This paper was published in the 2005 Spring Volume of the SCPA Newsletter and is used here with permission
The crimson river flows
and the pain recedes.
Circles, lines and bows
The sweetness of the bleed.
This is a poem written by a teenage girl with whom I have been working. She chose to use the name Anne, after her favorite poet, Anne Sexton. Now, some of you may know that Anne Sexton killed herself, and that my patient’s choice to use her name is somewhat suspect. But this Anne, a sixteen year old girl, has no intention of hurting herself. She is like most people who cut. She is trying to soothe herself, not kill herself.
What is Cutting?
Cutting falls under the umbrella of Self-Injurious Behaviors (SIB). Other forms of SIB include burning, skin-picking, wound-picking, skin puncturing and flaying. This paper, however, will focus specifically on cutting behaviors in individuals who are not psychotic or brain damaged.
Cutting can range from severe tissue damage to minor skin scratches. Cuts can take form in delicate lines, swirls, patterns and initials. “Like a tattoo,” one patient revealed. Cutting can be smooth from beginning to end, suggesting a slow, steadied hand doing the deed. Cuts can occur in haphazard slashes, revealing a fury in the strokes. Cutting wounds can present in a rippled manner, where blood spills intermittently through the skin, giving the lesion a bumpy, prickly look. Redness can accompany cuts, as can bruising. Cuts can be thick, deep and long, and as one patient discovered, can get infected and require hospital attention. Cutting is usually assigned to hidden places, not readily visible to the casual observer. With regard to moderate and mild cutting, clothing conceals them, bracelets hide them, band-aids cover them. More severe cutting may be noticeable in the way a person carries his/her posture (limping, hobbling or recoiling).
The style of cutting will be as individual as the person. So, too, will be the instrument chosen for accomplishing the act. Tools for cutting can be items specifically designed to cut: scissors, knives, razors. Ordinary items can be employed: pins, paper clips, needles, pen caps, forks, broken glass…anything that can break the skin.
Translating Cutting in Psychological Terms
The cutting, carving and scratching of skin in is an attempt to control overwhelming emotions, feelings of helplessness, and for some is a way to manage anger or shame. Cutting is a way to manage self-punishment, self-hate or self-nurturance. In its simplest form, cutting is a physical solution to a psychic wound. It is a deliberate, private act that can be habitual or isolated in occurrence. It is not attention seeking behavior, not meant to be manipulative, nor is it a conscious attempt to end one’s life. (Azar, 1995; Carll, 2003; Froeschle & Moyer, 2004; Kress White, 2003; Levenkron, 1999; Strong 1999).
Symbolically speaking, cutting is viewed psychologically as a method to communicate what cannot be spoken. The skin is the projected canvas, an encasement of sorts, where aspects of the psyche reside. Anzeiu’s (1989) theory of skin-ego best describes this, and is compelling reading for professionals. “Mutilations of the skin are dramatic attempts to maintain the boundaries of the body and the Ego, and to re-establish a sense of being intact and cohesive” (Anzeiu, 1989, p.20). It is important for psychologists to understand the skin’s symbolic representation in the act of cutting and the ego organization that is being attempted by the individual. Talk is always preferred over action in therapy. So the goal here is to help the patient translate verbally what is occurring physically.
Who is Cutting?
At present, little is known regarding etiology, course, diagnosis, assessment and appropriate treatment interventions for cutting. The data available focuses on self-injury behaviors as a whole.
Statistically speaking, approximately 4% of the population in the United States uses self-injury as a way of coping (Briere & Gil, 1998). Individuals who self-injure are represented in all SES brackets in the United States (Brier &amp;amp;amp;amp;amp; Gil, 1998; Dieter et. al., 2000). The behavior usually has its origin in adolescence, and has been shown to continue for some into adulthood (Kress White, 2004). Girls and women tend to self-injure more than boys and men, but this maybe represented by the fact that females tend to turn to professional help more than males.
Cutting and the DSM
Cutting is not a separate category in the DSMIV-TR, but researchers in the field are pushing for its inclusion in the DSMV. Pattison & Kahan (1983) have been writing about Deliberate Self-Harm Syndrome for over two decades, urging the recognition of cutting and the other self-injury behaviors as distinct disorders. Favazza & Rosenthal (1993) have supported this as well and have been detailing their research about Repetitive Self-Harm Syndrome for over a decade. For now, cutting can be diagnosed as an Impulse-Control Disorder NOS.
Cutting has been markedly linked to borderline personality disorder (Brodsky, et. al., 1995; Russ et. al., 1995). Akhtar (1995) states that the borderline individual uses cutting as both an attempt at self-delineation and to express a connection (or lack of connection) with others. Cutting has been moderately associated with histrionic and narcissistic personality disorders (Konicki & Schulz, 1989; Kress White, 2003), suggesting that the reactive traits in these disorders raises the likelihood of cutting tendencies. Disorders of the Self have also been companioned with cutting and can be seen in the impairment of a patient’s self-capacity for tolerating strong affect and the maintaining of a sense of self worth (Dieter et.al. 2000). Depression, anxiety, obsessive compulsive disorders and eating disorders have also been associated with cutting as have childhood trauma, sexual abuse, and gender identity, though not statistically linked as previously mentioned.
Research into self injury has revealed that the act can become physiologically and psychologically addictive. Clinical studies to date have attended to the role of endogenous opioids. Endorphins function as natural narcotics or opiates in the body as the self-injury occurs, and an individual learns to associate the act of cutting with the rush from the endorphin release (Azar, 1995; Simeon et al.; 1992; Villalba & Harrington, 2000). This “high” secures the cyclic addiction. Individuals who self injure also report feeling no pain as the cutting occurs. This is similar to "stress-induced analgesia" that wounded soldiers and athletes report experiencing (Hilgard, 1976).
Why is Cutting more Prevalent
Cutting behaviors have been reported for many years and are on the rise, reaching epidemic proportions (Froeshcle & Moyer, 2004), but there is no hard and fast evidence as to why. Concern is at such a fevered pitch that the American Self-Harm Information Clearinghouse named March 1, 2005 as National Self Injury Awareness Day to educate and inform medical and mental health professionals and the general public about the self injury. The United Kingdom and Australia have marked March 1st as National Self-Injury Awareness day in their respective countries as well.
Media contagion seems to be a common theory as to why cutting is on the rise. High profile individuals like Princess Diana, Johnny Depp, Christina Ricci, Fiona Apple, Angelina Jolie, and Courtney Love have revealed that they deliberately cut or self injured. Movies like “Girl Interrupted” and “Thirteen”, depict individuals using cutting behaviors as a means to reduce adversity. This gets translated as a possible option for individuals who are grappling with significant emotional turmoil. Peer contagion is also a factor in school and work settings - If she tried it, maybe this can work for me.
Assessment and Interventions
Kress White (2003) tells us that we are still in need of finding better assessment and intervention tools for cutting behaviors. For now, many clinical practitioners and school psychologists use eclectic approaches when dealing with cutting.
The first step in assessment is to determine if cutting is a suicide attempt. Therefore, a standard suicide assessment is paramount. Once ideation, intent, and plan are ruled out, the inquiry should address the patterns of cutting, the conflicts the teen or adult experiences, as well as inspection of said cuts if given permission to see them. Educating the individual about what cutting is in psychological terms will help start the recovery process.
Duty to warn will be a matter of interest. A breach of confidentiality may be appropriate when cutting occurs. Teens and adults who cut do not want to end their life, but cutting can put one at risk for significant injury and infection, tissue or muscle damage and accidental death.
Exploring family dynamics is another area that should receive great coverage. The person who cuts often feels that h/she doesn’t have the right to assert him/herself, doesn’t feel that thoughts and feelings are respected, or gets punished for his/her expression by family members (Levenkron, 1999; Strong, 1999). The exploring of the family dynamics will reveal that the family constellation is in need of help as well. Family therapy is very essential modality for recovery.
For teens that are not comfortable with family therapy, cognitive and behavioral approaches can be pursued to help address the maladaptive coping schemas. Psychodynamic therapy can also be a considered orientation to uncover the unconscious and symbolic aspects of the cutting.
Interventions that have been used with patients with dissociative disorders have been useful with individuals who cut. Visualization can be used to move through painful thoughts or affects, and keeps the person in-the-moment. Sensory Grounding Skills, holding something soft, listening to soothing music, drawing or writing, for example, can interrupt the trance-like state and can shift the person from engaging in the maldaptive cutting. Cognitive Grounding Skills, like “Who am I really mad at”, ”What is setting me off”, “I am safe and I am in control”, re-orient a person to the here-and-now, and can keep the impulse to cut from emerging.
If cutting is not addressed, a person will not only suffer scarring on a physical level, but will experience poor self-esteem, an inability to tolerate and master conflicts, and constriction in social and intimate relationships, just to name a few. Trust, expression and connection will likely be tentative and tumultuous at school, work and home as well.
Returning to Anne, she reports less frequency in her cutting, and her urges have lessened in intensity. She and I have come to learn that her personality and behavioral traits are dependent in nature. She sees how her need for attachment and the need to not be alone causes her to cut. She has taken very well to journal writing, giving new meaning to the phrase “the pen is mightier than the sword”.
http://www.selfinjury.info/ - Based in the United Kingdom, this website is volunteer based that raises awareness about self injury worldwide. Many of the contributors are former self injurers.
http://www.selfinjury.org/ - The American Self-Harm Information Clearinghouse website offers articles and resources to inform the general public as well as health professionals about the phenomenon of self-harm.
http://www.selfmutilatorsanonymous.org/ – Using a 12 step program, Self Mutilators Anonymous offers in-person and online fellowships to help in the recovery from self injurious behaviors.
http://www.sidran.org/ - The Sidran Institute, along with Ruta Mazelis, publish The Cutting Edge Newsletter. Articles are often penned by teens and adults living with self injurious behaviors, and there are empirical articles and clinical papers from professionals in the field who treat patients who engage in SIB as well.
American Self Injury Clearinghouse - www.selfinjury.org
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This paper was published in the 2005 Spring Edition of the Suffolk County Psychological Newsletter and is used with persmission.