and the older I got the more severe it got.”

Smith was sexually abused over three years during her childhood. She took the matter to court at age 19, but lost her case on a technicality.

Now, at age 24, she is searching for a qualified medical professional who will help her to mask her sorrow and shame.

“I’ve been in long sleeves since I was 12,” Smith says, “except for in the Muskokas where the beavers and the loons don’t judge. In the city, I wouldn’t even throw the trash out in a T-shirt.”

Her visits to three Toronto-area surgeons have left her thoroughly disheartened.

“One suggested I use makeup,” she says. “The second one was very rude and made me feel so guilty for how I looked. The third was also very rude and basically said he wasn’t interested. I definitely got the impression that I wasn’t worth fixing.

“I can’t seem to find someone who understands how much of a distressing thing this is for me. If I wanted to get rid of a bump on my nose or have my lips or boobs made bigger, I don’t think I’d get the same kind of insensitivity.

“I need to find a compassionate surgeon who will try to make my scars better. I can’t take them back myself. I need help.”

Smith intends to use some of the money she received as victim’s compensation to pay for the work.

Months after she’d read a Star Life section story (Oct. 10, 1997, titled Kids Who Cut), Smith decided to contact me, the writer.

“In 10 years it was the only story I’d seen written on it—ever,” she says. “But I was left wondering, ‘What now?’”

To any young person who may think that cutting is a relatively harmless form of attention-getting, Smith asks them to think again.

“Scars aren’t like a hangover. They don’t go away on their own. When I was young I thought they’d eventually be gone, like the scars you get as a kid from scraping your knee. I never imagined I’d feel this kind of regret.”

Gail Wilson, residential supervisor for Delisle Youth Services, where Smith spent time in her mid-teens, continues to see the young woman socially several times a year.

“She has come such a long way,” says Wilson. “I’m very proud of her. She has been able to overcome tragedies. But her scars stare her in the face day after day after day.”

Having her scars treated would help her “complete the healing process,” Wilson says.

“If someone is a burn victim, we’re pretty quick to help them with surgery. I think we have to take this just as seriously.”

Young people who self-mutilate have usually experienced trauma, witnessed tragedy or been abused, youth workers say. They often feel anxious, angry, alone, worthless, emotionally numb.

There can be an addictive quality to the cutting. “Soothing” and “hypnotic” are words abusers use to describe the feeling.

More females seem to self-abuse than males. Most begin in their mid-teens and stop by their mid-20s. All of them have turned inward in order to get by.

Although much of society is repulsed by it, self-injury is a very common response to trauma, experts note. Treatment focuses on the underlying issues, not the self-injury.

Smith is seeing a counselor, studies part-time and is a regular volunteer. But her field of study demands physical exertion. She knows she won’t be able to hide under long sleeves forever.

Dr. Arianna Dalcin, president of the Ontario Society of Plastic Surgeons, hasn’t seen Smith, but she is sympathetic to her concerns.

“A problem is a problem, regardless of the mechanism,” Dalcin says. “It could mean that the situation is quite complex, that it could be quite difficult to get a good result or that the outcome may not be predictable” depending on the way Smith’s body heals, she says.

Any surgery or procedure on thick scarring, for example, may produce little or no improvement. In some cases, it could even worsen the appearance.

“You can sometimes reduce or minimize (the damage),” Dalcin says. “There is some room for optimism. But it depends on her (Smith’s) ultimate goals. The results are not always what we want them to be. She has to decide what she is willing to accept.”

Some considered professional opinion and a bit of open-mindedness, Smith suggests, would be a good start.

The Guardian (London)
April 14, 1998

Scarred by a Secret Shame
By Graham Houghton

Rachel is 16 and cuts herself with whatever she can find—razor blades, utility knives, scalpels. She carves patterns on her skin and when she’s finished stems the blood with toilet paper then carefully bandages the wounds. She has cut so many different shapes into her arms that the scars are barely recognisable.

‘I used to cut daily,’ she says, ‘sometimes because of stressful events, or because of general depression and suicidal feelings, and after a while simply because I was bored.’ An estimated 0.75per cent of the population—one in every 130 people—are active self-injurers. That is comparable to the incidence of mental illnesses such as schizophrenia and manic depressive disorders, yet the condition is rarely seen as an illness and sufferers are often treated unsympathetically.

Self-injury (SI) is an act which damages one’s own tissue with the intent of causing injury or relieving tension. Typical behaviour ranges from biting, pulling hair, picking at scabs and punching walls, cutting (the most prevalent method), burning and piercing skin, breaking bones and rubbing dirt into open wounds.

Because we rarely see such activities, plenty of myths surround them. People assume that self-harmers are crazy or a danger to others, that they’re attention-seeking and manipulative, or that they’re trying to commit —not true.

Armando Favazza, author of the groundbreaking book on self-injury, Bodies Under Siege, claims that self-harm is ‘the opposite of suicide’. He was one of the first doctors to regard the condition as a proper syndrome and emphasises its links with depression and compulsive behaviours such as bulimia, kleptomania and alcohol /substance abuse. His research suggest the backgrounds of self-mutilators ‘often include child abuse (50-60 percent), and childhood illnesses and surgical procedures.’

Deb Martinson, administrator of the Bodies Under Siege (BUS) mailing list on the Internet, enhances this picture. ‘The common factor seems to be an inability to deal with emotion. Self-injurers are often people who, when they were children, were told their feelings were bad, inappropriate or inaccurate; and they have grown up not knowing how to handle feelings. Self injury provides a quick, dramatic release.’

She notes that studies often portray self -harmers as young, white, middle class and female, but she suggest anyone can be affected. ‘The one factor which shows up time and again is that these people didn’t feel they mattered to anyone...They never felt special or important.’ Many factors contribute, including domestic violence, loss of a parent through death or divorce, lack of emotional warmth in childhood, hypercritical fathers, parental depression, and neglect. Common personality traits include perfectionism, disgust with one’s own body, hypersensitivity to intense feelings, and inability to express emotions.

It’s generally accepted that two to three times more women than men are likely to injure themselves. Favazza suggests this is because in most cultures women tend to turn their aggression inward. Martinson says the opposite applies : ‘Men are socialised not to show feelings, so perhaps they have an easier time suppressing ‘bad’ emotions...’ When asked why they do it, a group of self -harmers gave replies consistent with Martinson’s observations: ‘I cut in order to feel something’, ‘I don’t like myself much’, ‘it takes away all the black inside’. It’s a way of externalising emotion, and imposing control on something which feels chaotic.

They also identified feelings of intolerable tension or emptiness which can only be relieved by self-injury. Rachel says, ‘the first time I cut, I was struck by the image of all the feeling I had slowly leaking out of my body through the wounds’. But the relief is only temporary: ‘after I cut I would be almost happy... but by next morning I would be depressed and wanting to self -injure again.’ When asked if what they do hurts, the feedback is more ambivalent with responses varying from not at all to very painful.

Shame makes it hard to admit to what you are doing and self-injurers find it particularly difficult to find support. The medical profession—psychiatric personnel excluded—is particularly criticised. Bulletins on various websites allege that self-harmers are treated as ‘a waste of time’, and that one doctor even stitched a girl’s wrist without anaesthesia: ‘It was like he wanted to teach me a lesson, but instead he taught me that I could withstand more pain than I thought.’

Deb Martinson argues for a more sympathetic approach. The best hospital programme she’s encountered is one in Beckenham, Kent, where clients are not forbidden to hurt themselves, but are expected to take responsibility for what they do. ‘If they cut, they bandage their wounds, clean up their mess and talk to staff about what happened and how it could have been different.’ Those closest to the self-harmer have most difficulty coping. Rachel says her parents ‘were scared by it. My dad gave me a lecture on God and took my blades away. My friends were scared too, though a few of them stepped in to help... but people trying to “fix” me only screwed things up more.’

Martinson offers some general advice for friends and families. ‘The worst thing you can do is go away... and the second worst is to give an ultimatum. In most cases they would stop if they knew how. They’re generally not doing it to annoy you or manipulate you—although it can feel as though they are.’ She suggests encouraging them to seek help from a counselor.

Whether you harm yourself or know someone who does, it’s important to remember that you’re not alone. Above all, everyone agrees that self-harmers should look for ways to change their behaviour.

Martinson says that first ‘you have to decide you no longer want to do it. After that, the only way to stop is to find other coping mechanisms and learn to substitute them for self-injury’. She suggests, for example, pressing ice against the skin rather than burning, then later substituting something for the ice. The main thing is to be kind to yourself. ‘Deal with the issues that underlie your self-injury... But do everything in small steps.’

The San Francisco Chronicle
October 11, 1998

The Unkindest Cut; An estimated 2 million self-injurers—or “cutters”—are suffering in America, most of them young women. Their secret is coming out.
By Sylvia Rubin

A dozen fresh gashes are beginning to heal on Lynn’s left wrist. The night before, anxious, angry and unable to stop herself, she held an Exacto knife steady in her right hand and attacked the left. Now she’s contrite.

At 23, she looks so young sitting in her East Bay apartment curled into herself, her arms wrapped tightly around her knees. Her thick black hair falls over her eyes. “It was a stupid thing to do,” she whispers.

Lynn is a self-injurer. She has repeatedly hurt herself over the last decade. She has cut her wrists so many times the scars have blended together into rosy red patches. Like so many others who injure themselves—including the late Princess Diana—cutting provides a release from overwhelming anxiety.

There are an estimated 2 million self-injurers in America. Most are not yet 25, and most are women. The majority are victims of child abuse and neglect.

Unable to cope with their anger or depression, they lash out at themselves, making cuts that look like cat scratches. Immediately, the sight of their blood calms them down. To cut themselves is to literally cut through their chaos.

Momentarily relieved, they may not cut again for weeks or years. But usually, the urge to injure themselves returns.

They wonder if they are crazy. Silenced by shame, they are terrified to tell anyone.

Recently, this disturbing behavior is being more openly discussed through Web sites, books, public admissions by celebrities, national magazine articles and, most mainstream of all, NBC’s “Dateline,” whose producers have visited the only in-patient self-injury treatment center in the country in preparation for a segment on the disorder. The behavior, often thought of as a symptom of other disorders, seems now to be gaining recognition as a separate behavioral abnormality. Slowly, it is coming to be more openly discussed. It wasn’t so long ago that the sight of a tongue stud was as shocking as the sight of Lynn’s scars.

“It is so difficult for people who don’t self-injure to understand what it’s all about,” says Deb Martinson, a former self-injurer from Seattle who runs the “Secret Shame” Web site and started the “Bodies Under Siege” e-mail support list and newsletter two years ago, for those who chronically harm themselves.

“It is not about killing yourself. It’s not even a last desperate act,” she says. “It’s that you get into a state of being hit with an overwhelming emotion. It could be anger, sadness, depression, loneliness. Self-injurers usually stumble into this by accident; they learn that by hurting themselves, causing pain, seeing blood, the level of anxiety just drops. It goes way down. The thing is, it works, and that’s why it becomes so addictive.”

After Princess Diana admitted during a 1995 BBC interview that she cut her legs and arms, celebrity confessions were later made by Courtney Love, Fiona Apple, Johnny Depp and others. The publication this week of the first general-interest book on the subject, The Bright Red Scream (Viking, $24.95), by Oakland journalist Marilee Strong, may help shed more light on the problem. Another new book, Bodily Harm (Hyperion), which details treatment for self-injurers, written by the two women who run the country’s only in-patient self-injury center outside Chicago, will come out at the end of this month.

Five years ago, Strong wrote the first in-depth magazine article on the subject in San Francisco Focus Magazine. For her book, Strong interviewed more than 50 cutters, the largest group of self-injurers yet given a voice in a non-academic publication.

Cutting, which often goes along with eating disorders, most typically starts in adolescence, usually in response to chronic trauma.

Self-injury can cover many forms of abuse, including burning, head banging, bone breaking and hair plucking, for example. Nearly all self-injurers in Strong’s book suffered some form of child abuse or neglect, she says. Self-injury of any type is a cry for help, but many parents, either in denial or too self-absorbed to care, do not listen, Strong says.

Often, Strong writes, they cannot grasp the concept. “The discovery that a child is a cutter sometimes causes parents to make matters worse,” she writes. “When the scars are uncovered and the depth of their children’s pain is revealed, some parents respond with anger and annoyance rather than sympathy and understanding. They overreact and police their kids... others underreact, dismissing the cuts, bruises and broken bones as melodrama—teenage bullshit,’ as one cutter’s father described it.”

One girl’s struggle to find help was stopped by her mother, a story that Strong found particularly sad. “One teenager told me she had been confiding in an adult friend who was helping her. When the mother found out, she forced her daughter to cut off the relationship. Apparently, it was so frightening, this parent did not want to believe it.”

Strong’s immersion in the subject left her angry at times, compassionate at others. “Some of these kids I wanted to adopt, sometimes I wanted to beat up the parents,” she says.

“We shouldn’t be so shocked by the cutting; we should be shocked by what causes it,” Strong says. “What was so painful for me to see is what goes on in way too many families.”

As more clinical studies are being conducted, the behavior is being linked most closely to post-traumatic stress syndrome, Strong says. “It is not manipulative behavior or even masochistic, but more likely a reaction to painful memories that cause extreme anger or sadness. By cutting, self-injurers have discovered a way to calm themselves down.”

There are many days when Lynn is able to focus on the positive: Her job as a teacher’s aide with special needs kids. Her love of art and music. Her ambition to go to graduate school. Two of her own well-executed paintings with architectural themes hang opposite her bed. She writes songs, composing on a keyboard in her room. While she feels sad and depressed much of the time, she also seems quick to anger.

In the past six months, there have been confrontations with housemates, an ex-therapist and people on the “Bodies Under Siege” message board.

While willing to talk about her habit, Lynn did not want her real name used in this article. Just last week, her housemate asked her to find another place to live. When Lynn feels threatened like this, she turns her anger inward. So she cuts.

She started at 14, using nails, paper clips and other scratching tools. Later, like many other self-injurers, she turned to a more efficient implement.

“The first time I used a knife, I was 19. I was really mad at my mom and my roommate and stressed out at school,” she says. “My roommate and I had different schedules. She studied late at night, and I had early classes. I had a test, and I studied really hard and I was hoping to get at least six hours of sleep. But my roommate was up late, and I couldn’t sleep. I was so angry, I wrote her a note, and then I threw a picture of us that was in a frame across the room and it broke.”

When Lynn returned to the room after her test, she was reprimanded by her roommate and several other students. “They made me feel like I did something wrong,” she says. “If I can’t be angry in my own apartment, what then? I just took it out on myself.

“I had this Exacto knife from architecture class. I took it with me and went for a walk. I felt like I was going to explode. I had to do something to get it out of me. Afterward, I felt calm.”

Any good feelings Lynn has about herself blow away as soon as the spiraling self-doubt begins. She has, unlike many other self-injurers, tried to commit suicide more than once. Still, she has dreams—opening an art gallery, becoming a therapist. “Maybe some day. Some day,” she says, looking away. “Right now, I need a really good therapist.”

Nothing helps when she is out of control. Sometimes, though, if she catches herself, she can get on the computer and let it all out.

Every day, another anguished voice is added to the “Bodies Under Siege” Internet message board.

The title is taken from an academic work of the same name by psychiatrist Dr. Armando Favazza, published in 1987. Word of mouth has made it required reading for those who injure themselves.

Alone in their rooms with their computers, self-injurers post raw, painful, stream-of-consciousness messages. In the moments leading up to cutting, many express feeling a swirling whirlwind of emotions. One likened the turmoil to having a volcano inside of her. They say they feel worthless. Words used over and over again: Self-hate. Restless. Depression. Hopeless. Stupid. Sad. Lonely. Lost.

Afterward, they write, they feel calm. Relieved. Cleansed. As if they are floating. Like they are finally “real.”

It was Princess Diana’s confession that made a South Bay woman aware that she was not alone. Sharon is 39. She has been cutting herself since she was 14, about the time she was first raped by a relative. The sexual abuse went on for years, as did the cutting. She always wears long-sleeved outfits to work at a real estate developer’s office, no matter what the season.

“I know why I do this, and sometimes I know how to stop it—by pampering myself. But just last week, after not cutting for a few months, I thought I had made a bad mistake at work. I obsessed about it, I felt like a bad person and I cut,” says Sharon, who did not want her real name used for this article. “The next morning, I realized that I hadn’t made an error after all.”

During one of her worst episodes, triggered by a breakup of a relationship and flashbacks of her abuse, Sharon slashed herself 50 or 60 times. “Sometimes, I’ve soaked up four tissues worth of blood,” she says. “I don’t feel any pain whatsoever. There is something about seeing the blood, seeing the cuts, there is something calming about that.”

She sounds confident that she can stop, yet she isn’t there yet. “Getting on the Web site really helps, and therapy is really important,” Sharon says. “I’m blessed right now to have someone who is really helping me.”

San Francisco therapist Michael Wagner knows what an arduous process it is to help injurers stop harming themselves. “This is a very complicated behavior that, at least in part, is their attempt to manage overwhelming anxiety,” says Wagner, a psychologist in private practice in San Francisco who wrote his dissertation on self-mutilation.

Typically, he says, a cutter’s ability to manage intense tensions has been traumatized. It’s often associated with sexual abuse, but it can happen to the kid with the best parents in the world, he says.

Most of us know how to analyze tension, to turn an experience into thought, he explains. “But if it can’t be thought about, what do you do about it? It gets turned into some kind of action. They use their body to provide the function that their minds are not available to do.”

Some cutters may be able to stop on their own, Strong writes, by growing out of a behavior “that served their needs during a particular stage or crisis in their lives. Or the symptom may disappear fairly quickly once they begin to explore in therapy why they feel depressed or angry or anxious and what is driving their need to dissociate from those feelings.”

But what often pulls them back into cutting is the addictive quality of the release, of wanting to see the blood, which is very important for self-injurers, says Strong. “It’s like watching the bad stuff inside of you flow out,” says Strong. “Then there is the healing aspect, which is just as important as the cutting.”

Chronic cutters keep well-stocked first-aid kits handy. They might lay out their gauze, creams, antibiotics and enough towels to wipe up the blood.

“I go to the bathroom and close the door,” wrote a 26-year-old woman, a health care professional, in answer to a questionnaire on the “Bodies Under Siege” message board. “I look in the mirror and think about how much I hate myself and how ugly I am. I start usually with my face or arms, then move to my breasts and abdomen, then to my upper legs. Sometimes when I think about God, I stop.”

Chronic injurers who are in dire need of treatment—and can afford it—may find help at the MacNeal Hospital in Berwyn, Ill., which houses SAFE (Self-Abuse Finally Ends) Alternatives, the only in-patient treatment center for self-mutilators.

Most patients are women in their 20s and 30s who have been doing this since adolescence, says Dr. Wendy Lader, clinical director of SAFE Alternatives. Traditionally, women tend to turn their anxiety inward, while men learn other ways to express rage. “Right now, we have three males out of 13 patients. It used to be that we’d go for months without any men, but that isn’t happening so much any more.”

Because more self-injurers may seek help in the coming years, Lader says the clinic may open other units, with a possible expansion into San Francisco. “We’re in the talking stages right now,” she says.

While Strong calls self-injury “the addiction of the ’90s” others are not so quick to agree.

“It is certainly more discussed now,” says David Frankel, a Corte Madera psychologist in private practice. “Sexual abuse was underground until the ’70s or ’80s, and what do you know, it turned out to be pretty prevalent.”

As former head of the adolescent child inpatient psychiatric unit at Ross Hospital in Marin County, he is not of the opinion that the behavior has reached epidemic proportions. “But I do think that just as there are more discussions about sexual abuse, more people are starting to talk about self-injurers now,” he says.

They are talking about it every day on the “Bodies Under Siege” message board. Martinson has more than 400 self-injurers who subscribe to her online newsletter.

“I think that books like Marilee’s and all this discussion is giving people who do this a chance to say, Look, you are not crazy.’ They know there is something wrong, they know that they are coping in a very maladapted way and they need to address that, but they are not psychotic. People are really scared out there. When they hear about others, it is such a relief.”

Cries from the Internet

Over the last two years, Deb Martinson, who runs the “Bodies Under Siege” Web site, has asked people to respond to a list of questions. All responses are anonymous. Here are some excerpts. “S.I.” stands for self-injure:

Why do you S.I.? How does it make you feel?

Do you have rituals for S.I.?

How did people react when you came out as a self-injurer?

How do you feel about stopping?

A Bright Red Scream

This excerpt from A Bright Red Scream by Oakland journalist Marilee Strong involves a teenage girl—the most typical cutter—with a history of childhood sexual abuse, the single most common factor that has been related to cutting. She eloquently describes the altered state of consciousness known as dissociation—which she describes as feeling like a “walking corpse”—a sense of deadness and unreality that often precipitates bouts of cutting.

“I remember looking at razor blades all the time when I was growing up,” recalls Lauren, a 19-year-old premed student at one of America’s top Ivy League universities. “It was like an obsession. I knew that I could just slice my wrists and die, but I felt that was too good for me. I felt like I deserved everything bad in the world, and that death would grant me the type of freedom and peace that I did not deserve.”

When Lauren was born, her father didn’t bother showing up. Her mother threatened to throw her daughter into a wall when a nurse brought Lauren in to be fed, insisting the nurse had switched babies on her. The doctors attributed her mother’s attitude to postpartum depression. Yet it is a story Lauren’s mother has related over and over again to her daughter throughout the years.

Lauren spent much of her childhood in gambling parlors waiting for hours on end while her mother played video poker. “I always felt she abandoned me to a goddamn machine,” she says sadly. Her mother was such a compulsive gambler that when Lauren choked on a Parcheesi piece one day while visiting her cousin, her mother ran over to get her, then took her to the place she gambled and left her there for three hours.

“She always asked me if I was mad at her, like I had no right to be angry, even when we got into bad financial situations because of her gambling,” says Lauren. Her mother also had violent outbursts, once breaking a hairbrush over her daughter’s head, another time pushing her off a chair into a wall.

“Today she thinks that we’re best friends, but she can be so cruel one minute, nice the next,” Lauren says. “You never know what you’re going to get.”

At age 10, Lauren was sexually abused repeatedly by her brother’s best friend. “I felt that boy in me all the time,” she says. One day she stopped staring at razor blades and grabbed one up. “When I cut, I was trying to cut him out of me,” she says. She stopped cutting for a while, but only moved on to other self-destructive behaviors: head-banging, punching herself, and giving herself second- and third-degree burns.

“Sometimes it feels like I’m watching my body move without controlling it,” she says, describing the various levels of dissociation in which she self-injures. “Other times I wake up with this razor in my hand and blood dripping everywhere. I’m so scared then. I never know what I’m going to do with myself. I cut or burn much worse when I’m not aware of what I’m doing. I really do feel dead, disconnected from myself,” she says, oozing self-loathing. “I hate my body. It is fat, ugly, dirty. The abuse made me feel like this, but I can’t seem to shake it. I feel like I’m the only person in the world who doesn’t exist. I’m like a walking corpse.”

WIN Magazine
November 1998

The Silent Scream—An Account of a Self-Injurer
By Julie Farrand, Britain

When I was a little girl I lived in a small village in Hampshire, England. One evening as I came out of my bedroom, I saw my mother in the bath with a razor blade in her hand. I knew immediately and instinctively that she was thinking about hurting herself, so I ran out of the house to get help from a neighbour, Jean. Jean seemed very concerned and immediately walked me home again across the dark village green as I held on tightly to her hand. Mum assured Jean that she was absolutely fine and that I was probably just imagining things. I knew for sure that something was very wrong, despite the contradiction in my mother’s words. I still remember the feeling of powerlessness and fear the incident brought about.

I am now 39 years old, and for the past 24 years, at irregular and infrequent intervals, I have also been deliberately injuring myself. My last incident occurred in May 1998. Maybe that will be my final time, but it is impossible to say. I am like a recovering alcoholic who can never say “never” again.

For many years I believed that the small scars parading sideways along the length of my arm from the cuts I made with a razor were minus signs that cancelled me out. No matter how attractive, how intelligent, how virtuous I was, or tried to be, my scars betrayed me because they gave away my secret self, the bad and “dark” side that lurked underneath the false exterior I projected to the world. Like tiny, half-closed mouths, these scars muttered the truth that I was unbalanced, a little mad, and worst of all, in need of help.

Help came and went in the guise of psychiatrists, counselors, friends and boyfriends. In the end I found that the only person who could really help me was me, and in order to do this I had to begin a conversation with my self-injury. I needed to listen to what it had been trying to tell me for so long, which is that I was not mad, but unhappy and in need of help and understanding.

It is incredibly difficult, if not impossible to get accurate statistics on people who self-injure. A much quoted figure here in Britain is that of 10,000 individuals, based on those who pass through accident and emergency departments of hospitals every year, according to the Bristol Crisis Service for Women. However, this is likely a rough estimate since record-keeping systems vary from one hospital to the next and much self-injury is carried out in private with wounds treated secretly. Moreover, there is confusion in the classification of self-harm with attempted suicide. Self-injury is a violent act that an individual inflicts upon the body, which usually brings on relief from suffering and release of tension. But there is no intention of ending life.

It is generally agreed by researchers that women overwhelmingly self-injure more than men, but again figures vary from a ratio of 1:3 to 1:10. I believe it is because women tend to internalise their problems and blame themselves when things go wrong. In contrast, men in distress usually lash out at others.

Three years ago a Bristol Crisis Service survey of 76 women who self-harm found that significant factors leading to the practice are: loss of someone close in childhood, sexual/emotional/physical abuse, and also adult trauma (rape, violence) amongst others. The most common form of self-injuring is cutting, with burning in second place.

Like many who self-injure my first incident occurred when I was a teenager. I was 15 when my boyfriend at the time left me for another girl—he had been my first love and I took it very badly. After receiving the “goodbye” phone call, I ran out of our front door and down the driveway. Halfway down the gravel path one of my shoes fell off. I kicked the other one off in the road and walked barefoot down country lanes the five miles or so to Paul’s house. His parents drove me straight home again, and I was delivered up to my mother like a curious, sad and battered little package. I told mum I wanted to go upstairs and have a bath and attend to my poor blistered feet. Instead I took a razor blade from the bathroom cabinet and cut across the vein in my left arm where it lay on the soft side of my elbow. Something happened then that was all about punishment, self-hatred, anger, and a real and very deep misery that had begun a long time before that day.

I had never heard the terms “self-injury” or “self-harm” and had never heard of anyone else who did it. When my cutting and overdosing became public, medics, friends and relatives called it an inept attempt at suicide. I believed this myself. After all, I had no other explanation.

But that changed one day in the Spring of 1991, I stayed overnight at a friend’s house out of fear that I would pull out the stitches in my arm that the hospital had put in the night before after another incident with the razor blade. That evening we watched a shod British documentary programme about a woman who did something called “self-harming.” This was my first moment of revelation: the lightning bolt ripped through the myths, the secret fears, and the ignorance that had built inside me over the years. This was what I did. I thought. It had a name and others did it too. I had been awakened, but I still wasn’t ready to look hard at what I was doing to myself. The self-injury still felt like a monstrous, dark, scaly beast lurking underneath my bed waiting to get me. I didn’t want to pull it out into the light of day in case it ate me up and spat me out in pieces that I might not be able to put together again. By pushing it to the back of mind, I could tell myself that it didn’t really have anything to do with me, and that the real me was O.K. Drawn to other people’s problems, I later began working as a counselor at an advice organization. But I was unable to cope with the job after the sudden death of my mother. The year following my loss, I left the organization without a clue about where I was going next, except that I wanted to set up a group for women like me. I was depressed and on the dole, but I felt that the time had come to look at myself, to look at the scars on my arm, to look at the cigarette burns on my arm and leg, and to ask myself why I was doing this. I realised that I wanted to tell other people what I knew and to drag the monster out from under the bed.

I began by making contact with a woman who ran a self-harm group in Nottingham whose name I found in a magazine article. From there, one contact led to another, and I began pulling together a group in Manchester. Although that particular group no longer exists, there are many self-injury groups across Britain.

I have stopped pretending that my scars were the result of some bizarre accident and admitted that they were a result of unhappiness. I don’t want to glorify what I did in any way. I believe that if people like me can talk openly about self-injury and challenge the outdated authoritarian views and psychiatric models, then change can come about and prejudice can in part be overcome. Self-injury must be accepted and understood. I know others feel angry, concerned and confused when I cut myself, but I hope there can be some kind of middle ground between “us” and “them.” We are not weird, mad or miserable. We have just found a different way of dealing with things.

Now, looking back on my childhood and adolescence, I am not surprised that I hurt myself. I came from a home filled with sadness and anger which was rarely, if ever, talked about honestly. Instead my father was verbally violent and even sexual with me. He also hit me once, and physically abused my mother several times. Self-injury has been described as the “silent scream” which rings very true for me. As a girl and a young woman I didn’t have the words, or the means, to communicate how unhappy I was (and sometimes still don’t). But the razor blades and the broken glass were instruments that I could use to express my sorrow. It’s a hard language to learn, but shutting your ears won’t make it go away. It is a part of the human condition.

Time Magazine
November 9, 1998

What the Cutters Feel; Long scorned and misunderstood, people who injure themselves are finally being taken seriously
By Tamala M. Edwards

Cathy Collins’s first memories are of knowing that she was adopted. The hardships of childhood—the difficulty of communicating with her parents, the cruelty of other children—all fed her belief that she was unwanted, her sense of being alien and unreal.

She began abusing drugs and alcohol as an adolescent, but by freshman year discovered a better release. Using a knife or a razor, she would methodically slice open her arms. “A main part of it was to know I was real,” she says. “With the blood flowing down my arms, I was real.”

For the past decade, Collins, 31, a Belvidere, Ill., health-care worker, has been hospitalized at least once a year for the self-injury that scars her arms, legs and stomach. Her boyfriend of eight years left her, saying her self-mutilation made him miserable; most of her friends have dropped her. A few months ago, she cut herself so badly that she was soaked in blood at the end of a five-minute ambulance ride. “But I didn’t want to die,” she explains. “What people didn’t understand was this was my way of staying alive.”

For many of these years, Collins continued to feel like a little girl alone, the only person with her problem in a Ken Kesey world of psych wards. Now the problem of “cutters” like Collins has come out into the open; some are calling it the “anorexia of the ’90s.” An estimated 2 million Americans purposely cut or burn themselves, break bones or otherwise mutilate themselves. That figure may even be low, say many experts, judging from the growing number of reports from hospitals, schools and therapists. Karen Conterio and Wendy Lader started S.A.F.E. (Self-Abuse Finally Ends) Alternatives, the nation’s only in-patient center for self-injurers, in Chicago in 1985. “We used to be able to check the calls on our hotline number once a week. Now a staff member has to do it every day,” says Lader. “We’re getting 700 calls a month.”

The disorder made its first major public appearance three years ago, when Princess Diana confessed that the strain of her marriage had caused her to throw herself down the staircase and cut herself with razors, pen knives and lemon slicers. “You have so much pain inside yourself,” she said in an interview with the BBC, “you try and hurt yourself on the outside because you need help.”

Says Steven Levenkron, a pioneer in the study of anorexia and author of two books on self-injury: “It feels like an epidemic, but it’s an epidemic of disclosure. And I credit Diana with that.”

One sign that the malady is fully emerging into the daylight: it has been the “disease of the week” topic on recent episodes of the teen-oriented TV series 7th Heaven and Beverly Hills 90210. And now come two major books: Bodily Harm (Hyperion) by Conterio and Lader, based on their successful treatment program, and A Bright Red Scream (Viking), in which journalist Marilee Strong provides a compelling tour of the trauma and science of self-injury.

Both books chronicle how disturbingly misunderstood the malady has been. Sufferers have traditionally been met with disgust by doctors, who find their self-injuring offensive. Therapists are often unwelcoming too, mistakenly labeling such people suicidal or dismissing them as “borderline,” a catchall category for manipulative, difficult patients with intractable disorders. In reality, the authors say, cutters are people frozen in trauma. More than half of self-injurers are victims of sexual abuse, and most report emotionally abusive or neglected childhoods, the strains of which send them into an emotional grave. “To me, it wasn’t the self-injury that was shocking but the things that brought them to this point in their lives,” says Strong. Typically, at some point in adolescence, they happen to injure themselves. Not only does it not hurt but the blood seems to voice their pain and also take it away—a “bright red scream,” as one self-injurer told Strong, of all they can’t communicate. “It’s like the old movies where someone was hysterical, someone slapped them and they sighed thank you,” explains Levenkron. “We all understand the physical can mediate the emotional.”

Contrary to the stereotype, self-injurers are not all middle-class, teenage-to-twentysomething white women, an image reinforced because the behavior is often linked to another affliction common to that group, eating disorders. Self-injury is prevalent in all races; minorities are simply less likely to get psychiatric treatment and thus be counted. More surprising, an estimated 40% of self-injurers are men. They are often overlooked because they tend to dismiss their injuries as the product of macho outbursts.

In their book, Conterio and Lader challenge the orthodoxies of conventional treatment. Typically, patients are placed in restraints, given high doses of sedatives and kept away from sharp objects. Instead, Conterio and Lader opt for tough love. They refuse to view or discuss scars with patients who enter their five-week program. They push injurers to take responsibility and control in counseling sessions, using an aggressive “Why would you do that?” approach worthy of Dr. Laura. It’s a method they say has decreased serious recidivism 75%. “We help them earn back their self-respect,” says Conterio. “There’s a difference between caring for someone and taking care of them.”

But Bodily Harm is not meant for the layman. Instead, it’s more a workbook for the initiated, complete with checklists and common Q&A advice for injurers, their family and therapists. Strong’s effort, by contrast, is a richly reported and achingly well-written account that benefits from a reporter’s storytelling skills. As she profiles a range of injurers—from Andrew, a star chemistry student at a British university, to Fran, a wealthy suburban New York matron—Strong deftly crafts not a freak parade but a sad march of the familiar.

She weaves her anecdotes together with science—for example, a Harvard study finding that severe trauma may alter both the chemistry and structure of the brain and other body systems meant to handle stress. And she chronicles the problems that researchers have, even today, in getting institutions to take the problem seriously. Two scientists at the National Institute of Mental Health, for example, were stymied when they attempted to undertake a groundbreaking study of the connection between childhood sexual abuse and adult disorders such as self-injury. “We don’t do that kind of research,” the researchers say they were told by NIMH officials, as funding for the project dried up. Strong doesn’t advocate a particular therapeutic approach—though, like Levenkron, she prefers coddling to the tougher tactics of Conterio and Lader.

For Collins, those tactics seem to have been successful. On her last day at S.A.F.E., her voice is strong and her dark eyes shimmer with hope. “I don’t believe I’m cured,” she says. “But I feel like I have a choice not to do this. And I have a choice now to let myself feel.”

Idaho Falls Post Register
January 24, 1999

Cutting through the pain—Guilt and rage lead some to injure themselves
By Warren Cornwall

Chris carries a razor blade in his wallet.

“Just in case of emergencies,” he says, fingering the thin slip of metal wrapped in white paper, little bigger than a postage stamp.

It is not to defend himself. It is to use against himself. The razor is a security blanket of sorts. It reminds Chris that if his rage grows too great, he can do what he did in years past and relieve it by turning the sharp edge on his own skin.

“It’s better than yelling at someone, or breaking something,” says the lanky, 6- foot-2-inch 19-year-old, as he sits in his parents’ living room on the southern outskirts of Idaho Falls. Chris’ family asked that his last name not be used.

Chris is a recovering self-injurer, one of a group of people—some estimate 2 million in the U.S.—who suffer from a compulsion to hurt their own bodies to relieve mental pain. Known as cutting, self-mutilating or self-injuring, the illness has gained national attention in recent years, prompted by a growing awareness of the disease and admissions from celebrities like Princess Diana and actor Johnny Depp that they had been self-injurers.

In eastern Idaho, far from the celebrity spotlight, some are experiencing the same thing.

Dr. Thana Singarajah, a counselor who works with teens in Idaho Falls, said he doesn’t see a lot of patients who self-injure. Perhaps one out of 40 will admit to hurting themselves—usually cutting themselves with knives, razors or pins, he said. But it does happen here, as he and several other counselors testified at a Saturday conference in Idaho Falls featuring Wendy Lader, a psychologist and co-founder of the country’s only treatment center dedicated to self-injurers.

“We have had some patients who are self-injurers,” said Lou Parri, a clinical social worker who works in Idaho Falls and the Teton Valley.

The injuries run the gamut: from tiny cuts by a knife to wrists broken by hammers or arms scalded by toxic chemicals like oven cleaner.

While it may seem gruesome, the damage serves as a form of medication to ease mental suffering, said Lader. Unlike suicide attempts, it’s about survival, not destruction.

“Self-injury is most often a coping mechanism,” Lader said.

There is no single description for people who turn on themselves like this, Lader said. But there are familiar traits.

Many are diagnosed with a mental illness, such as depression. As children, perhaps as many as 60 percent of self-injurers suffered abuse, said Lader. Others grew up in unstable families that moved frequently, had to take over adult roles as children or were forced to bottle up their thoughts.

Lader also attributed the condition partly to an increasingly fast-paced society in which family bonds are strained and dysfunction has become hip. It is also a society, she said, that puts enormous demands on women to control the appearance of their bodies. Most of the patients at Lader’s program are women, but the percentage of men has risen to as much as 40 percent in recent years, she said.

Chris traces much of his self-injuring to depression, and to childhood abuse by an adult outside his immediate family. He had been in therapy and was diagnosed as depressed before he began cutting himself.

Throughout grade school and junior high, he said, he was verbally aggressive. Sometimes he berated kids until they cried. Then, between his sophomore and junior years at Skyline High School, he began to feel he was hurtful to everyone.

Self-inflicted pain became the answer. It eased unbearable feelings of guilt that took hold when he thought he had hurt someone else. It was a punishment and a deterrent. Often, as he cut he warned himself that he would make it hurt more next time, he said.

The first time, he cut himself with a hunting knife. Over the next two years, he used razors, pocket knives and, when he couldn’t find anything else, a blunt knife at a restaurant. At school he would lean over in the back of a class and jab himself with a pen, or pinch his skin as hard as he could. Sometimes he would hurt himself every day, sometimes he went without it for a week. The thin, white scars on his arms and shoulders became a map of his guilt.

“It felt like the more blood that I shed made up for the bad stuff that I felt that I did,” he said.

Such feelings are common among self-injurers, said Lader. Some will hurt themselves to overcome a sense of emotional numbness. In other cases, the sight of blood can soothe overwhelming anxiety. The injury can serve as an expression of self-control in a world that feels out of control, said Lader.

“There isn’t a true appreciation of how much terror these people must face, to come up with a coping strategy like this,” she said.

The price, however, can be tremendous. People may severely injure, or even kill themselves. Some bear permanent, disfiguring scars, Lader said.

Friends or family may be repelled by such a graphic symbol of someone’s problems. “We were just kind of shocked. We just told him we’d help him any way we could,” said Chris’ father, who asked not to have his first name used. “I just never heard about it before, especially in Idaho. You think about tribes down in Africa, stuff like that, marking on themselves.”

Tribal markings, however, aren’t the same thing as self-injury, said Lader. Flamboyant tattoos, pierced noses, ears and eyebrows, and even decorative scars, have gained popularity in some parts of youth culture.

Lader distinguishes between those who do it as a form of artistry, and those who do it because they enjoy the pain.

“I got my ears pierced. But I didn’t really like having it done,” she said.

Singarajah said he sees some patients with piercings in places like their tongues who will play with them to cause pain.

But there are differences between self-injury and artistic markings. Tattoos can serve as an initiation into a group, piercing may be displayed with pride. Self-injurers usually feel shame about their injuries, and try to hide them behind long sleeves or pants, Lader said.

Chris has no tattoos, and no earrings. With cropped brown hair, baggy blue jeans and a flannel shirt, only his height and deep-set brown eyes would make him stand out in a crowd.

And now, he has no new scars. He last cut himself 10 months ago.

Some people simply grow out of it, said Lader. In other cases, therapists and medication can help, she said. It may also take intensive treatment at a place like S.A.F.E. Alternatives—the program Lader runs at a hospital in a Chicago suburb.

“Treatment can make a tremendous difference,” Lader said.

Chris said therapy, a two-week trip to a mental health facility in Utah and a growing sense of selfrespect have helped him overcome his urge. He has developed little tricks to beat down the urge to “reach for a knife,” as he puts it. He tries to distract himself, or even takes a nap and wakes up to find the feeling gone. But he still hasn’t left the razor out of his wallet.

“I’ve come a long way with my whole situation, but I still have a long way to go,” he said.

Wisconsin State Journal (Madison, WI)
February 9, 1999

TV Show Focuses on Wisconsin Teens’ Self-Mutilation
By Dee J. Hall

Sixteen-year-old Desiree is popular, athletic, outgoing, a straight-A student and a devout Christian.

And every so often, when she gets very upset, the Green Bay teenager pokes and scrapes her arms with safety pins until her skin is bloody and covered with welts. Other times, Desiree bites herself. And then, Desiree says, she feels much better.

Hurting herself, Desiree said, stops the ‘‘uncontrollable rages’’ that sometimes well up inside her.

“It (cutting) is a distraction from the things that are bothering me. The emotions—they’re overwhelming. They seem to take control,” said Desiree, who suffers from depression and attention-deficit disorder.

Desiree, who asked that her last name not be used, is among a largely hidden population of people known as self-mutilators, self-injurers, self-abusers, or, in slang terms “cutters.” Anecdotally, the prevalence of self-injury appears to be on the rise, with an estimated 2 million Americans suffering from it.

Contrary to popular opinion, people who hurt themselves are not trying to commit suicide. They are often the victims of physical, emotional or sexual abuse.

In addition, “Many of our patients express growing up in homes where the climate to express feelings wasn’t there,” said Karen Conterio, administrative director of the S.A.F.E (Self Abuse Finally Ends) Alternatives Program in Berwyn, Ill., the only inpatient program in the United States that deals exclusively with self-mutilators.

“These people simply don’t know how to cope with emotional pain,” said Tony Renier, a counselor in DePere who has worked with such sufferers. “What they do is transfer that emotional pain to physical pain.”

Today, Wisconsin Public Television will air a Teen Connection program on the topic of “Teens and Self-Mutilation.” The live program will include a taped segment featuring Desiree and her mother, a panel of teen-agers who injure themselves and experts. Counselors will be on hand to take calls from viewers.

Self-injury has been the subject of increased attention in recent years in a flurry of books and a handful of magazine articles. Princess Diana admitted harming herself; so have celebrities such as Roseanne and Johnny Depp.

The behavior can range from largely benign, such as using an eraser to rub one’s skin raw; to extremely harmful, such as gouging out an eye or slashing wrists. One nurse even infected herself with the AIDS virus.

“When your body is under attack, it goes into a mild state of shock,” Renier said. “You do get a release of adrenaline, which gives you both a sense of well-being and a sense of strength.”

Experts disagree about whether excessive body piercing or tattooing should be included as self-injury. Some say no, because those with pierces or tattoos aren’t seeking out pain. Others say that altering one’s body through excessive pierces or tattoos is similar to the self-injurer who makes scars on himself.

Self-injury is considered to be a symptom of mental illness, such as depression or borderline personality disorder. It’s a coping mechanism used by those who feel isolated and unable to express their negative emotions in a healthy way.

According to experts, self-injury often begins around puberty and can go on long into adulthood. Fortunately, however, there’s a good chance that many self-mutilators can stop, Renier said.

“Youngsters, if you catch them early enough, it’s quite workable,” he said. “Once they get into adulthood, it’s much more difficult.”

Meagan Loichinger, 17, of Green Bay, said she began hurting herself about two years ago. Meagan, who was raised by both parents, then her father, then her mother, has bounced in and out of treatment programs for mental illness.

Meagan, a student at a Green Bay alternative high school, suffers from depression. She said she began slicing her wrists “to sort of show I was alive.”

“I hate pain,” Meagan said. “I just cut until I could feel it. As long as I could see blood, it was a way to show my heart was still beating.”

Like many self-injurers, Meagan was ashamed of her cuts and scars. “I wore long-sleeved shirts in the dead of summer,” she said with a little laugh. “I didn’t want my mom to know. I didn’t want my friends to know.”

But Meagan said she stopped hurting herself after being confronted by a friend. For Brad Barden, 17, the behavior stopped when he confronted himself.

“I just kind of looked at myself and decided, I didn’t like it and stopped,” said Brad, a senior at Stevens Point Area High School.

Brad said he began slicing and burning himself during a long spiral into drug abuse that began in his sophomore year and spanned his junior year.

Brad said he would cut or “burn big patches” on his arms with cigarettes. “The only reason I have for it is I was mad at myself—I hated myself,” Brad says.

The teenager, who plays and sings in two rock bands, said he’s always had a hard time expressing his negative emotions. “I didn’t show any anger,” Brad said. “I would wait until I was alone and take it out on myself. Now, when I’m angry, I tell somebody I’m angry and why.”

Amber Wolf also stopped the abuse on her own.

Amber, a 17-year-old senior at Stevens Point, is an accomplished musician who plays the flute, piccolo, piano and sings. Nevertheless, Amber said, she’s often plagued by feelings that “I could never be good enough.”

“I have scars from my wrist to my elbow,” she said. “I cut myself with razors and sometimes cut glass—anything sharp,” she said.

Amber said she stopped when “I saw myself going down the drain.”

Mitch Fisher, a counselor at Stevens Point High School, said he urges self-injuring teens to redirect their behavior into harmless activities. If it’s blood they want, he advises them to draw on their arms with magic marker. If it’s pain, he tells them to hold an on ice cube on their skin.

Renier, the counselor from DePere, said he tries to get his patients to deal with their anger and frustration through positive activities, such as sports, writing journals, playing music and communicating with others.

Desiree’s mother, Margaret, said she hopes the Teen Connection show will help teenagers see they’re not alone.

“It doesn’t just happen to poor people. It doesn’t just happen to people who don’t pay attention to their children. It happens to people with everyday lives. This is a cry for help,” she said, “and it really does need to be taken seriously.

The Associated Press State & Local Wire
April 6, 1999

Blue Cross agrees to pickup $30,000 tab for self-abusive teen’s treatment

Blue Cross-Blue Shield of Illinois says it will pay the estimated $30,000 cost of a special treatment program for a 15-year-old girl who has been mutilating herself since she was 10.

The insurer notified the girl’s attorney it would pay for the girl’s 30-day treatment at the S.A.F.E Alternatives (Self Abuse Finally Ends) program at MacNeil Hospital in Berwyn, where she was admitted Monday.

Blue Cross initially refused to pay the bill, prompting the girl’s mother to file a lawsuit in Madison County on Thursday, asking the court to order the insurer to cover the treatment.

Bob Kieckhefer, a spokesman for Blue Cross in Chicago, said Monday the company only hesitated to pay for S.A.F.E because it had not yet determined whether it was the best program for the teenager.

“Our concern wasn’t to deny treatment for her, but to get appropriate treatment,” he said.

The girl’s attorney Jonathan Isbell, said the insurer’s decision apparently resolved the lawsuit.

“I’m waiting for the letter (ensuring coverage) from Blue Cross,” he said. “As soon as I get it, I’ll dismiss the lawsuit.”

The girl’s family learned in October she had been secretly cutting herself with razor blades and trying to strangle herself since she was 10, Isbell said. She has been hospitalized for treatment in Granite City five times since then.

S.A.F.E, is a residential program that deals exclusively with people who suffer from what experts call “self-injury” disorder. Officials with the program said they determined the girl required treatment and had enrolled her Monday morning before final word came from the insurance company.

Bismarck Tribune (North Dakota)
May 10, 1999, Monday

Self-Mutiliation Increasing; Uncommon Disorder Can be Hard to Treat
By Karen Herzog

It can be chronic, secretive and a challenge to treat. It’s not just a teen thing, but it often starts there. It’s not an epidemic, but it’s on the rise. Parents may never have heard of it.

Self-mutilation, self-injury, cutting or “carving,” often on the wrists, arms and legs, is hardly rampant in this community, but it does exist, said Dr. Matt Doppler, clinical psychologist at Medcenter One in Bismarck. Doppler has seen the phenomenon occasionally even in the smaller communities he visits.

Doppler’s Internet research suggests that between 1 and 2 million people may be carving in the U.S., a behavior which is related to conditions such as depression, post-traumatic stress disorder and to a condition called “borderline personality disorder.”

In simplified terms, those with borderline personality disorder feel chronic emotional chaos, Doppler said.

“These may be exquisitely emotional people who have a lot of difficulty coping,” Doppler said.

So for those people, hurting themselves becomes a coping strategy to deal with overwhelming feelings, a distraction to shift attention away from emotional pain.

Cutting isn’t seen much in younger children, Doppler said. Though many of those who self-injure have been victims of child abuse, younger children will act out in other ways, such as banging their heads into a wall or punching a wall, he said.

Since the roots of self-injury are so tangled, Doppler said, there is no “typical” self-mutilator, but more female cases have been reported.

One expert suggests, Doppler said, that self-injury seemed to be a way for women to express so-called “unwomanly” feelings, like anger, or is a rebellion against being the “good girl.”

“The theory is that women tend to more internalize emotions and tend to take it out on themselves,” Doppler said. “Whereas men or boys, because of socialization, are trained to externalize emotion. An adolescent male might pick a fight, where an adolescent girl doesn’t have that option as much.”

Experts are exploring a number of theories to explain self-injuring, including these, Doppler said:

Self-hatred is very common among self-injurers, Doppler said. A “shame cycle” builds—self-hatred leads to self-injury, to momentary relief, then to added self-hatred. So the solution becomes part of the problem, he said.

Because the causes of self-injury can be so complex and deep-seated, it’s the kind of behavior that doesn’t quickly go away, Doppler said.

Experts find talk therapy one of the best tools for treatment, Doppler said. Medications may include antidepressants, antianxiety drugs and tranquilizers.

Spotting A Self-Injurer

Parents should never dismiss self-injury, Doppler said. If they discover their teen is hurting herself, parents should at least get a consultation. Telling a kid to “just stop it” is futile, Doppler said.

Some adolescents may experiment with cutting and then drop it, while others may become chronic self-injurers into adulthood. So the earlier the intervention, the better.

“And with anything else, the crucial thing is that the person wants to quit,” Doppler said.

Warning signs of self-injury are similar to those of depression. They can include substance abuse, noticeably different behavior, volatile or explosive emotions.

The scars may be visible if parents pay attention. Though it’s common for self-injurers to cut themselves on the wrists or arms, once that’s discovered, they may switch to cutting the legs or other parts of the body.

Here are what Doppler says are myths about self-injury:

Bristol Evening Post
July 8, 1999

Helping Heal The Wounds; A&E Staff Get Advice on Dealing with Self-Harmers

Casualty staff in Bristol are being taught how to cope with people who have attempted suicide or deliberately harmed themselves.

Accident and emergency units are among the first to come into contact with people who have suffered serious self-inflicted injuries.

A conference being held today was teaching doctors and nurses how to deal with patients who may be deeply psychologically disturbed.

Specialist nurses from the Avon and Western Wiltshire Mental Health Care NHS Trust were speaking at the conference, called Self Harm—The Accident and Emergency Perspective.

It was being held following criticism that staff in casualty units are ill-trained to deal with self-harm victims.

Organiser Anthony Harrison said: “Supporting the nursing and medical staff who are trying to help people who have hurt themselves, perhaps even attempted to kill themselves, is extremely important.

“The trust is recognising this in holding this conference. Our aim is to equip the conference attenders to give clients in these circumstances the very best understanding and care.”

Speakers at today’s conference in Bath were including trust staff, a clinical psychologist, psychotherapist and consultant psychiatrist.

Consultant senior lecturer from the University of Bristol, Dr Jonathan Evans, was also speaking about trends and treatment for those who attempt suicide or self-harm.

It is hoped this will be the first of many conferences on this subject and that it will lead to patients who suffer psychiatric problems getting the right treatment.

Charge nurse Ian Milsom, from the privately-run Heath House Priory Hospital in Stapleton, says self-harm is a big problem in the city.

He told the Evening Post in January that patients offer receive little sympathy from hospital staff, pushing the problem underground.

Mr Milsom said: “Most of the time self-injurers come into contact with people in casualty departments who are simply not au fait with the condition. As a result they are treated quite badly.

“They are often stitched up and treated without anaesthetic because doctors are under the misconception that these people like pain.”

He said the most common form of self-harm was cutting with a razor blade or burning with cigarettes.

Personalities such as Princess Diana have brought the problem out into the open.

Jane has a secret she hides under her sleeves—dozens of ugly purple scars on her forearms. It is the work of 20 years’ worth of self-harm.

The 34-year-old from Southville slashes herself with razors—not because she wants to kill herself, but as a cry for help. She is an example of the complicated conflict that can arise between treating physical and emotional scars.

Staff in casualty units can stitch her up and ensure the bleeding stops.

But she is no normal patient—she also needs help to understand why she harms herself. Her self-harming started not long after she was first abused as a child.

But Jane (not her real name) says that when she asks for help staff don’t know whether to treat the cuts or the depression or put her in a mental hospital.

She said: “The abuse left me feeling dirty and odd as it was, without feeling a freak for doing these things to myself.”

Jane and her friend have now set up their own support group and want other women to come forward. If you would like to be involved, call Bristol Crisis Service for Women on 925 119 and they will pass your number on.

Calgary Herald (Alberta, Canada)
July 14, 1999

Self-injury: The rising tide of intentional bodily harm knows no cultural or class boundaries
By Hildegarde Chambers

Does your adolescent or teenager seem withdrawn and spend a lot of time alone in her bedroom? Have you started noticing cuts, burns, or an unusual amount of bandages on your child’s arms or legs? Are you beginning to suspect your child is deliberately harming himself?

For most parents, it’s almost unthinkable that their child would do such a thing, but in some cases, that’s exactly what’s happening.

According to the most recent U.S. estimates (no Canadian statistics currently exist on the problem), approximately 1,400 out of every 100,000 people—or 1.4 per cent of the general population—have engaged in some form of self-injury.

In their book, Bodily Harm, Karen Conterio (the founder of the first self-injury treatment program called S.A.F.E.—Self-Abuse Finally Ends) and Wendy Lader argue that the problem may be even bigger, pointing to such evidence as a recent survey of 245 college students, in which 12 per cent admitted to self- injury at one time or another.

In certain segments of society, the problem is widespread: Among adolescent psychiatric inpatients, the prevalence of self-cutting is a disturbing 61 per cent; among adolescents with a history of sexual abuse, 83 per cent, according to a group of American researchers who reported their findings in the Journal of the American Academy of Child and Adolescent Psychiatry.

But such statistics, say those who work in the mental health field, are deceptive. Because of the complex nature of self- mutilation and the attendant secrecy and shame surrounding the act, many suspect that the numbers of people engaging in such behaviour are much higher.

According to Conterio and Lader, all signs indicate that self-injury is a growing mental health issue.

Although self-injury is not a new phenomenon and knows no geographic, cultural or class boundaries, it has taken the 1990s by storm, tightening its grip on schools, college campuses, jails and other sectors of society, write Conterio and Lader.

From American public schools to elite private schools, teachers and counselors report an alarming rise in the number of students who come to class with scars.

“College mental health services are flooded with patients who show these symptoms,” say Conterio and Lader.

“Medical reports of self-injury are rising. Across the country, psychiatrists and other doctors have been blindsided by the number of patients—many of them high-functioning adults, who confess to this type of behaviour...A particularly alarming aspect of the rising tide of self-injury is that the behaviour is making its appearance earlier and earlier in the childhood and adolescent years.”

Harold Lipton is program manager for the Alberta Mental Health Board’s Family Adolescent and Child Services in Calgary. Lipton, who has been a psychologist for 21 years, says they are seeing more cases of self-injuring cross their doorstep than in previous years. “It’s turning out to be more common than we might have thought.”

The apparent rise could be due to more kids self-injuring today, he says, as well as more kids coming forward for help.

S.A.F.E. in Canada, formed in 1990 in London, Ont., fields calls from around the world from counselors and parent groups seeking training and information.

Though it’s not certain how prevalent self-injury is, there are some things that are known about the disorder.

Self-injuring usually starts during the early teenage years, and the majority of self-injurers are female, but increasingly more males are coming forward and seeking help, says S.A.F.E. in Canada’s executive director, B.J. Thom.

Other types of abuses, such as eating disorders and substance abuse, often accompany self-injuring. “It all has to do with how they feel about themselves and trying to mask the pain,” says Thom.

People who are prone to self-injuring often don’t have a strong support system around them that they can turn to when things trouble them, says Lipton. They are emotionally isolated, lacking in self-confidence, and haven’t learned good problem-solving skills. For some, self-injuring is a coping response to growing up in abusive or emotionally invalidating, hypercritical environments.

Other self-injurers are hypersensitive individuals from relatively normal home environments who internalize, catastrophize, and harmfully act upon negative emotions.

That’s important information for loving parents who are bewildered by the behaviour and agonizing over how they “failed” their child, particularly when siblings appear to have healthy coping behaviours.

“Some kids can grow up in very dysfunctional homes and grow up very rock solid, while other kids seem to grow up in very good homes and are very troubled,” says Lipton.

Loving parents who have done the best they know how in raising their child shouldn’t heap blame on themselves for their troubled son or daughter, but should take responsibility to try and help where they can, says Lipton.

This means being available and responsive, alert to signs of problems and taking time to build a relationship with their child.

If their child won’t respond to overtures of communication, they need to connect them to resources that can help, advises Lipton, remembering that the most important step is the first step.

Self-injurers share common traits such as perfectionism, dislike of their body and an inability to cope with and express strong emotions.

Such people tend to have black and white thinking, says Thom, and engage in negative self-talk, such as, “I’m a failure. I’ll never amount to anything so I might as well hurt myself.”

People self-injure when feelings such as rejection, anger, failure, isolation, guilt, worthlessness, disempowerment and hopelessness become so intense they think they’ll explode if they don’t find some form of release.

Self-injuring is a means to try to escape from or cope with these feelings. It is a means of self-punishment, of feeling in control of one’s own body and of substituting unbearable emotional pain with manageable physical pain.

“It’s like this monster inside of you,” explains Thom. “There is so much pain inside and it’s so bottled up, it feels like you’re going to explode. Then everything shuts down...You look at yourself and you go, I need to do need to get that poison out of your body, and the only way to do that is to self-injure.”

When self-injurers cut themselves, they feel an initial sense of release, like a hundred pounds have fallen off their shoulders, says Thom.

Afterward, though, they may look at the cuts and think they must be stupid and crazy, which in turn continues the cycle of negative self-thoughts.

Experts say the willingness and ability to delay self-injury is the first step to recovery. Treatment includes teaching self-injurers alternative, more appropriate coping strategies such as getting out for a change of scenery, having a trusted support person to talk to, or getting involved in a physical activity that helps release tension and provide a grounding.

One of the first things family members can do to help is to educate themselves about self-injuring. There are a number of books available at the local library and S.A.F.E. is happy to provide information to both parents and counselors.

Family and friends can also help by providing a safe, non-judgmental, accepting atmosphere that encourages a self-injurer to express rather than suppress emotions.

“You just have to listen,” says Thom, “to say we need to sit down and talk about this because this is not a healthy way to cope.”

Although cutting is a copycat behaviour for some teenagers, parents shouldn’t downplay it, says Thom, because it can become repetitive if preventative steps aren’t taken.

Self-injuring should be treated as a serious mental health issue and is often a symptom of other problems, such as depression.

Taking anti-depressant medication in conjunction with therapy and a support system can help lift a self-injurer out of their cycle of negative self-thoughts.

Some people struggle for years with self-injuring behaviour, while others are able to resolve core issues or learn how to cope more effectively with stress as they age and mature.

Thom advises parents not to overreact when they find out their child is cutting, but also not to ignore the behaviour. “It may be a way of saying, ‘There’s something wrong and I don’t know how to help myself. I don’t know how to ask for help.’”

Los Angeles Times
July 18, 1999

For Some Troubled Youths, Pain Offers Escape
By Anna Gorman

In the battle against their own bodies, everything is a weapon. Razor blades, pushpins, lighters, staples, paper clips.

With each cut, burn or scrape, a flood of relief washes over them. Relief from agonizing memories. Relief from years of sexual and physical abuse. Relief from inexpressible emotions.

But for teenagers who injure themselves, the relief doesn’t last. The depression always returns. And when it overwhelms them, they cut themselves again.

Until the wounds go so deep that the child inside gets scared. Or until somebody sees the maze of scars. If they are lucky, that is when the teens begin to learn how to live without cutting themselves.

Because the youths often hide their wounds, local experts aren’t sure how widespread the problem is.

But Ventura County doctors and therapists have treated dozens of self-injuring youths in the last year at local hospitals and residential treatment centers. And they say the number is increasing all the time.

The typical “cutter,” they say, is a young woman who begins at age 14 and continues until she is in her 20s. She is likely a victim of physical, emotional or sexual abuse, often by an alcoholic or drug-addicted parent. She may struggle with an eating disorder or a drug addiction. And she probably suffers from depression or obsessive behavior.

She cuts herself because she feels worthless. She thinks she deserves to be punished. She wants to show the world how much pain she feels. And she doesn’t know how to communicate her emotions otherwise.

Toni, an articulate 16-year-old, was one of four teenagers from the Casa Pacifica treatment center who described their horrifying journeys through abusive childhoods and tortured adolescence.

She started injuring herself four years ago because “so many things were going wrong” and she wanted “to let people know how much they hurt me.”

She said that as a toddler, her parents sexually and physically abused her. She had so much rage and pain and suffering inside, she said, that she cut herself. And it was a relief—temporarily.

“It’s kind of a high—like a drug,” she said. “And when you start doing it, it becomes a habit.”

At first, she scratched herself with her teeth and fingernails. Then she turned to sharp objects, and “the next thing you know, I was really digging in.”

That is when she started to keep her cutting a secret.

There is no chemical cure for self-injury, doctors say, but with the right combination of therapy and medication, teens can heal and can stop the cutting.

With help, they can learn to write down or talk out their feelings and turn to friends and family for support. And in time, their self-esteem can improve.

“The hope is to let people know they can get better,” said Dr. M. David Lewis, medical director of Anacapa Hospital’s family and adolescent program. “ With therapy, the behavior does go away. If they continue in the therapy and the medications, the behavior does not recur.”

Emerging From the Shadows of Taboo

Self-mutilation isn’t new. People have been scarring themselves in rage and humiliation for decades, experts say. One Chicago program has specialized in such treatment since 1985.

But only in recent years has it attracted the attention of medical professionals who want to know why an estimated 2 million Americans are now burning or cutting themselves on purpose. And doctors are treating the self-destructive behavior, which for so long was misunderstood and misidentified.

If self-mutilation was once shocking and unspeakable, it is becoming less taboo. A few celebrities, including Roseanne and Johnny Depp, have admitted that they wrestled with the problem. Music groups, television shows and movies have touched on self-mutilation. And half a dozen books, including three published last year, have been written on the subject.

In one, Bodily Harm, self-injury is defined as the “deliberate mutilation of the body or a body part, not with the intent to commit suicide but as a way of managing emotions that seem too painful for words to express.”

“Kids who cut on themselves experience an intense and severe inner rage,” Lewis said. “There is a rage inside that is going on, and they cut on themselves because they get relief from it.”

Their behavior ranges from superficial fingernail scrapes to gashes with knives. “Cutters” usually target their arms, thighs and wrists, because those areas can be easily hidden. They burn themselves with cigarettes or lighters. They use their skin like a canvas, cutting words and images onto their bodies.

Some doctors fear that self-injury may spread among friends.

“It’s kind of like a behavioral epidemic,” said Dr. Richard Deamer, a Ventura-based psychiatrist. “Kids will share this sort of thing. You have one kid in school doing it, and soon you have three or four more doing it.”

Andre, 16, another Casa Pacific resident who asked that his real name not be used, carved “kill me” on his arms.

The wide-eyed, outgoing Toni scraped “slut” on her stomach. Another time, she cut a drawing of a boy on her forearm, then stabbed the picture repeatedly with a piece of glass as if it were a voodoo doll.

Mary, 17, still so withdrawn she stares at the floor and seems to hide in her own skin, started cutting herself at age 13, after being physically, emotionally and sexually abused for most of her life.

Several times a day, she hid to slash or scrape herself. With time, she had to cut deeper and harder, because her skin was layered with old scars and had lost most of its feeling. Every time she carved into herself, she said, she felt “less stressed.”

Now, after years of intensive therapy, she remains fragile. Fragments of metal are still buried in her arms, hidden by an intricate pattern of old gouges and scars. And sometimes she can’t fight off the urge to hurt herself again. Just two weeks ago, she scraped her chest with a razor blade.

“I think somebody else is going to hurt me,” she said, “so I hurt myself first.”

But she cuts herself less often now. And when she does, it’s less severe.

Common stresses, such as a new school, a boyfriend’s rejection or parents divorcing, may provoke teens to cut themselves. But the behavior is rooted in childhood trauma or abuse, experts say.

An Expression of Anger, Depression

“They have a rage and anger and nowhere to put it,” said Pat Pope, a clinician at Casa Pacifica, “so they turn it in on themselves.”

They cut themselves to cope with emotional pain, much in the same way people turn to drugs or alcohol, she said. Their physical pain deadens their emotional pain. But doctors say that self-injurers don’t feel pain like others do. They disengage from the act of cutting, almost like they are watching it from afar.

Abused adolescents also cut and burn themselves out of self-hatred. They see themselves as “bad” and “worthless,” and cut themselves as a form of punishment.

When Mary had a good time, laughed, smiled or simply enjoyed being a teenager, her urge to cut herself intensified. “I didn’t deserve to do fun stuff,” she said. “I had to punish myself.”

For many, self-mutilation is a cry for help. And sometimes it is a way to punish their parents.

Andre, who is muscular and nervous, said he cuts himself “so people can see how bad I’m suffering.”

For almost six years, he said, he was sexually abused by his babysitter, who lived with him and his mom. When he turned 13, he started cutting himself. “My family didn’t love me,” he said. “I wanted them to see how depressed I was.”

After his mother found out, she locked up sharp objects. And she stayed up all night. “My whole family was afraid of me and afraid I was going to do it again,” he said. “My mother always slept with one eye open.”

The adoptive mother of one of the Casa Pacifica teenagers said that sometimes trauma runs both ways. “It was very frightening at first,” the mother said. “I didn’t understand it. I mean, how many of us can?”

While some teenagers do try to kill themselves, doctors say self-mutilation differs from attempting suicide.

“It provides temporary relief from anxiety and depression,” psychiatrist Deamer said. “They don’t want to die. They just don’t want the emotional pain.”

Teens say that before cutting themselves they feel sorrow, guilt and frustration. While doing it, they feel happy, peaceful and satisfied. And afterward, they are depressed and feel like they have to do it all over again.

Doctors say the behavior may be addictive because endorphins are released in the brain when people cut themselves. Those chemicals dull pain and produce a “high,” which often lasts a few hours.

Doctors worry not only about the emotional impact of self-injury, but also about the physical effects. Fresh surface cuts on open wounds and burns can cause infection and scarring, and deeper incisions can lead to nerve damage.

Learning Other Ways to Handle Stress

At Vista Del Mar Hospital in Ventura, therapists help the adolescents develop healthy ways to deal with daily stress and take responsibility for their actions. They encourage the youths to keep a journal of how they feel. They also teach them how to turn to friends and counselors for support.

“We want them to learn coping skills so they can deal with difficult problems,” said Dr. Blake Darrington, a program director in Vista Del Mar’s adolescent unit.

At Casa Pacifica, therapists occasionally place severe self-injurers on safety watch, where somebody stays with them around the clock until the threat abates. In some cases, nurses will examine the youths several times a week, checking for abrasions and scrapes.

Casa Pacifica’s Pope encourages self-injuring teens to take it one day at a time. “Success isn’t about stopping immediately ,” she said. “It’s about decreasing the severity and increasing the time between episodes.”

Youths who want to cut themselves will, she said. While one teen was in a mental hospital, he sliced his face with a plastic fork.

Andre said he used to hide razor blades, pencil sharpeners and pushpins in his mouth so he could cut himself whenever he wanted.

For some teens, stopping the behavior cold is too difficult to imagine.

“I want to do my cutting, but then I don’t,” Mary said. “I saw how bad it affected people around me. But I can barely go a week without doing something. If I don’t, it builds up too much.”

Coventry Evening Telegraph
August 19, 1999

Self-Harm Mum Starts Aid Group; Sharing Experiences May Help Others Cope with Depression
By Josie Steedman

A Coventry mum who physically injures herself to cope with depression has launched a support group for other “self-harmers” in the city.

Tracey Franklin, aged 25, of Wood End, began harming herself as a teenager, using the tops of food tins and glass to cut herself.

She said: “It wasn’t until I was 19 I realised I wasn’t the only one in the world and I wasn’t mad. I call it my coping mechanism. It’s my way of switching off the emotional rubbish. Without self-harming I probably would have committed suicide.”

The group has been set up with the support of Chrysalis—a mental health service user empowerment group—and meets at the Central Methodist Hall in Coventry City Centre. Miss Franklin said she hoped to break the taboo surrounding self-harming.

The mother of three added: “Every self-harmer has different reasons for doing it but negative feelings and thoughts start in my head and the only way I can get rid of them is to harm myself. I used to be ashamed. I’ve come to deal with it now, it is part of me and it’s part of my identity.”

People are known to cut themselves, pull their hair out, as well as burn themselves. Miss Franklin said it was a “taboo” condition that people tended to keep to themselves.

She said: “I’m probably on the lower end of the scale. Some people are admitted to hospital with injuries. I have never been.

“Hopefully, by being around other self-harmers and being able to talk we will be able to work through it and find other ways of coping.”

The support group meets fortnightly on Tuesday evenings from 7pm to 9pm.

Good Housekeeping
September 1, 1999

“I Couldn’t Stop Hurting Myself”
By Christine Roberts

From the outside, I seemed like a normal girl—happy and well-adjusted, outgoing and pretty. But on the inside, I was angry, guilty, and sad.

In junior high, in the Chicago suburb where I grew up, I seemed to fit in as well as anyone. I was in the gifted and talented program, had a couple of good friends, and was actively involved in choir, cheerleading, student council, and the school newspaper.

But no matter how hard I tried to pretend that everything was okay, it definitely wasn’t. I had been sexually abused by a family member from the ages of 7 through 12. When my mom and stepdad found out, they sent me to a therapist. No one else knew what had happened, and I didn’t feel safe talking about it. I was afraid that other kids would laugh at me if they knew.

At school I put my energy into my studies and all my extracurricular activities—and into keeping this awful secret. But no matter how many things I did or awards I won, I still felt terrible about myself. In seventh grade, I developed an eating disorder and became very depressed, so my parents sent me to a hospital for treatment.

The hospital was its own protected little world. But when I was discharged after six weeks, I still wasn’t doing very well. One night, I was at home in my bedroom and feeling anxious about going back to school. I grabbed a pair of scissors, sat down on my bed, and scratched my wrists with them. I was 13.

I didn’t tell anyone about it, and I didn’t hurt myself again until the next year, when I was a freshman. I was having a rough time that fall because my family was taking my abuser to court. And I wasn’t getting along well with my two younger sisters or my mom, who was busy starting her own business.

One day, I noticed that a friend of mine from typing class had all these scratches on her hand. I asked her what had happened, and she said something like, “I did it to myself because it makes me feel better.” At first, I was surprised and felt bad for her. But then I thought about it some more and decided to try it again myself.

A couple of nights later, I shut myself in my bedroom. I was afraid to use anything sharp, so I scratched one of my arms really hard with my fingernails and it started to bleed a little bit. I watched the blood run, then grabbed some tissue and cleaned up my arm. It hurt, but emotionally it was like a runner’s high. For some reason, I felt calmer afterward.

I was scared by what I’d done and didn’t think I wanted to try it again. But a few days later, I did. This time, I used a razor blade on the lower part of my left arm. During the next year, I started regularly injuring myself in secret.

After awhile, I couldn’t stop hurting myself no matter how hard I tried. My emotions were all jumbled: I was angry and guilty and sad all at once. And the cutting seemed to feed off itself. I would feel bad about injuring myself, then have to do it more to feel better. In a way, it made me feel tougher. Nobody can really hurt me, I thought, because what I’m doing to myself is even worse, and I can take it.

I told a counselor at school about what I was doing, and she told my parents. They got worried and sent me back to the hospital. But the staff there didn’t know what to do with me. I guess they’d never seen this problem before. They would ask, “Why do you do this?” I would say, “I don’t know.” They had me write with crayons because they thought I might hurt myself with pens or pencils. But that didn’t stop me: I used my fingernails when I was alone in my room.

When I got out, my mom found a therapist who had experience treating self-injurers, and I started seeing her twice a week. I learned to really trust her—to feel comfortable enough to tell her almost anything. She made me sign a contract promising that I wouldn’t harm myself, and I seemed to get better.

Then came junior year. In the winter, I missed a few weeks of school because I was sick. By the time I went back, there were only two weeks left in the quarter and then finals. I had a lot of hard classes, and I was faced with having all this stuff to make up. I felt like there was no end to it. It’s hopeless, I thought I’m going to fail all my classes and never go to college!

Right before exams, I ended up injuring myself badly. I cut myself with a razor blade on both arms—probably ten times total. The cuts were deep, and they bled more than usual, but it felt like a tremendous release. I knew I probably needed stitches, but I was fed up with the doctors and nurses. (“What are you doing? What are you thinking?” they kept saying.) So I put butterfly bandages on the cuts and tried to hide what I’d done.

Of course, my parents found out They were upset, but still supportive. My mom said, “You don’t have to go back to the public high school. You can take classes at the community college, you can learn at home, or we’ll find a private school.” I chose a private Christian school and started the second semester of my junior year.

My new school was small and welcoming. I made many good friends, and I liked my teachers. I started to feel a lot better, and I stopped cutting myself. I also stopped going to therapy, because I felt like I didn’t really have anything to work on anymore. Life went smoothly until after graduation.

I wasn’t ready for a huge change like moving out of state, so I decided to go to the local community college. But when classes began, it was a shock—the school had 36,000 students. I missed my close-knit relationships with my high school friends and teachers. The first day, not only did I get lost looking for my classes, I couldn’t find my car in the parking lot.

Trying to manage school and my job at a local video store started to wear me down. Five days a week, I would work really late, until midnight or 1:00 A.M. Then I would go home and do homework for class the next morning. I was getting just six hours of sleep a night

My eating habits started to slip, and all these emotions—loneliness, sadness, fear—were running through me. I kept thinking about how self-injury had helped me feel better in the past. That October, I cut myself on several different occasions. The injuries weren’t serious, but by November, I was still cutting myself about once a week and hiding the results by wearing long sleeves. It was something I really struggled with: I wanted to do it all the time.

Then I heard about a special treatment program for self-injurers that was near my home. In February, I enrolled in the S.A.F.E. (Self-Abuse Finally Ends) Alternatives Program. I stayed for 37 days.

At S.A.F.E., I discovered that a lot of other people have this problem. Nearly all of the other patients were women, most in their 20s or 30s. I met people who hurt themselves with knives and with scissors, and some who also burned themselves. To the outside world, most of the patients were smart, highly functioning women. But many had eating disorders, and almost all had been sexually abused. The staff was used to dealing with all of it Nobody thought it was strange, and I started to feel less embarrassed.

We learned to record our feelings in books called impulse logs. We would write down an impulse (like wanting to injure yourself), the feelings behind it (sadness or anger), and what would happen if we followed the impulse (like feeling worse or wanting to injure yourself more). Before, I had trouble identifying my feelings. But the writing exercises really helped.

We also had group and individual therapy. It took some time for me to feel comfortable enough to open up to everyone and talk. I’d always felt I had to keep my secret so people wouldn’t be disgusted and turn away from me.

The big breakthrough came when I was able to talk about being abused. When I got to S.A.F.E., I could barely admit that it happened. I had always tried to avoid discussing it with my therapist, focusing more on day-to-day things. I’d tell people, “Well, I don’t remember very much,” which was a total lie, because I remembered a lot more than I admitted. When I told my S.A.F.E. therapist what had happened to me, I was so scared that I couldn’t look her in the eye. But she was perfectly calm about it. She gave me a hug, and didn’t treat me any differently afterward.

After I learned to talk about the abuse, I started to feel less guilty. I also felt a lot more anger toward my abuser, who never went to jail for what he did. But I realized that being molested was a horrible thing that happened to me and that I couldn’t just pretend it didn’t. That used to be my strategy: If I didn’t think about it, it would go away.

Since leaving S.A.F.E. last April, I’ve put what I learned into practice. The program changed the way I react to situations and taught me not to be so hard on myself. I go to school only part-time now and limit my job to 30 or 35 hours a week. I try not to take things so personally. If I get a bad grade on a test, I’ll think, Okay, I need to study mom, instead of automatically thinking, Oh, I’m so stupid. If my boss criticizes me at work, his comments don’t throw me as much as they used to.

I go to a relapse-prevention group each week, and when I feel really bad, I write in my impulse log or talk to my college roommates or my friends. Since leaving the program, I did slip and try to injure myself once. I was feeling down and grabbed a tack off my wall and scratched myself. But it wasn’t the same: It didn’t bring the same release or make me feel better like I wanted it to. I realized there were other things I could have done instead.

At the moment, I’m very focused on the future. I’m 20 and will be starting my junior year at the local community college in the fall. I’m taking premed classes and want to go on to graduate school and maybe become a doctor. I’d like to get married and have a couple of kids—to lead a normal life.

I don’t think I’ll ever injure myself again, but I have scars that remind me of it every day: They are pink, and a few are raised on my skin. You can’t see the ones on my upper arms very well, but there are six on my lower left arm that are quite visible.

I’m embarrassed about them. When strangers notice, I usually say, “I got scratched by a cat” or “I was in a car accident.” I put lotion on them and hope they will fade. But other times I look at them and realize they were part of a really rough period in my life, a time when I didn’t have all the tools I needed to deal with my feelings. Now I do, and I don’t have to hurt myself anymore.

Nevada Employment Law Letter
October 1999

Self-inflicted injuries not covered by workers’ compensation
By Hicks & Walt

The Nevada Supreme Court blocked an avenue for employees to receive workers’ compensation benefits. Believe it or not, an employee who injures his hand by punching a wall will not be able to receive workers’ compensation benefits for the injured hand.


While working on a roof, an employee banged his head on the corner of an air conditioning unit. Several minutes later, after banging his head again on the same unit, the employee lost his temper and slugged the unit, breaking his hand. Is that an on-the-job “accident” compensable under the employer’s workers’ compensation insurance? The Nevada Supreme Court says “no.”

Court’s decision

In this well-reasoned and sensible ruling, the supreme court recognized that compensating individuals who engage in self-injurious conduct would be both “unwise” and “contrary to the spirit of workers’ compensation laws.” Noting that the Nevada Industrial Insurance Act (NIIA) defines “accident” as “an unexpected or unforeseen event,” it found that an intentional violent act by an employee that produces a foreseeable and reasonably expected self-injury is not an “accident,” and therefore, the resulting injury is not covered under Nevada’s workers’ compensation law.

The court reasoned that the key issue was not whether the employee intended to injure himself, but that it was foreseeable and reasonably expected that the injury would occur as a result his conduct. In other words, although the employee might not have intended to break his hand when he hit the air conditioning unit, because he did intend to hit the unit and because it was likely that an injury would result from doing so, the employer should not be held responsible for the risk of that type of injury occurring in the workplace.

Practical application

Since this case creates a rule that self-inflicted injuries of such a nature are not compensable, you need to be conscious of this fact when investigating on-the-job injuries. The most likely situations when this case will be important will involve hand injuries and foot injuries from employees hitting or kicking things out of anger or frustration while on the job. So, when faced with injuries of that nature, determining the factual circumstances behind the injury and speaking with witnesses will be important to determine if the injury is compensable.

Capital Times (Madison, WI)
November 11, 1999

Cutting The Pain; Some Resort to Self-Injury as a Coping Mechanism
By Kathy Foster

While most people bend over backward to avoid harming themselves, a few—particularly women who have been sexually abused—actually do it on purpose.

Erica Serlin, a psychologist at the Family Therapy Center in Madison, says for most people who practice self-injury, it’s a coping mechanism. “For them, it’s the best way they currently know how to deal with intense emotional pain, regulating feelings, and releasing tension and pain,” she explains.

It actually works, Serlin says. And it’s addictive. She says it releases endorphins. It becomes a behavior that is not only habit-forming but also has its own reinforcement built in. It’s their own Prozac.

They cut various parts of their bodies. The most common areas are arms, wrists, sometimes inner thighs, occasionally genitals. And it’s done secretly. The damage is not seen.

She says it can also come in the form of scratching, picking at scabs, banging the head, kicking until the person hurts herself or burning.

Admitting that you self-injure is akin to admitting you are an alcoholic or gay, says Serlin.

“I work with the cutters, the slashers, the burners,” she says of her clients. “They are usually females who start hurting themselves when they are young, as young as preteens,” she says. “And it continues into adulthood.”

Serlin says she works with adult survivors of trauma, some of whom continue to self-injure well into their 50s. “Most, but not all, have been subjected to severe, severe sexual abuse, including ritual abuse.”

Serlin says she sees it associated with the severe abuse—doing the same thing to yourself others have done to you. She says the behavior is sometimes the result of self-hatred in the sense that it’s a way of punishing yourself for the guilt of having been damaged—and feeling that you caused it.

Many women, Serlin says, feel responsible for their abuse because sometimes their bodies responded in positive ways. Those are the people who have the hardest time moving away from self-injury.

She says it calls into question what it is in our culture that is contributing to this behavior.

“Mary Pipher (feminist author of Reviving Ophelia, a study of adolescent girls) writes about our society as somehow destructive to girls, particularly young girls,” Serlin says. “She says that some of the self-injury may be a reflection of the pressure on adolescents in our society—particularly on girls—and the devaluing of girls and women.”

Serlin says although statistics indicate it is mostly females who self-injure, when men do it they get more attention because it’s more unusual, and they do it more seriously. “It’s the same with suicide attempts, which are more lethal in men.”

Shari Cohn, a clinical social worker at Midwest Center for Human Services, also works with self-injury.

“I’ve had clients who punched themselves in the face, slapped and pinched their breasts,” she says. “Part of it can be anger at their breasts for having responded with arousal during the assaults. It can also be women blaming their breasts and bodies for having developed and for bringing this attention to them.”

Cohn says she also sees self-injury in the form of compulsive behaviors like having unsafe sex. “They don’t feel they deserve respect or to be treated well because of the assault,” she says. “And they sense they should have been able to stop it. And,” she adds, “sometimes they never learned that it’s OK to say no. When they tried to say no and take care of themselves, they were further abused.”

Serlin says she sees people who also swallow toxic substances, including poisons in small amounts.

One of her clients has a very bad esophageal reflex problem and burns from doing this. Self-injury can also put the person in control. “If the abuse was done to them, now they are doing it to themselves,” Serlin says. “At least they can start it and stop it. It’s very sad.”

Cohn agrees. “It repeats what was done in the abuse so the survivor can be in control of it. But they can also be feeling shame and believe they deserve the punishment.”

Cohn says self-injury is hard to treat because she assumes the survivors are doing the best they can to cope with their intrusive, negative feelings.

“I can’t just say stop it because they need something else to take its place,” she says. “It’s a long process of building trust, and getting them to know I won’t abuse them. They have to learn different ways to take care of themselves when these troubling thoughts of hurting themselves come up—like anxiety, flashbacks, feelings of powerlessness, guilt that they couldn’t stop the abuse.”

The survivor needs to decrease his or her isolation by telling the secret—the secret that they hurt themselves.

“During therapy, it often isn’t until I specifically ask the sexual assault survivors if they are cutting or burning themselves that they finally can tell me,” Cohn says. “It’s a secret of a secret.”

She says it is very difficult for the clients to get through this. “Like quitting smoking,” Cohn says. “You feel this lack of something major missing. What do you do when you’re stressed? Eat. Drink. So you can’t say stop until you help them find other strategies to use to help them.”

She says supporters of survivors should ask how they can be helpful. “They sometimes need help dealing with their sense of frustration or powerlessness about stopping the survivor,” she says. “They can talk to friends or professionals to get support for them.”

It’s not just the survivors who are affected by the abuse, it’s a ripple effect, Cohn says.

“The people who love and care for the survivors also have to deal with their reactions to the abuse and its effects on the survivor,” she says. “It’s not an easy thing for anyone.”

The Tampa Tribune
November 30, 1999

Mutilation Serves as Way to Cope
By Deborah Kurelik

In the world of self-mutilation, there are big-time injurers and small-time injurers.

“I’ve seen a lot of wrist-cutting and cutting on the insides of thighs, arms and across the neck,” says Denis Donovan of St. Petersburg, a psychiatrist who has treated dozens of patients who harm themselves physically.

“I’ve seen breast cutting and breast hitting. I’ve also seen people deliberately burn themselves with matches and brand their skin.”

Experts estimate that some 2 million people in the United States injure themselves, often young females forging their way through a turbulent adolescence.

“Simply in terms of numbers, the vast majority of those who cut themselves do so once or only occasionally and do not do so with the intention of seriously hurting themselves or leaving obvious scars,” Donovan says.

Among those who injure themselves more often was one patient who “poured scalding oil on herself,” he says.

People cut themselves for different reasons, Donovan says, but the behavior serves as a coping mechanism. Self-inflicted violence helps express feelings not easily articulated and releases tension.

Liz Pomeroy, a mental health counselor at the Brookwood residence for women in St. Petersburg, worked with one girl who inserted lancets beneath the skin in her arm.

“She literally just pushed on her arm as a way of dealing with frustration and anger.”

Some self-injurers, says Pomeroy, are so emotionally numb that they hurt themselves in order to feel something.

“They develop a serious relationship with self-injury. It makes them feel more alive,” Pomeroy says. She points out that self-injurers typically have trauma in their pasts, usually neglect or sexual abuse.

“Self-injury is an attempt to either calm themselves when they’re feeling out of control or stimulate themselves if they’re feeling numb,” says M.J. Sutcliffe, manager of the Sexual Assault and Family Emergency Center in Clearwater. “Victims of sexual abuse have difficulty regulating their feelings. (Cutting) can establish a balance again, psychologically.”

In his experience, Donovan says, perhaps 60 percent come from abused backgrounds, while a “fair number of people who do it feel hurt by life.”

The emotions self-injurers feel are intense.

“A kid who is cutting or burning isn’t just angry but severely angry,” Pomeroy says, “not just depressed but severely depressed. In most cases, while they are cutting or injuring, their bodies are flooded with messages—like ‘stop, this hurts.’ That a girl continues to injure despite the messages means she has such intense emotions that they overcome the pain.”

In treatment, counselors usually start with the behavior and then dig deeper to get to the root of the problem, Pomeroy says. The challenge is getting the patient to understand that self-injury meets a need.

“We acknowledge the behavior and honor it because it helped them get through a rough time and it helps them let go of it,” she says. In time, the old behavior is replaced with better coping skills.

Directors of SAFE (Self-Abuse Finally Ends) Alternatives, a treatment program outside Chicago, report a high recovery rate even in severe cases.

Self-injury is a choice, Donovan says. “You can choose not to beat the crap out of yourself—which is an absolutely necessary first step to solving all those problems that lead to self-injury in the first place.”

The Tampa Tribune
November 30, 1999

A Cutter’s Story: Life of Self-injury
By Bill Lohmann

Caroline Kettlewell seemed a well-adjusted adolescent. She was a good student, popular, well-behaved and attractive. She didn’t smoke, drink or use drugs. Her father was a minister; her mother would become one.

Who knew the churning emotions inside her, the inability to cope with the slightest curve thrown by life?

Who knew that her method of dealing with her overwhelming anxiety and despair was to go off alone, take out a razor blade and carefully slice her skin and draw her blood?

“It was very soothing,” says Kettlewell, who began cutting when she was 12 and continued for much of the next two decades. “It made me feel better.”

It remained her dark secret until she decided to tell the world with a new book, Skin Game: A Cutter’s Memoir, published by St. Martin’s Press.

Kettlewell, who works for an advertising agency, is married with a 2-year-old son named Sam. Her husband, Joe, an archaeologist, declared his wife brave for writing the book. She wonders.

“What will my neighbors think?” she says. “Will they let their children play with my son?”

But Kettlewell wanted to put a human face on a behavior that is, at minimum, baffling to others. “It could be your daughter or your mother or even your son or father. I think it’s a great deal more common than people realize.”

Cutting seems to be the most prevalent method of self-injury. It often begins in adolescence. Girls and women seem to be most affected, and self-injury and eating disorders frequently go hand in hand.

The first time Caroline Kettlewell tried to cut herself, she used a Swiss army knife. She was in a bathroom at school. She was in the seventh grade.

She found the notion of liberating the blood from her veins fascinating. The knife was too dull but her curiosity remained sharp. She moved on to razor blades. Her fascination turned into addiction. It was how she lived. It was how she survived.

“It is oddly, perversely an act of hope,” says Kettlewell, sitting in the living room of her handsome home in South Richmond. “It allows us to go on for another day. It will vent for you what you feel will tear you apart otherwise.”

And no one has to know.

Kettlewell discreetly carved the skin on her shoulders and hips, and then covered up with clothing. “It’s very easy to hide cuts and scratches,” she says. “Most people don’t cut themselves ... seriously enough that it’s obvious. It was very, very important to me that nobody knew about it.”

She is quick to say that her problems are not an indictment of her parents or her upbringing. “You don’t have to come from a terrible situation to wind up in this place,” she says.

She did well academically, graduating from prestigious Williams College. All the while, she suffered “a creeping uneasiness,” an anxiety that never ventured far away. She developed an eating disorder. She drifted in and out of ill-advised relationships. She kept cutting.

She survived a failed marriage. She threw herself into obsessive exercise; bicycling becoming her prime passion. She entered therapy. She took medication. She began to get better.

Why did she start cutting? Kettlewell can’t clearly say. Neither can she say exactly how she was able to stop. Medical intervention helped and so did the fact that good things began happening in her life. She has found the control she never knew she had. She learned how to cope.

Kettlewell says the key is this: No one can make someone stop cutting. The strength has to come from within.

“I was tired of living that way,” she says. “I just said to myself, “There’s got to be a better way.’ I was living my life from panic to panic. I couldn’t keep doing that.”

She is 37 now. The scars from her earlier life are not plainly visible to a stranger’s eyes. She hasn’t cut in years, she says, although the urge still arrives from time to time. She has a loving husband, a good job and a son who needs her. They kept her firmly planted in the present as she journeyed deep into her past—digging into diaries, sifting through letters from old boyfriends—to write her book, which began as an essay in graduate school.

Kettlewell has a well-developed sense of humor and irony. A gifted writer, she is thrilled to be a published author. At the same time, she is “fairly squeamish” talking about the book.

“It’s a terrible quandary,” she says.

Yet, she is certain she is doing the right thing. Her aim is to be a voice for those who self-injure and do not believe they can escape the miserable life that has trapped them. She wants to be an example that things can get better.

She might change a few choices in her life, she says, but “I still wouldn’t change my overall history—even the struggle and the cutting—because it is the sum total of one’s experiences, good and bad, that shapes who one becomes. And the place I have ended up seems worth the trouble it took to get there.”

Sunday Mercury
December 12, 1999

Actress Admits Painful Secret

Young movie actress Christina Ricci, star of the new horror film Sleepy Hollow, has a dark and painful secret—she likes to hurt herself with burning cigarettes and sharp metal bottle tops.

Millions of people, including 19-year-old Christina’s co-star Johnny Depp, have an uncontrollable desire to mutilate themselves. The late Princess Diana once claimed she slashed her wrists with a lemon peeler in a desperate cry for help.

Christina, who hates the very sight of herself in a mirror, says she hurts herself to calm down. Now doctors have put her on the antidepressant Wellbutrin. And Christina says she has been in therapy since she was six.

The actress’s arms and the back of one hand are covered with ugly scars. She tries to explain: “I’d be upset so I’d do it and it would calm me down. It’s a horrible way to feel better. You can actually faint from the pain but, sometimes, the idea of self -destruction is very romantic. I can understand how people might be shocked by the injuries I’ve inflicted on myself—but I can’t stop.”

An expert on the condition, Karen Conterio, says: “Self-injury is a symptom of other underlying emotional or mental disorders—like depression.”

In an interview with the magazine Rolling Stone, Christina goes on: “For years, I hated myself. I covered the mirrors in my house. I literally couldn’t have a mirror in my room. I still can’t sit in a restaurant or some place where I can catch my reflection. I get so paranoid.”

The actress, whose parents divorced when she was 13, goes on: “Obviously, it has to do with stuff that went on in my family. This was the usual dysfunctional, crazy family. For a long time, I felt as though I were dying. You can feel this part of you withering and dying, and I always felt like that. I’d manipulate all the bigger kids at school into picking fights with me. Once, just because I loved confrontation and causing trouble, I got this big kid to throw me into a bookshelf. It was so worth the attention.”

During her troubled early years, 5ft. 3ins. Christina suffered from anorexia. Then, when she turned 16, she ballooned from 110lb. to 135lb. She says today: “I began having panic attacks. I was really depressed. I was sleeping all the time and wouldn’t go to school. I would attend, maybe, on Monday. Then I’d have an anxiety attack and stay in bed for the rest of the week.”

Now Christina’s weight is steady and her career is flourishing she feels she is at last on the right track.