Scottish Daily Record
March 1, 2004

Vital: Every Wound You See on Angela’s Body She Inflicted Upon Herself; This Is Her Story
By Lindsay Clydesdale

WHILE other little girls were playing with dolls and listening to pop music, Angela Young was dragging a razor across her skin.

A quiet, unhappy 12-year-old, she worked out her aggression and anger by punching walls and furniture. By the time she was a teenager, she had progressed to cutting her arms and legs and enjoying the feeling of control it gave her.

Today, on Self-Injury Awareness Day, she has been abusing her body for 15 years without ever managing to stop. Despite graduating from teacher training college and being happily married for five years, Angela, 27, still harms herself at times of stress.

Her brutal and bloody way of coping has become as natural to her as a smoker having a cigarette, or a drinker relaxing with a gin and tonic. Research by the Samaritans shows that more than one in 10 teenagers in Britain have deliberately harmed themselves. More than 24,000 teens in the UK are admitted to hospital every year as a result.

Sufferers tend to be adolescent girls, like Angela was when she started. But in reality they can be any age, male or female, and from any background.

Angelina Jolie, Johnny Depp, Shirley Manson, Christina Ricci and the late Princess Diana all admitted to harming themselves.

‘It’s hard to say how it started,’ said Angela. ‘Things at home were difficult and I wasn’t having a good time. I know it sounds bizarre, but cutting myself made me feel better, it was something I could control. I don’t feel pain when I’m doing it or for quite a while afterwards.’

For many years she managed to hide what she was doing behind long sleeves and trousers.

But in the last couple of years, her condition deteriorated so badly that she was being admitted to her local accident and emergency department five times a week, needing 40 or 50 stitches every time.

She’s also had to have several blood transfusions and required surgery to repair a badly-damaged artery. Her limbs are now such a mess of scars that she has taken to cutting her shoulders. What most people will be wondering is: why?

‘There’s all these myths,’ said Angela. ‘People think self-harming is a failed suicide bid or attention seeking, but most people use it as a coping mechanism, the same way a smoker will have a cigarette when emotion or tension is really strong.’ Angela no longer works when her health, both mental and physical, deteriorated, her employers understandably decided to end her contract as a primary teacher.

Due to the stigma attached to self-harmers, Angela doesn’t want to be identified and her name has been changed for this article.

‘Sufferers don’t talk about it because it’s not socially accepted, so it’s hard to get other people to open their minds to the problem,’ said Angela. LifeSIGNS, a voluntary support group for self-harmers in the UK, says the shame attached to self-harming means it is usually kept private, and becomes a very lonely experience.

‘Self injury is a coping mechanism,’ said a spokesman. ‘An individual harms their physical self to deal with emotional pain, or to break feelings of numbness by arousing sensation.

‘Self injurious behaviour may calm or awaken a person but it only provides temporary relief, it doesn’t deal with the underlying issues.’ Angela fell into this pattern very quickly.

Fortunately, she’s been able to count on the support of her family, in particular her husband. He bandages her wounds and decides whether they are serious enough to need hospital treatment.

She told him about her condition before they married but it has got considerably worse since then. Her horrified parents only discovered her terrible secret two years ago. Although she’s not managed to stop hurting herself completely, Angela, with the support of her family, friends and counsellors, has greatly reduced the frequency and severity of her attacks. ‘It’s not an everyday experience anymore, but it is quite frequent,’ she said.

More information and support is available on the LifeSIGNS website: www.lifesigns.ukf.net


The Brown University Child and Adolescent Behavior Letter
March 1, 2004

Self-injury: is this troubling behavior a growing problem in adolescents? Wounds, scars and the visibility of self-injury

Self-injury (also known as self-mutilation and self-harm) has become a more visible mental health issue for adolescents in the past decade. Many Internet chat boards and web-based forums contain wrenching examples of reasons given by teens who self-injure (see bullets, right).

* “I cut myself as a way to deal with the pain and frustration in my life.” (Female, age 19)

* “(Self-injury) makes me feel relaxed and in charge of myself.” (Female, age 14)

* “I get so angry and hateful sometimes that I don’t know how to let out my deep frustration and then after it is just such a relief to me. It calms me down.” (Female, age 14)

* “Because I hate my ‘external’ self.” (Female, age 17)

“Anecdotally, there is no question that there is an increase in self-injury among adolescents, and this is not just due to an increase in reporting,” states Wendy Lader, Ph.D., Clinical Director and co-founder of SAFE alternatives, a treatment approach and professional network located at Linden Oaks Hospital in Naperville, IL, that is focused on self-injurious behavior.

The teens quoted on this specific website claim to have started this behavior around age 12 or 13, although some have been self-injuring since as early as age 6. Other websites (usually developed and maintained by a recovering self-injurer) contain similar quotes in addition to artwork, poems and stories describing these teens’ struggles with self-injury.

The visibility of self-injurers extends beyond the Internet into popular media. The 2003 movies “Secretary” and “Thirteen” each feature lead characters that engage in self-injurious behavior. Hollywood’s impact also includes the real-life experiences of high-profile actors, including Angelina Jolie and Johnny Depp. The burgeoning prominence of self-injurious behavior in popular culture brings needed attention to this misunderstood and complex issue; however there is also concern that these Internet sites and media portrayals may themselves lead to more teens using self-injury as a way to deal with their problems (the “contagion” factor).

Lader told The Brown University Child and Adolescent Behavior Letter that she is not comfortable with the preponderance of Internet sites constructed by people who continue to injure themselves and thinks that, similar to what is seen with some anorexia websites, many of these pages purposely glorify and support this behavior. “Our philosophy is that these web sites provide a venue for the dissemination of inappropriate coping strategies and that they often encourage ‘catharsis for the sake of catharsis,’ which can be dangerous for self-injurers who already have difficulties with self-soothing,” says Lader.

Defining and classifying self-injury

Self-injury is defined as the deliberate, direct destruction or alteration of body tissue without conscious suicide intent. In the past, self-injury has been mis-identified as a failed suicide attempt and considered solely as a symptom of other mental illnesses (e.g. bordeline personality disorder). Armando Favazza, professor in the Department of Psychiatry and Neurology, University of Missouri-Columbia, is an expert in this field and author of several books and journal articles. Favazza divides self-injury (he uses the term “self-mutilation” or SM) into three types: major SM, sterotypic SM, and superficial/moderate SM.

Major SM is the most extreme and uncommon form and is often associated with psychotic or intoxicated states. This behavior consists of infrequent acts that involve the destruction of large amounts of tissue (i.e. amputation, castration and eye enucleation). Stereotypic SM is common among institutionalized mentally retarded persons and is sometimes associated with autism spectrum disorders, schizophrenia and Tourette’s syndrome. Stereotypic SM consists of repetitive and sometimes rhythmic acts including head banging, eyeball pressing and self-biting.

Superficial/Moderate SM is the type of self-injury most commonly seen in adolescents. Superficial SM consists of impulsive types (cutting, burning, carving, interference with wound healing) and compulsive types (trichotillomania, nail biting and skin picking). In a 1998 study, Favazza approximated the prevalence of superficial SM to be at least 1,000 per 100,000 population per year.

According to Favazza, compulsive SM is different in nature and origin from impulsive self-harm and is more closely associated with obsessive-compulsive disorder (OCD). The most studied type of these behaviors is trichotillomania (hair-pulling), a syndrome classified as an axis I disorder of impulse control that involves self-harm occurring in response to an irresistible urge, resulting in relief or gratification.

The most common form of impulsive, superficial SM is skin cutting and burning. Favazza subclassifies these behaviors as either episodic (occurring every so often as a symptom or associated feature in a number of disorders) or repetitive (a stage beyond episodic, when the self-harm behavior becomes an overwhelming preoccupation). Disorders associated with episodic SM include:

* Borderline personality disorder
* Antisocial personality disorder
* Posttraumatic stress disorder
* Dissociative disorders
* Eating disorders (bulimia, anorexia)
* Substance abuse
* Depression

The transition from episodic to repetitive SM varies depending on the person, occurring after as few as five episodes in some and after as many as 15-20 in others. Unlike episodic SM, which is associated with the disorders listed above, Favazza considers repetitive self-harm to be “best regarded as a separate axis I disorder of impulse control known as the deliberate self-harm or repetitive SM (DSH/ RSM) syndrome.” This syndrome is not recognized by the DSM-IV, but Favazza states that it may be coded as an impulse-control disorder not otherwise specified (312.30).

Why and who?

It is thought that these behaviors represent a coping mechanism used by young adults to deal with the stress and emotional turmoil associated with adolescence. Favazza regards it as a “morbid form of self-help” that provides temporary relief from emotional distress. As indicated by the quotes from self-injurers, these acts lead to immediate relief from tension, depression, loneliness and alienation, satisfaction from self-punishment and a sense of regained control.

Superficial SM behavior is commonly initiated during adolescence and sometimes continues into adulthood. Although both boys and girls self-injure, girls are almost four times more likely to engage in self-injurious behavior than boys, according to a 2002 study of students in England (Hawton, et al.).

Several risk factors for SM behavior have been described, including childhood abuse (sexual, physical or emotional), exposure to an abusive relationship in the childhood home, parental divorce, incarceration, and family history of alcoholism or mental illness. According to Favazza, most repetitive self-mutilators have problems with other forms of impulsivity such as eating disorders, alcoholism, substance abuse and kleptomania.

What to look for?

Most acts of superficial SM involve repeated cutting with a sharp object (razor blade, needle, glass shard), although skin carving, burning, punching and scratching are additional methods of SM. Commonly, the arms, wrists, ankles, and lower legs are targeted—although some self-injurers use “hidden” sites such as the underarms, abdomen, inner thighs, feet and under the breasts. Scars may be evident upon physical examination, appearing as faint markings that may be in a pattern or as a single line.

There are several signs to look for that may indicate someone is self-injuring or is at risk for this behavior (see box, left). Parents, school counselors and teachers should be aware of these warning signs and should be prepared to handle the situation appropriately. If someone displays the signs and symptoms of self-injury, a mental health professional with expertise in self-injury should be consulted to assess and begin a treatment program. Peers are in a unique position to recognize that a friend is involved in self-injurious behavior and can be powerful forces in encouraging a self-injurer to seek professional help. Therefore, it is important to educate adolescents on the seriousness of this type of behavior and provide them with a safe environment to discuss their concerns.

Experts suggest that a critical component in assessing and treating self-injurers is the establishment of a trusting relationship. Anne Dourin and Terrill Bravender of Duke University, recommend that clear assurances of confidentiality and a nonjudgmental communication style are crucial to initiating and maintaining a therapeutic relationship between a health provider and a self-injuring teen (Dourin and Bravender, 2004). For parents concerned that their child is self-injuring, Lader suggests that they be direct and matter of fact, express concern, and refrain from reacting with anger and fury. She also suggests that parents not threaten punishment or minimize their child’s behavior as being “just a phase.”

Treatment

Lader states that “self-injury is the injurer’s attempt at a solution to a problem, but is not the problem itself. Therefore, to stop the injury, you need to address the underlying problems—the ‘why.’ At SAFE, we use self-injury as a ‘clue’ for identifying the causative problem(s). We ask, ‘Why at that moment did you SI? What was going on?’“

Treatment for self-injury involves multiple levels:

* Counseling. Experts suggest that in addition to individual counseling, family counseling as well as group sessions can be helpful in treating a self-injurer. Lader suggests that parents of a self-injurer may also need individual counseling to provide them with support.

* Therapy strategies. Focusing on communication skills and alternative coping strategies can help the individual express herself without self-injuring. To develop these skills and help keep the adolescent engaged, therapists often use multiple techniques including music therapy, journal writing and role-playing.

* Medication. Although not all self-injurers require medications, antidepressants (selective serotonin reuptake inhibitors (SSRIs)) or mood stabilizers (e.g. valproate (Depakon) and carbamazepine (Tegretol, Epitol)) can be used in combination with cognitive and behavioral therapy if needed.

There is no question that self-injurious behavior has a greater visible presence in the mainstream media than it did 10 years ago. The true impact that this increased visibility has on self-injury incidence rates is unknown, but experts do acknowledge concern for a “contagion factor” influencing adolescent behavior. For parents, health care professionals and educators, it is important to be aware not only of this self-injury behavior, but also the influences (both good and bad) of the Internet and mass media.

Identifying potential self-injurers:

* Mood swings
* Low self-esteem
* Poor impulse control
* Sadness/tearfulness
* Anger
* Anxiety
* Disappointment in themselves
* Inability to identify positive aspects of their lives
* Propensity to dress in long sleeves and long pants, even during hot weather
* Resistance to being unclothed
* Tendency to invent excuses to avoid participation in activities that require undressing or exposing their skin (physical education classes, sporting events, outdoor summertime activities)

References

Conterio K, Lader W, Bloom J: Bodily Harm: The Breakthrough Healing Program for Self-Injurers. New York: Hyperion, 1998.

Derouin A, Bravender T: Living on the edge: the current phenomenon of self-mutilation in adolescents. MCN Am J Matern Child Nurs 2004; 29(1):12-18.

Favazza AR: The coming of age of self-mutilation. J Nerv Ment Dis 1998; 186(5):259-268.

Favazza AR: Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry, 2nd ed. Baltimore: The Johns Hopkins University Press, 1996.

Hawton K, Rodham K, Evans E, et al.: Deliberate self harm in adolescents: self report survey in schools in England. BMJ 2002; 325(7374):1207-1211.

Resources on self-injury

* For the past several years, March 1st has been designated as Self-Injury Awareness Day. This was initiated by American Self-Harm Information Clearinghouse “to educate and inform medical and mental health professionals, the media, and the general public, sorting myth from fact and explaining what is known about self-harm.” (www.selfinjury.org/)

* S.A.F.E. (Self Abuse Finally Ends): A nationally recognized treatment approach, professional network and educational resource base. www.selfinjury.com; phone: (800) DON’T CUT (366-8288).

* Secret shame: A self-injury information and support website. www.palace.net/ llama/psych/injury.html

* Self Injury: A Struggle: a website by self-injurer; serves as a forum for others to share stories, art, experiences; contains graphic images and other potentially “triggering” material. www.self-injury.net

* Conterio K, Lader W, Bloom J: Bodily Harm: The Breakthrough Healing Program for Self-Injurers. New York: Hyperion, 1998.

* Favazza, A. R. (1996). Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry, 2nd ed. Baltimore: The Johns Hopkins University Press, 1996.


Community Care
March 4, 2004

Death was not a worry; After intensive care in the community, Alex Williams has managed to break a cycle of self-harming

Last October I relapsed into serious self-harming. I don’t know what triggered it except perhaps my continued fears around recovery. There was also a family crisis and the lead up to Christmas was stressful and lonely. Once I started harming myself I couldn’t stop. I’d need to justify to myself that I’d gone “far enough” after each episode. This usually meant needing wounds stitched or having repeated blood transfusions, each after just a few days of cutting. Having a parvolex infusion after taking paracetamol also made the overdose “complete”. I also felt the only time this would happen was if I almost killed myself through self-injury.

My actions caused professionals to think I was suicidal. This wasn’t the case although I wouldn’t have cared if I’d died as a result of self-harming. I just wanted to push my body to its limits, like when I walked for 35 minutes to accident and emergency after losing a lot of blood.

Respite came in the form of involuntary admissions to the local psychiatric ward (under sections 2 and 3 of the Mental Health Act 1983). The first time I was in hospital I resented being there. As I didn’t have the means to harm myself I’d bang my head on the rim of the toilet out of frustration. I’d fantasise about escaping and throwing myself under a car on the nearby motorway. My second admission coincided with Christmas and I decided to use the time to think through why I was hurting myself in such extreme ways.

Other than containment, hospital didn’t offer any solutions. I willingly took both olanzapine and then risperidone (atypical antipsychotics) but hated the side-effects that occurred even on low doses. These included a vastly increased appetite and slurred speech. The only interaction with qualified nurses was when they dressed my arms. There was no one to talk to about how I felt except for when my community psychiatric nurse (CPN) and support worker visited. Although I had a named nurse, she worked nights and never offered to give me any time. A charge nurse admitted to me that they didn’t know what to do with patients who self-harmed.

What did break the cycle of self-injury was being discharged and having an intensive care package in the community. This involved thorough care co-ordination by my CPN and extra hours with my support worker. I also had the opportunity to see the CPN from the deliberate self-harm team at A&E. This was up to three times a week and we’d discuss harm minimisation. We also covered gender issues, distraction and cognitive techniques. He encouraged me to rearrange the priorities in my life so that self-harm was further down the list. I also appreciated the involvement of my consultant psychiatrist who didn’t force any medication on me or see it as the answer. I’m now confident that I’ve stopped harming and think I can live self-harm free for longer than the 18 months between the previous and most recent cycles.


Chicago Daily Herald
March 8, 2004

Cutting through pain Suburban hospitals aim to help those who deliberately hurt themselves
By Lorilyn Rackl

Casey locked her bedroom door and slipped the Korn CD into her stereo.

Hunched beside the bed in her McHenry County home, the 13-year- old looked over her supplies. Paper towels. Bath towel. Razor blade.

A few days earlier, Casey had been raped. (“Casey” asked that her name be changed to protect her identity.)

She couldn’t stop thinking about the assault. And she couldn’t stop crying.

Casey didn’t want to kill herself. But she did want to stop the onslaught of aching feelings that had plagued her since the rape. So the junior high school student picked up the razor and poised it over her stomach.

“It took me a while to work up the courage,” she said. “Finally I closed my eyes, counted to three and just did it.”

When she opened her eyes and looked down, she saw an inch-long cut across her abdomen.

A rivulet of blood trickled out of her body. So did her depression, anxiety, anger and numbness.

“I know it sounds crazy, but I started to laugh,” said Casey, who’s now an 18-year-old student at a junior college. “I felt happy and relaxed and so much better.”

The euphoria was short-lived. Less than two weeks later, Casey cut herself again.

Pretty soon, she was doing it every day. Like an alcoholic craving a drink, she needed her fix.

“In the end, I was doing it 10 or 15 times a day,” she said. “I couldn’t sleep unless I was injured.”

Starting younger

No one has solid numbers on how many people self-injure. Experts estimate that nearly 15 out of 1,000 people deliberately hurt themselves in a year, typically by cutting or burning their skin.

It’s thought that cutting—a term often used interchangeably with self-injury—is more common among females than males; females certainly are more likely to seek treatment.

Roughly half of those who self-injure say they’ve been physically or sexually abused as children. Many have an eating disorder, too.

Self-injurers often say they feel empty inside, lonely, misunderstood. Some say they cut so they can feel—feel something, anything. Others cut to stop feeling. The cuts generally aren’t a desperate attempt to get attention. In fact, self-injurers often go to great lengths to hide their scars.

People who treat self-injurers are convinced of two things: It’s a growing problem, and it’s a problem that’s starting earlier than ever.

“We’re seeing it happen younger and younger,” said Denise Styer, clinical coordinator of SIRS, or Self-Injury Recovery Services, based at Alexian Brothers Behavioral Health Hospital in Hoffman Estates.

“Research indicates that the average age to start injuring is 14,” Styer said. “Based on those who’ve come through our doors the past two years, the average age to start is 8.”

Styer has seen children who’ve started hurting themselves as young as 2 years old, usually by repeated head-banging.

The problem has spurred some suburban hospitals to set up treatment programs aimed specifically at cutting and other forms of self-injury.

Alexian Brothers launched SIRS in 2002. Within a few months, additional staff had to be hired to keep up with demand.

An inpatient treatment program called SAFE Alternatives started in Chicago nearly two decades ago. SAFE—Self-Abuse Finally Ends—relocated to Naperville’s Linden Oaks at Edward Hospital in 2001.

Late last year, SAFE’s co-founders added a day program for local adolescents that doesn’t require overnight hospital stays.

“There was so much need in the community,” said Wendy Lader, SAFE’s clinical director. “We get so many requests for help from schools. But not everyone can come to our inpatient program. They can’t afford it or maybe they’re not bad enough where they need to be out of school for that long a time.”

Without treatment, self-injurers might go on hurting themselves—often secretly—for more than a decade, said Dr. Armando Favazza, a psychiatry professor at University of Missouri-Columbia School of Medicine. Favazza’s book “Bodies Under Siege,” originally published in 1987, is widely hailed as the first comprehensive look at the disturbing phenomenon of self-mutilation.

While some self-injurers eventually stop on their own, others can become so demoralized over their inability to quit cutting that they resort to suicide. In a study of 290 females who were habitual self-injurers, 59 percent had overdosed on drugs, Favazza said. A third of the total group said they expected to be dead within five years.

“You have to jump on it right away before it becomes ingrained as a habit,” Favazza said. “At the first sign of scars, parents really have to get them to see a mental health professional and not accept their excuses and rationalizations.”

‘I just felt relief’

Stacy had a whole list of excuses for the slender scars running down her arms. Like many people who cut themselves, she relied on the old standby: “My cat scratched me.”

(Stacy, who lives in the Northwest suburbs, also asked that her real name not be used to protect her privacy.)

As a 12-year-old, Stacy started dragging paperclips along her forearm, creating superficial wounds. She knew it was “weird,” but cutting her body seemed to lessen the pain she carried inside.

Like Casey, she’d been sexually assaulted. She had low self- esteem and battled depression.

Treating herself as her own live voodoo doll, as she put it, had a soothing effect on the agonizing emotions she didn’t know how to deal with.

“After I cut, I just felt relief,” said Stacy, now 21. “If I didn’t do it, I felt like I was going to lose it.”

It’s a refrain Favazza has heard many times while treating self-injurers.

“They say that when they cut, it’s like popping a balloon,” he said. “All the anxiety goes out of them. Trouble is, it only lasts a few days or a few hours, and then they have to cut again.”

And that’s exactly what Stacy did. She soon abandoned the paperclips for razor blades, which she hid from her mother by stashing them away in her closet.

She didn’t always cut. Sometimes she’d use cigarettes or lighters to burn her flesh. She’d bang her head against the wall. She once smashed a glass candle holder on her head and used the shards to carve her skin.

Most of us can’t fathom why people willingly would inflict that kind of pain on themselves. But experts point out that for the vast majority of people who injure themselves, the physical pain doesn’t register.

“There’s an analgesic effect,” said Lader of SAFE. “I had one patient who poured oven cleaner on her arm, got on the phone with a girlfriend and totally forgot about it until she smelled her flesh burning.”

To keep her scars out of sight, Stacy began targeting her stomach and thighs. The cuts were getting deeper, sometimes landing her in the emergency room for stitches.

“I kept wanting to do it worse, go deeper,” she said. “It’s like an addiction.”

And like other addictions, self-injury often serves as a coping strategy, a misguided attempt to feel better.

“When most people see that someone is self-injuring, they assume it’s a suicidal gesture. It’s not,” said Kammie Juzwin, clinical director of Alexian Brothers’ SIRS program. “Most of our patients will tell you it’s their mechanism to help them cope and stay alive, not die.”

Adds Lader: “Self-injury is a form of self-medication. It’s like using drugs or alcohol to get away from the intensity of uncomfortable feelings. It’s an avoidance technique. But it doesn’t solve the problem.”

Kicking the habit

Both Casey and Stacy credit SIRS with helping them break their self-destructive cycle and give up cutting.

At SIRS, they spent five or six hours a day with therapists and other people like themselves, talking about feelings, learning healthy coping skills, and using art, music and other creative outlets to express their emotions. People stay in the program an average of three weeks.

SAFE Expressions in Naperville also is a day hospital program, but SAFE’s more intensive 30-day treatment regimen typically includes two weeks as an inpatient.

SAFE’s Lader said that treating self-injury often calls for a combination of talk therapy and medication—mood stabilizers, antidepressants or atypical antipsychotics, for example.

Follow ups with former SAFE patients found that 75 percent were injury-free after two years, Lader said.

Before going through treatment at Alexian’s SIRS, Stacy couldn’t imagine living without cutting.

Sometimes she still gets the urge to put a blade to her skin. But she hasn’t succumbed since June. And the urges aren’t nearly as frequent as they used to be.

“I have a lot more confidence I can overcome it now,” she said. “(Cutting) just doesn’t have the same effect on me that it used to. I think that’s a good sign.”

Another good sign: The scars on her arms and abdomen finally are fading.

“They don’t bother me as much,” Stacy said. “I’ve grown more comfortable with them.”

And the internal scars?

“I’m getting more comfortable with those, too.”


South China Morning Post
March 10, 2004

Self-injury fad brings school alert
By Benjamin Wong

Sha Tin College has written to parents about students engaging in “self-harm behaviour”.

In an e-mail sent to parents on March 3, the college’s assistant principal Christine Rowlands said “a handful of students” have engaged in self-mutilation such as cutting themselves with box cutters.

“Unquestionably, this is gravely worrying for us,” said Ms Rowlands in the e -mail. “As with many other aspects of adolescent behaviour, there is a danger that such risk-taking practices become contagious, faddish or fashionable,” she said. The e-mail said the college had only limited resources to tackle the problem and advised parents to seek counselling for their children if they found signs of self mutilation. The school has given advice on organisations that parents can seek help from.


Deseret Morning News (Salt Lake City)
March 14, 2004

Conflicting emotions of self-inflicted injury

In an Internet chat room, cutter answered the questions posted by the Deseret Morning News:

— “I started because I was very much into the idea that I scar my skin. I could hurt myself, and cause a scar, and it was very much something I could control. I didn’t learn it from someone else or another source really, though I’d heard of it once before.”

— “I’d say for me it’s more about control. You can’t control the pain others give you but you can control the pain you inflict on yourself.”

— “In my case, I started because I was punishing myself for being unhappy, and I thought I deserved the bad things that were happening in my life. I was punishing the person I hated most and blamed for all my problems. It seemed perfectly natural.”

— “For me, it puts emotional pain that can’t be dealt with into something physical that can be. It also serves as a form of self-punishment for things I should have known better than to have done or not done. No, it doesn’t make me feel alive. On the contrary. I cut to stop feeling.” — “I can’t stop. I don’t even want to stop. Imagine that everything that has ever bothered or hurt you can disappear in a moment of time. Why should you ever give that up?”

— “This is insanely difficult ground to tread on. I can’t imagine that everyone like me wants to do this. We lose so much because of it — friends, family, short sleeves. I would love to believe that we all want to stop. But how can I say that when I’m cutting left and right?”

— “For me it came from inside. One night I was drunk, and upset, broke a bottle and just felt like I should hurt myself. Strange, I know.”

— “I think everyone wants to stop at some time, but there are a lot of conflicting emotions involved in self-injury. Sometime I’ll want to. I’ll be disgusted by what I’ve done and want to just never pick up a knife again. Most of the time, though, I need it and can’t imagine what I’d do without it. I get scared at the thought of cutting. I can want to quit and not want to at the same time, and it gets really frustrating.”


The Orange County Register (California)
March 18, 2004

Cut to the quick cut; Feeling the Pain: The Laguna Playhouse explores self-injury among adolescents and the emotional agony at its root in `Cut,’ adapted from the book. By Theresa Walker

Callie is a cutter.

She slices her skin with sharp objects to relieve emotional distress. She cuts where it won’t show. She is 15. She won’t talk about how she hurts herself. It’s self-injury, and mostly teenage girls do it.

Callie is a fictional character from a book called “Cut,” published four years ago.

Yet what she does and why she does it are all too real for an estimated 3 million Americans who cut, scratch and burn themselves, interfere with the healing of wounds, bite their nails until they bleed, pull out their hair.

Joe Lauderdale, a director at Laguna Playhouse, was so struck by the book and the growing problem of self-injury that he adapted “Cut” into a stage production that runs Friday-Sunday.

This is first staging for “Cut,” a young-adult book written by Patricia McCormick and recommended by the American Library Association and the Children’s Literature Council. The play is this year’s offering in Laguna Playhouse’s teen subseries, Theatre for a New Generation.

Typically, after each Theatre for a New Generation performance, the audience, cast and crew participate in stage talks focusing on the theatrical experience. For “Cut,” Los Angeles-based therapist Andrew Levander, one of the country’s few experts in treating self-injurers, will join the question-and-answer session.

Orange County is an apt staging ground for “Cut.” Hospital data from the county’s Health Care Agency show that where only one adolescent was hospitalized in 1994 for attempted suicide or self-inflicted injury by a cutting or piercing instrument, the number grew to 58 in 2000, the latest year for which statistics are available. Girls made up two-thirds of those admitted over the six-year span.

In Levander’s 90-day adolescent-outpatient program, four of the 10 teens are from Orange County, the most from any one area. He is not sure why that number is so high, but he believes it has to do with both word of mouth and referrals from UCI Medical Center.

Self-injury is different from the self-mutilation — body piercings, scarification, even tattoos — that have cultural or religious origins dating to ancient times.

People who self-injure don’t want to die, either, Levander says. They want relief. Or to feel something other than numbness.

Levander defines self-injury as an attempt to alleviate tension, anxiety, stress and depression. It works quickly, he says, because chemicals in the brain take over and block out the pain sensation. Physically, the result is like a runner’s high, with the endorphins that are released.

“Primarily they do it because it works,” Levander says. “It’s a wonderful relief. One client said it was like taking a warm bubble bath. Another said it was like giving herself a hug.”

Levander says early-childhood sexual abuse seems to be the No. 1 determinant in those who self-injure. Physical abuse and severe invalidation in the home are other factors.

Cutting and other forms of self-injury can become the means of expressing emotions that have no other outlet.

“It doesn’t take long for somebody to stop talking if you think nobody is interested in what you have to say.”

Often, alcohol and drug abuse affects the family. Always, communication is a problem, Levander says.

It typically starts between 11 and 14 in adolescents who are easily frustrated, easily overwhelmed and don’t know how to deal with their emotions.

The number of therapists who specialize in treating adolescents is small to begin with, because teens — typically reluctant to participate in therapy — are a difficult population to work with, Levander says. Then, to find someone with expertise in self-injury is next to impossible, he adds.

“There’s still very little known about self-injury. It’s scary and it’s very misunderstood. Even in the professional community, it’s thought of as a failed suicide attempt.”

Four years ago, Levander modeled his long-term adolescent residential-treatment program — populated by kids referred from child-welfare services — after the pioneering 30-day psychiatric-hospital program run by SAFE (Self-Abuse Finally Ends) Alternative in Illinois. His voluntary outpatient program for teens started nine months ago.

Most of the kids he sees in his outpatient program have been hospitalized at least three times for self-injury or attempted suicide.

Lauderdale had never heard of cutting until he happened upon McCormick’s book. He found that researchers at the Menninger Clinic, the Texas clinic noted for its innovations in psychiatric and behavioral treatment, had briefly documented self-injury in the 1950s. But the disorder didn’t gain more serious attention until decades later.

“People didn’t think it was a health issue; they just thought it was some sort of bad behavior,” Lauderdale says. “Now it’s known as a psychological disorder, but the general public doesn’t know that.”

Lauren Bennett, the young actress who plays the part of Callie, knows girls at her school who cut, and her mother, a clinical psychologist, has several patients who are cutters. Bennett sought advice from her mom on how to help one of her best friends.

“It’s becoming more common with teenagers,” says Bennett, 17, who is a drama major at Orange County High School of the Arts in Santa Ana. “Sad to say, it’s almost a fad at this point. There are fad cutters who see it from other people and think that’s the way for them to show that they are hurting.”

Bennett couldn’t be further from the character she portrays. She says she was raised in a loving home by parents she felt she could always talk to. At one point, Lauderdale tells Bennett she needs more desperation for a scene in which Callie draws her arm across a prop, trying to cut herself.

After a couple of tries, she delivers. Bennett says it’s important to her to represent the real girls that Callie personifies.

“So many girls are unable to speak out, to reach out for the help, to hold out their hand. This is Callie going through that same struggle. This may lead girls to ask for the help they need.”

Cutting first gained media attention in the late ‘90s. McCormick chose it as a subject for a creative-writing class after reading a 1997 piece in The New York Times Magazine.

“I was both fascinated and repulsed, but mostly fascinated,” says McCormick, who once covered families, women and children for a newspaper in New Jersey and was on the staff at Parents magazine. “I just couldn’t understand how people could hurt themselves that way.”

The first 10 pages of “Cut” are pretty much word-for-word what she wrote for her class assignment, she says.

She points out that she is no expert in self-injury: “I tried not to tell the story of the disorder, but to tell the story of the one girl.”

The emotional truth in her book resonates with young people who continue to write to her and even call her, as one 13-year-old girl did the day of this interview, to talk about a friend who was cutting herself.

McCormick says the letters move her to tears. It’s mainly girls who write, many of them much younger than she expected to reach.

“When I wrote this book, I thought it would be for ages 13 to 17,” says McCormick, who has a daughter, 20, and a son, 14. “I’m amazed at how many 11-year-olds have written. A lot of kids say this is so similar to what a friend is going through. Or they say, you told my story — I can’t believe you understand how it feels.”

McCormick will come to see the play. But she plans to stay on the periphery.

“This is their project,” she says of the Laguna Playhouse production.

Lauderdale worried about the play triggering kids who don’t cut to start injuring themselves. Librarians had raised the same concerns about the book, McCormick says.

“But it’s the exact opposite,” she says. “It makes the reader or viewer see that this is really destructive behavior. Even if you were thinking of trying it, you wouldn’t.”

Levander says Lauderdale expressed his concerns: “Is it more important to tell the truth or to keep quiet? I think it’s more important to tell the truth. And with that truth, make sure you give appropriate resources.”


The Daily News of Los Angeles
March 29, 2004

Self-Destructive ‘Cutters’ Living Their Lives on the Edge
By Jennifer Radcliffe

Like a lot of young girls, Sarah Kalaba dreams of her wedding day, but she cringes when she sees the pink scars up and down her arms.

When she was younger, Kalaba, now 19, engaged in self-mutilation, an activity used by thousands of young people as a way of dealing with life’s stresses. Kalaba employed knives and razor blades in cutting herself so badly that now she sees little choice but to wear a long-sleeve gown on what she had hoped would be the happiest day of her life.

“I’m really worried about that,” said Kalaba, who lives in Simi Valley. “There’s not many cute long-sleeve dresses out there.”

A lifetime of scars is one consequence Kalaba faces because of her obsession with self-mutilation as a coping mechanism. Considered the fastest-growing adolescent behavioral problem, self-mutilation has educators across Los Angeles trying to figure out how to stop teens from cutting, scratching or burning themselves.

It’s an uphill battle because these adolescents and teens—mostly girls—rely on the morphine-like endorphins their bodies release when they’re hurt to get them through family troubles, insecurities and, often, memories of abuse.

“It turns more into an addiction, so to speak,” said Kalaba, who is in treatment and has gone more than 100 days without cutting herself. “They know this helps them, so that’s what they’re going to keep doing.”

The Los Angeles Unified School District started tackling the disorder about two years ago, when calls about students intentionally hurting themselves began flooding the district’s suicide-prevention hotline. Reports ranged from young children repeatedly poking themselves with thumbtacks to teenage girls using knives to cut their arms and legs.

Richard Lieberman, head of LAUSD’s suicide prevention unit, quickly became well-versed on self-mutilation, self-injury or “cutting,” as it is commonly called. He revamped his crisis training to address the growing problem.

Among his first lessons are that these students are typically not suicidal.

“The myth is that these kids cut to kill themselves; the reality is that they cut not to kill themselves,” Lieberman said.

Crisis workers must be trained to understand the difference and to be considerate of the insecurities that cutters struggle with.

“This is a complex behavior that fulfills an awful lot of needs,” said Lieberman, whose hotline fielded 600 calls in 18 months, many of which were about self-mutilators.

In the San Fernando Valley, the number of cutters referred has increased dramatically just this year, Lieberman said, although specific numbers were unavailable.

Experts say about one in every 250 people intentionally and repeatedly hurts herself.

“Every day, we seem to be having more and more; this is something new we’re dealing with right now,” said Lilliam Rodriguez, a psychiatric social worker at the Kennedy High School clinic in Granada Hills.

Hundreds of district employees in the Valley attended seminars this month about self-mutilation. Local District A is trying to start a support group for students who purposely injure themselves.

The growing number of cutters “points to the fact that our children have such serious psychological issues that they’re dealing with. It’s a very necessary and needed training,” said prevention facilitator Janis Lake, who oversees District A’s school health clinics.

And because training has increased, teachers and counselors are doing a better job watching for warning signs and getting students help.

“In the last couple of months, I’d have to say, the referrals have shot through the roof,” said Tracy Hoberman, a psychiatric social worker at Columbus Middle School in Canoga Park.

Schools are on the front lines of identifying these students, who are overwhelmingly middle school-age girls.

Usually, they’re intelligent perfectionists, struggling with self-esteem and confidence issues. They have a hard time expressing their emotions, and often, abuse and addiction strain already tense family relationships.

The girls usually try harder to hide the scars from their families and—sometimes—their parents aren’t paying enough attention to notice.

For Kalaba, watching the blood flow from her cuts offered both the emotional relief and the attention she so desperately needed.

“I realized it takes the emphasis off everything else and puts it on this one thing,” said Kalaba, a student at Moorpark College who aspires to be a therapist.

Even though cutters feel ashamed and guilty about hurting themselves, experts say they enjoy being able to control their emotions with the pain.

“It creates a sense of calm and peace,” said Andrew Levander, clinical director of the Vista Del Mar outpatient self-injury treatment program. “It’s very common to a runner hitting the wall, a runner’s high. It’s a rush, and they start chasing the rush.”

Some self-mutilators, who started by maybe just scratching their skin, find that they eventually have to turn to deeper cuts or more elaborate methods to get that high. Levander said he’s even seeing an increasing number of cases where students pull out their hair, a strand at a time.

While treatment methods are still being researched, Levander said, one key is to help youngsters and teens develop better relationship and communication skills.

“What we let them know is that they don’t have to be an injurer to get attention. With adolescents, it’s like anything less than dramatic might go unnoticed.”

Teaching students proper coping skills can help get them back on the right path. Without those, self-destruction is likely to continue, said William Reynolds, chairman of the psychology department at California State University, Humboldt, and one of only a handful of researchers in the United States studying self-mutilation.

Treatment must also specifically address the problems that precipitate cutting, such as a history of abuse or family fights.

Because awareness is growing, some students feel more comfortable talking about cutting, and that will be key to understanding and eliminating it.

“We’re ending the conspiracy of silence about this disorder,” Lieberman said.

Kalaba said she’s relieved that people are starting to understand her disorder. She’s confident that students will benefit from the training and outreach efforts.

“If there’s hope for me, there’s hope for everyone,” she said. “There’s always hope.”


Irish Independent
April 14, 2004

The Pain of Those Who Cut

Self-harm accounts for thousands of injuries treated in Irish hospitals every year. Martha Kearns reports on why an increasing number of young people are risking their lives by hurting themselves

What makes a child as young as 13 hide in their room and deliberately cut themselves? What mental torment must a young teenager be going through that burning themselves with cigarette butts or hot knives eases it for a while?

Most people who self-harm do not want to kill themselves, they simply want their life to change. They just want some way to stop the pain and want to turn their home or school life into something bearable.

Self-harm is a catch-all phrase for parasuicide, attempted suicide and intentional self-injury. It is a major problem in Irish society with thousands of people, 90% under the age of 50, seen in hospitals every year with evidence that they have self-harmed.

The latest figures available show that in 2002, there were 10,537 parasuicide cases at hospitals across the country involving 8,421 different people. More than 60% of them were women and in every age category female episodes outnumber those by males.

The typical profile of someone who self-harms is a young female aged between 15 and19. She is likely to take an overdose of medication but other methods include poisoning, cutting, hanging and attempted drowning. There is a one-in-five chance that she will try again.

Detailed research in Ireland, which is among the best in the world, shows those who self-harm are more likely to hurt themselves during the months of December, January and the summer months, with Sundays and Mondays being the worst days.

There is also a striking pattern which reveals that the likelihood to self-harm increases as the day progresses and peaks during the nights and in the early hours of the morning.

But why does a person want to inflict harm on themselves? Steve Lamb is the project nurse for assessment of deliberate self-harm with the South Eastern Health Board. He says the self-harm can be a distraction from whatever mental torment the person is going through.

“The majority don’t intend to kill themselves. They cut or burn themselves just enough to cause damage but not to kill themselves and it is the same with overdoses. They are likely to cut themselves on their forearms, their torsos and the inside of their legs where it is not immediately visible,” he says.

One child and adolescent psychiatrist says her patients tell her that the feelings build up inside and they feel this is a way of releasing the frustration. She adds: “They often tell me that at the time it doesn’t hurt but then afterwards, it hurts like hell. It’s only afterwards that they realise how far they have gone.” She says that some people describe it as a way of showing the pain they feel inside on the outside.

“They look at themselves in the mirror and sees someone who looks normal. They think they don’t look how they feel. It can then become a habit, something to do when they come up against an obstacle.”

Dr Ella Arensman, research director of the National Suicide Research Foundation(NSRF), says that self-harm does not just happen overnight and usually stems from a predisposed vulnerability, such as living with a parent who has psychological or psychiatric problems.

“Most often there is not one specific reason for self-harm but a combination of different reasons. On the one hand they want to die but on the other hand, they have a tiny bit of hope that their situation will change. Most people who self-harm do not want to die but they do want a different life. They feel that the intense emotional pain can almost be brought into balance by the physical pain.”

Dr Arensman, who has worked in the area in the Netherlands and Ireland for the past 16 years, says it is possible to identify some of the signs and that very often you can see a change in a person’s mood leading up to them harming themselves.

“They might seem sad, withdrawn and anxious as they feel they are increasingly losing control. People also send out indirect signs. It’s rare that they would say that they are going to take some pills but would say something like ‘I don’t know if I can take it anymore’.”

Parents who feel there is a problem should take the time to listen to their child. A lot of young people talk about their faults or problems with peers but rarely feel the same ability to talk to parents or teachers because they fear that they won’t react the way they want them to.

It is important that someone talks to the teenager. However, it is essential that they talk to someone they trust and it is better that it is not a peer, as often the pressure for them can be too much. An adult relative or friend is the best option.

All the experts believe the first professional port of call should be a GP. Sometimes the young person might resist going to the family GP. It might be wise to go to one who is independent of the family so it can be as confidential and anonymous as possible. It is even harder to get men to talk about their problems, even on anonymous phone lines. I tis found that they find it easier to share their feelings online. The NSRF is currently lobbying to get an interactive website set up that would be manned by professionals and allow people who self-harm to talk in a private forum.

It is crucial that they get help as parasuicide is closely linked to completed acts of suicide and Ireland has one of the fastest rising suicide rates in the world. Those who engage in parasuicide are approximately 20 times more likely to eventually kill themselves.

Intensive study in Ireland shows that self-cutting is more prevalent in men than women, which is unusual. In most other countries it is the opposite but is possibly connected with the fact that in 20 years, the number of Irish male suicides has quadrupled, one third of suicides is preceded by parasuicide and one in five people who self-harm do so again within six months.

Mental Health Ireland (MHI) says the problem of self-harm is a critical issue for the organisation and it works at crisis intervention and tries to prevent young people from self-harming.

“It is important to focus on intervention and prevention as well as on the cure,” says MHI deputy chief executive Caroline McGrath. “Young people have to know that they can look for help with confidence, that they will get the support. We try to inform them through school-based curriculum, art and public speaking. We need to be there at primary-school level as this is not just about intervening when things go wrong.”

If you or someone you are close to is self-harming, here are some contacts that can helpyou. Childline: 1800 666 666, Samaritans: 1850 60 90 90, www.aware.ie, www.youth.ie, www.mentalhealthireland.ie, www.reachout.com.au or contact a GP.


IPS-Inter Press Service
April 21, 2004

U.S.-Health: Girl Talk—Why We Cut And Burn Ourselves
By Emma Pearse

Corin (a pseudonym), a 19-year old teen from central south Connecticut, can remember the first time she cut herself. She was 15 and watching a Disney movie. She picked up a razor and sliced into the veins on her right foot.

“I discovered cutting by attempts at killing myself,” Corin wrote in a recent e-mail to Women’s eNews. “As early as seventh grade I had been slicing at my veins, with the intention of killing myself. I realized that sometimes just cutting the skin away from the vein made me feel better. And I began to do it more and more often.”

Corin is one of thousands of female teens logging on to hard-to-locate Internet chat rooms. Many users keep their chat room addresses private or for use by a select few, yet some go so far as to create personal Web sites. One such site, Self Injury: A Struggle, was started by Gabrielle, a 19 year old, eager to share her experience with self injury “to let others know that they are not alone in their struggle,” she writes.

“It started as an attempt on my part to contribute my voice and my opinions in the then growing awareness of self-injury,” she writes. “To use my voice to say that self-injurers are valid individuals and that they are more than a label.”

Although no current data exist to prove their hunches, analysts and clinicians say that the incidence of self injury, which consists most commonly of behaviors such as cutting, burning, and hair pulling, may be increasing. They point to the emergence of a culture in which it is acceptable—perhaps desirable—to talk about it.

Research from the Atlanta-based Centers for Disease Control and Prevention indicates that 1-in-4 adolescents in the United States thinks about suicide each year and by the end of high school at least 1-in-10 has made a suicide attempt. In 2000, suicide was the third leading cause of death among 15-to-24 year olds. Data from the National Institute of Mental Health in Bethesda, Md., indicate that between 1995 and 2000, though four times as many men as women died from suicide, women attempted suicide two-to-three times more often than men.

Existing research indicates that during adolescence, female teens are twice as likely as teen-age males to suffer from depression, often with self injury as a related behavior. The research also indicates that people born in the last two decades are likely to experience depression earlier in life than in previous decades.

Dr. David Fassler, a child and adolescent psychiatrist in Burlington, Vt., warns, however, that self injury has been difficult to research due to its secretive nature.

“For many years self harm was something that kids kept to themselves,” says Fassler. “Now it’s something that they’re more likely to talk about.”

Linda Lebelle, director of Focus Adolescent Services based in Salisbury, Md., agrees. She says that, among professionals working with teens, most are aware that cutting is a particularly female affliction and there is a growing sense that, during the past few years, more female teens have begun to call help lines to talk about hurting themselves.

“Traditionally boys are able to express anger outwardly more directly. Girls live in a much more body-focused culture,” says Dr. Wendy Lader, clinical director of Safe Alternative, a hospital-based program in Naperville, Ill., that caters exclusively to the treatment of self injury.

“Skin is a bulletin board,” Lader says. “They’re saying, ‘Can you see how much pain I’m in?’“

Lader believes the behavior is increasing for several reasons. “A lot of kids are feeling very invisible these days,” she says. “There are many reasons for this—higher rates of divorce, more isolated activities such as computers.” Self harm makes their experience more visible, she adds, and sometimes there is the contagion effect. “Movies are showing beautiful girls who are self injuring. There is a desire to glamorize this.”

Last year, the movies “Secretary” and “Thirteen” portrayed adolescent females cutting and burning themselves in response to loneliness and family neglect. Sexual abuse was hinted at, but never made explicit. The play “Cut,” adapted from the four-year-old book of the same title by Patricia McCormick, ran at a playhouse in Laguna Beach, Ca. Local newspapers have covered the subject and Tracey Gold’s documentary, “Cutters: Self Abuse,” ran last year on the Discovery Health Channel. This month, one of the main characters on a MTV series, “The Real World, San Diego,” Frankie, revealed a habit of cutting.

Whatever their cultural cues, teens who cut themselves are indicating a state of mind and perhaps a personal history—tough childhoods, mental illnesses or peer pressures—that call out for medical attention, says Lebelle, from Maryland’s adolescent services. “It seems to be that a high proportion of kids who cut or self injure have suffered some sort of trauma: abuse, molestation or rape.”

Both Fassler and Lader regard self harm as a symptom rather than a diagnosis.

“The goal is to get people to recognize that self injury is a clue,” says Lader, the self-injury specialist. “There’s some kind of a feeling that they don’t want to experience. And they need to figure out why at that moment they are having that impulse. And rather than self medicate it with self injury, we want them to understand what they are feeling, label their feelings and challenge those irrational thoughts.”

Lader has her clients keep “impulse control logs” in which they track every time they feel an impulse to injure.

The teens who responded to a Women’s eNews posting openly described lives of enormous sadness, little-understood emotions and an inexplicable attraction to the thrill of self-inflicted pain.

Corin was just one of many girls who responded to a posting on the Web site operated by Focus Adolescent Services. Teens from the ages of 14 to 26, from Colorado to Connecticut, wrote introducing themselves with lines such as “Hi, my name is Abby. I am 17 and I am a cutter.”

Corin says she was sexually abused as a child and that she has seen therapists, psychiatrists and been in a hospital outpatient program for suicide attempts. She writes she is grateful not to have had access to weapons more serious than razors and Tylenol.

“All I have to say is that I am very lucky that my parents don’t keep a gun in the house,” she writes. “I am convinced I would not be here today if they did.”


The Arizona Republic
April 26, 2004

Self-Injury Among Teens on the Rise; ‘Cutters’ Say Mutilations Help Ease Their Internal Pain
By Joelle Babula

Elizabeth carves into her flesh with knives when she’s upset. She uses a box cutter to hack out profane words on her legs, or she sneaks a kitchen knife to slice her arms repeatedly. Sometimes, the Glendale teenager heats up an iron just to sear her skin.

The 14-year-old, The Arizona Republic is withholding her identity, says the acts of cutting or burning her skin relieve tension and anxiety, especially after fighting with her parents or getting dumped by a boyfriend. She says the burns and cuts temporarily distract her from her problems and make her feel better.

An increasing number of girls are cutting, burning or bruising their bodies to help cope with stress, Valley school nurses, counselors and doctors say, sparking a flurry of training sessions for guidance counselors and referrals to therapists.

“The increases everywhere are alarming. It has caught our attention to the point that we’re now training all of our counselors,” said David Shuff, director of guidance and counseling for Mesa Public Schools. “This is the first year we’ve done this kind of (self-injury) training.”

There are no national or local statistics on the number of teenagers who self-injure. Health professionals and school personnel nationwide, however, say they are dealing with a steadily increasing number of teenagers, mostly girls, who hurt themselves.

A Chicago-based self-injury treatment program called S.A.F.E. has seen inquiries rise from a few hundred a month to thousands, co-founder Karen Conterio said.

She said the increase had been steady over the past few years, but has spiked during the six months of this school year.

Health professionals say that without intervention, the behaviors can escalate to more dangerous acts, such as carving deeper cuts with jagged instruments, breaking bones or purposely infecting open wounds with bacteria and filth.

“We’ve had people who have cut off a digit or those who inject themselves with HIV, urine, feces or other substances,” Conterio said.

“Usually people start with a more common form of self-injury, like cutting, but it can progress.”

Elizabeth first began hurting herself in December by using a curling iron to burn her skin. She progressed to irons and now she mostly uses knives or box cutters to cut her flesh. Sometimes she carves words like, “(expletive) the world,” on her lower leg. Or she cuts a boy’s name into her skin, which she later crosses out with further slashes when the relationship turns sour.

“I have 32 scars on my arms and legs,” Elizabeth said quietly. “I don’t want to do this anymore, but it takes the pain away. If I didn’t cut myself, I’d cry, and that would be the worst thing.”

Elizabeth, a freshman at Sandra Day O’Connor High School, says she has a few friends who cut themselves as well. She says they all do it privately and usually at home.

“I always take a shower after I cut myself because they bleed a lot,” Elizabeth said. “Then I wear pants the next day to hide it.”

Experts say the reasons people self-injure are varied and sometimes complicated. Often those who hurt themselves suffer from an underlying psychiatric disorder, such as depression. Some were victims of sexual, physical or emotional abuse, while others feel alone or neglected or simply don’t know how to communicate properly or deal with anxiety in a healthy way.

Many say the rise in self-injury is due in part to the changing family dynamic. Kids today are often forced to deal with divorced parents, Mom or Dad’s new companion, working parents or substance abuse in the home. Young girls especially are often also faced with increasing pressure to be slim, sexy and attractive.

“There’s a real sense these kids have that they have disappointed everybody, that they are not good enough and that nobody loves them or really cares,” said Andrew Levander, director of a self-injury treatment program at Vista Del Mar Child and Family Services in Los Angeles.

He said self-injury is the “fastest growing adolescent behavior problem of our time.”

According to Levander, between 60 and 70 percent of kids who self-injure were abused in some way. Those who weren’t abused, he said, sometimes hurt themselves to deal with increasing strife in the home.

“These kids are looking to relieve that stress but for some reason, they can’t do it verbally,” Levander said. “Kids who use razors seem to be depressed and unable to cope, while kids who use glass or burn themselves tend to be aggressive and angry and turn all that anger into themselves.”

Experts say it’s important to remember that kids who self-injure generally are not trying to commit suicide; they simply want to feel better and don’t know how to cope.

“It’s a red flag that the kid is hurting and is unhappy with some aspect of their life. They are in emotional pain,” said Dr. Richard Spiegel, past president of the Arizona Council of Child and Adolescent Psychiatry. “Kids tell me they are hurting because their parents are too demanding or because other kids don’t like them or that they are ugly and hate themselves.”

Elizabeth says she has a good relationship with her parents but she’s suffered from mental problems for several years. The teenager takes medication to combat depression and she’s been hospitalized for an eating disorder.

“I don’t know why I do it (cut), but I can’t cry. I hate crying, and this seems like a good way to make me feel better,” she said. “Once I’m done cutting, it hurts so bad that I can’t feel the pain inside me anymore.”

Elizabeth’s parents, Mike and Jenny, say they don’t know why their daughter refuses to cry or communicate her pain. They have her in therapy and are trying to teach her better communication skills at home.

“Certainly tears are allowed in this house, they always have been,” Mike said. “I think she has real issues of self-acceptance and weight issues, which, unfortunately, she probably learned from me.”

Mike said he worries that Elizabeth’s cutting will escalate to more dangerous acts, or that she’ll accidentally cut herself too deep and slice an artery.

“As a parent, you’re bewildered by this and frightened because you just don’t know where it will lead,” he said. “They aren’t deep cuts now, but you certainly just can’t blow this off and ignore it and hope it will go away.”

Psychiatrists and therapists say the earlier kids are identified and receive treatment, the better chance they will have of getting well. Treatment can include antidepressants, therapy, behavioral modification and, in some cases, inpatient treatment programs.

“I really want to stop,” Elizabeth said. “Most of us do. My best friend cuts, too, and we made a pact. We have to run five miles for each slit we do.”

Elizabeth pleads with other teens to stay away from self-injury.

“Please, don’t do it,” she said. “Get help. Otherwise, you get into this horrible cycle that you can’t get out of.”

What is self-injury?

Self-injury is also referred to as self-mutilation, self-harm or self-abuse. It is defined as the deliberate, repetitive, impulsive, non-lethal harming of one’s self.

Forms of self-injury include cutting, scratching, picking at scabs, burning, punching or slapping oneself or poking oneself with needles.

More severe forms of self-injury include swallowing or injecting oneself with harmful substances, bruising or breaking bones or inserting objects into orifices.

QUESTION: Who suffers from self-injury?

ANSWER: Girls and young women typically are involved in self-injury more often than boys or young men. Typical acts of self-injury usually begin at the onset of puberty and can continue for years without proper treatment. Many self-injurers report that they were physically or sexually abused as a child or that they were discouraged from expressing emotions, particularly anger or sadness. Many also suffer from undiagnosed psychiatric disorders, such as depression.

Q: What are personality traits common among self-injurers?

A: Perfectionism, poor body image, low self-esteem and difficulty expressing or controlling emotions.

Q: Why do people purposely themselves?

A: People who self-injure seek to relieve tension, stress or emotional pain. Some say they feel empty inside and want to feel something on the outside, while others say the pain distracts them from acute sadness or anxiety. Many say they feel lonely and unable to express their feelings.

Q: Are self-inflicted wounds merely failed suicide attempts?

A: No. Self-injurers rarely want to die. Although they generally are not trying to commit suicide, some can accidentally kill themselves by cutting too deeply and severing an artery.

Q: What are the treatment options?

A: Treatment can consist of medications, inpatient or outpatient treatment programs, counseling and therapy.


The Detroit News
May 2, 2004

Center helps stop mutilation; Troy-based facility helps teen cutters stop urges
By John Wisely and Janet Sugameli

Lindsay McKenna is encouraged by the scars on her forearm.

The 16-year-old Waterford Mott High School sophomore spent almost two years trying to dull life’s pains by intentionally cutting herself with a pair of scissors before starting a recovery program seven weeks ago.

“I don’t need to do it again,” she said. “I’m a lot stronger now. I don’t need that fix anymore.”

For McKenna and a number of middle schoolers, high schoolers and college students, cutting or self-mutilating behavior is an addiction, but not a suicide attempt.

Each week, 50 to 100 students who cut themselves walk into Perspectives of Troy, an outpatient therapy center, for help. The center’s clinical director, Leslie Ayers, said she speaks to groups of school counselors about twice a month to raise awareness of the problem. Requests for her to speak have quadrupled in the past two years.

Researchers estimate 1 percent of the population cuts itself, but see a much higher rate in adolescents. While that’s far less prevalent than drug or alcohol use, local health officials believe the numbers are rising.

Oakland Intermediate Schools has offered training to school counselors for two years, in response to requests from schools, said Jim Whitledge, a counseling consultant.

Therapists say cutters risk infections, permanent tissue damage and, in rare cases, death if the cutter is unable to stop the bleeding.

Coping skills

Those who cut themselves use household items, including knives, staples, paper clips, picture frames or razors to get deep enough to draw blood. Researchers said the trauma of the cutting causes the brain to release endorphins, hormones that can dull pain and affect emotions. Some people experience a sense of euphoria.

“The main reason people self-injure is because it’s oddly effective in reducing emotional distress,” said Barry Walsh, a Massachusetts-based researcher who has spent 30 years studying self-injury. “The general population of youth tends to be a highly stressed population.”

They often feel invalidated by their families, schools and peers, he said. The causes range from abuse to broken homes to emotionally absent parents.

“They have a lot of pain and don’t know how to handle it,” Ayers said.

Walsh said the behavior has long been found among people diagnosed with personality disorders. But now, clinicians are seeing it in others.

“There is an explosion of the behavior where it didn’t appear before,” he said. “The behavior is now emerging in the general population. It’s a national epidemic and an international phenomenon.”

Bulletin boards

A preoccupation with bodies is a product of the culture, said Wendy Lader, clinical director at Self-Abuse Finally Ends, an inpatient clinic program in Naperville, Ill.

“We are a body-focused society,” she said. “The body is a bulletin board where people express themselves. I don’t think it’s a coincidence that at the same time we are seeing body art and piercing, we’re seeing self-injury.”

Treatment for cutting usually involves teaching teens other ways to cope with emotional distress, said Sara Van Wormer, a therapist at Brookfield Clinics in Westland who has worked with cutters and trains school counselors.

“Artwork, writing and music help them deal with the pain,” Van Wormer said. “It can be an addictive type of behavior. I treat it just like substance abuse.”

Never suspected

Royal Oak seventh-grader Katlyn Dresden starting cutting herself when she was 12, after watching a relative do it.

“I thought it would be helpful to cope with my pain because she said it would help her,” she said. “It made me feel lighter, like my problems were off my mind.”

For Katlyn, many typical teen-age stresses, including teasing and family problems, drove her to break a razor and hide it in her bedroom for those stressful moments. Sometimes, she would cut in several locations, several times a day.

Her mom, Cindy, never suspected. Katlyn often wore long-sleeved shirts or plastic bangle bracelets to hide the cuts.

“We had talked about drugs, smoking, alcohol and sex, but cutting never entered my mind,” her mother said.

Now in recovery for seventh months, Katlyn, 14, said she is stronger and can deal with her problems without cutting.

“Now there are still scars, but the deep cuts are gone,” she said.

Internet research

For Lindsay, cutting herself was a serious decision. Before she started, she researched human anatomy on the Internet to avoid any veins or arteries.

“There are times when there is so much emotional pain that cutting makes you forget it, because you focus on the physical pain,” she said.

A variety of Internet sites and chat rooms discuss the topic in detail, including offering advice on how to conceal the behavior.

“It’s a secretive behavior, and it can be hidden,” Ayers said. “They know why they are doing it and the effects of it. They know they are scarring themselves.”

Therapists said that with proper treatment, there is a good chance for success. Lindsay’s mother, Kathy McKenna, agrees.

“You need to listen to your kids and not try to fix their problems,” McKenna said. “You’ve got to be there for them and listen to them. They will work on the solution.”

Cutting

Though the behavior is often hard to detect, there are some signs:

* Emotional distress, mood swings.
* Especially long periods of time in the bathroom or bedroom.
* Disassembled razors.


The Patriot Ledger (Quincy, MA)
May 4, 2004

Scarred; More Teens Trying to Cut Away the Pain
By Anne Trafton

Kristen Putignano used to lie when friends asked about the scars on her arms. She would say her cat had scratched her or that she fell off her bike so no one would realize she was cutting herself with a razor blade up to seven times a day.

“It was really out of control,” Putignano says now. “Every single time I felt an emotion, I’d just do it.”

Dealing with anxiety and emotional trauma by harming oneself is not a new phenomenon, but psychologists say more and more teens are turning to this kind of self-destructive behavior.

Estimates of how many people injure themselves range widely, from 1 to 10 percent of the U.S. population. The recent movie, “Thirteen,” which portrayed girls who cut themselves, has also brought more attention to the problem.

“I think it has become more common than we ever realized,” Canton psychologist Sharon Maxwell said, adding that some of her teenage patients cut themselves, and those who don’t often know someone who is doing it.

Self-injury is more commonly observed in girls, and teenagers who injure themselves usually suffer from mood disorders like depression or anxiety.

“The girls I have seen that have done this kind of self-destructive behavior have lost all connection with their selves, with who they are,” Maxwell said. “They’re adrift and in a great deal of pain.”

Putignano, 18, started cutting her arms with scissors and razors when she was 13, around the same time she developed an eating disorder. Brought up in a family that did not easily express emotion, she found it difficult to cope when a traumatic event occurred during her childhood.

“I couldn’t really deal with emotions but when I hurt myself I felt better, so I did that instead of talking,” said Putignano, who lives in Middleboro.

Self-destructive behavior among teenagers is often triggered by a traumatic event such as rape or abuse and can be associated with feelings of worthlessness.

“The vast majority of kids who self-harm have had some harm inflicted on them by others,” Joseph Shrand, a psychiatrist at Pembroke Hospital, said. “They begin to really believe that the world sees them as worthless and inconsequential.”

Though cutting is the most common type of self-injury, some people also burn or bruise their bodies. In most cases, the patients are not suicidal, Shrand said.

“They just wish they had a different life,” he said.

Many cutters, including Putignano, say the physical pain of cutting themselves actually makes them feel better. Doctors say that’s because human brains are programmed to release pain-killing endorphins when the body is under stress.

For some, once they start cutting, a brain mechanism similar to alcohol or drug addition can take over, driving the patient to continue the destructive behavior.

“The kid cuts and they get this rush and this enormous sense of relief from whatever their emotional trauma has been,” Shrand said.

A drug called Naltrexone, also used to treat heroin addicts, can help stop the cycle, but doctors say therapy is critical to recovery.

Psychologists say treatment includes teaching the patient to realize the thoughts that make them feel worthless are not true. Patients must also develop healthier ways to cope with their emotions.

“They become pretty convinced that (cutting) is the only thing they know how to do,” said Meg Striepe, a psychologist at the Center for Research on Women at Wellesley College. “If you threaten to take that away, it can become terrifying.”

After four years of therapy, about a dozen hospital stays and one suicide attempt, Putignano says she has overcome the need to cut.

“I don’t plan on doing it anytime soon,” she said. “Now I’ve gotten to the point where I know in my heart it’s not the right thing to do. There are a lot of other things I can do to get my emotions out.”

She’s now working with the National Alliance for the Mentally Ill to try to raise awareness of such illnesses and erase the stigma often associated with them. She still sees a Duxbury therapist and recently gave a lecture at Bridgewater State College about her experience with self-injury.

Putignano doesn’t try to hide her scars anymore, and when people ask about them, she tells them she used to hurt herself. “It’s in my past now,” she said.


Milwaukee Journal Sentinel (Wisconsin)
May 13, 2004

Daughter must retain privacy as she recovers
By Marguerite Kelly

Q. Seven weeks ago we discovered that our 16-year-old daughter had been self-mutilating.

After a brief hospital stay, a diagnosis of depression and much crying and hand wringing, we are in therapy and are very hopeful that we are on the road to recovery. There are too many details to cover here, but let me say that we discovered things about our child that we never would have suspected in a million years.

As a result, I find myself constantly on the lookout for any sign or any information that would tell us if she is in danger. I search her computer files, go through her trash, search her backpack, dresser, car, etc. It leaves me with a tremendous amount of guilt.

Am I out of control? What is too much? How much privacy can my daughter expect after hiding so much?

A. You’ve really come up against a tough problem, but family therapy should help your daughter best because it recognizes this basic truth: If a child has a problem, the whole family has a problem and it takes the whole family to fix it.

Self-injury won’t seem so frightening, however, if you remember that young teenagers seldom consider consequences. This makes them do goofy, dangerous or mindless things sometimes.

Like cutting.

Experts say that as many as 2 million to 3 million people cut or mutilate themselves in one way or another, that they usually begin this practice in adolescence and that they usually do it because they’re depressed, and they’re depressed because they have bottled up their fears and feelings and are trying to deal with them alone.

Moreover, almost all self-mutilators are girls and they seem to follow the same pattern. First a cutter slices a delicate, deliberate line across her thigh or her belly with a razor blade. And then a week or a month later, the pressure builds up again, and she cuts (or burns or bites) herself again. Unless she stops she might become more addicted to self-injury than a smoker is to cigarettes or a pothead is to pot. On top of that, she is likely to develop bulimia or anorexia.

Although family therapy can work wonders, your daughter should also be supervised carefully by chores, classes, rehearsals or team practice after school. Your relationship with your daughter won’t get close, however, if you keep rooting through her possessions.

It’s true that she has broken your trust, but if you dig into her knapsack, her clothes and her trash, you will break her trust in you. Be honest with your daughter instead, as she is beginning to be honest with you. She needs to know that you have lost your self-control, too, and have been going through her things when she wasn’t around, just to make sure that she was safe.

And then apologize and ask her to help you overcome this habit. Tell your daughter that you know you’ll be scared and anxious about her for quite a while and that you’ll sometimes need her to show you what’s in her knapsack or in her desk. But only look through her things when she’s with you and only if she says it’s OK.


Health & Medicine Week
May 31, 2004

Study argues that self-injury in lesbians, bisexuals is a coping response

In a recent paper, researchers in London, England, suggest that self-injury in lesbian and bisexual women is a coping response to societally-imposed stresses.

The authors conducted one-on-one interviews with 16 lesbian or bisexual women who had self-injured multiple times to gain an understanding of the women’s “subjective experience and meaning of self-injury...”

“In individual interviews, the women talked about their experiences of self-injury and the role it played in their lives as lesbian or bisexual women. Interpretative Phenomenological Analysis (IPA) was used to elicit themes arising within their accounts,” said N. Alexander and colleagues.

They said that “the women’s accounts raised a number of important issues about the way in which mental health services respond to lesbian and bisexual women who self-injure

“It is argued,” Alexander and colleagues wrote, “that self-injury can be understood as a coping response that arises within a social context characterized by abuse, invalidation, and the experience of being regarded as different or in some way unacceptable. These factors are especially salient in the lives of women, and they emerge particularly strongly as part of the experience of women who are developing a lesbian or bisexual identity.

The paper appeared in the Journal of Community & Applied Social Psychology (You still feel different: The experience and meaning of women’s self-injury in the context of a lesbian or bisexual identity. J Community Appl Social Psych, 2004;14(2):70-84).

For more information, contact N. Alexander, Newham Community Health Team People with Learning Disabilities, Units 7 & 8, Stratford Off Village, Romford Rd., London E15 4EA, England.

Publisher contact information for the Journal of Community & Applied Social Psychology is: John Wiley & Sons Ltd., the Atrium, Southern Gate, Chichester PO19 8SQ, W Sussex, England.

The information in this article comes under the major subject areas of Lesbianism, Bisexuality, Psychiatry, Mental Health, Self Injury, Stress, Risk Factors.