One evening, many years ago, I received a call from a seventeen-year-old patient I was treating for depression and feelings of alienation. The voice at the other end of the phone was hollow, drowsy, expressionless.
“Hello. This is Eileen.* My little sister won’t stop crying.”
“Why is she crying?” I prompted.
“She’s crying because I’m cutting my hand with a kitchen knife and it’s bleeding a lot and I won’t stop.”
She sounded almost bored reporting this to me. I had no concept of what her behavior or tone meant. In my ignorance (and some alarm), I reverted to my practical Boy Scout training.
“How long is the cut?”
“There are three of them, about one inch each,” she responded in the same hollow tone.
“How deep have you cut?”
“Not so deep. Maybe an eighth of an inch, or a little more.”
She was becoming a little more responsive.
“I would like you to wash the cuts with soap and water, dry them, and put hydrogen peroxide on them; that will stop the bleeding. Then I want you to place Band-Aids very tightly across each one and call me back when this is done.”
She responded compliantly. “Okay.”
Half an hour later she called me back, announcing, “I did what you said to.”
“Do the cuts hurt?”
“A little.”
“Has your sister stopped crying?”
“Yes.”
“How old is she?”
“Seven.”
“When will your parents return?”
“Probably very late.”
“It’s ten now. Why don’t you put her to bed. After that, go to bed yourself and we’ll talk about this tomorrow. I’d like you to come in right after school at three-thirty.”
“Okay.”
This “Okay” was a little more expressive than the zombie voice earlier. That was a good sign, but I certainly needed to think, and to consult with colleagues about this strange behavior before I spoke with Eileen again.
I have been treating self-mutilators since 1976. As I saw more instances of patients cutting or burning their own skin, I maintained my Boy Scout stance. I rationalized that my main concern was figuring out what this behavior meant to them so that I could help them understand and overcome it. They all gave me different hypothetical reasons for their actions.
I was soon shocked to discover how often psychiatrists encountered this behavior in their patients. And yet their reactions were, for the most part, almost as casual as Eileen’s had been.
“Oh yeah,” I’d hear, “another cutter. They’re pretty sick cookies.”
“Sick cookies?” I thought. Were they simply writing their patients off as hopelessly mentally ill? For me, the patients’ behavior was a clue to the severity of their emotional disturbances, and maybe to the severity of the causes of those disturbances.
Today, cutting is a behavior found all too often among the emotionally disturbed or mentally ill, but one that still has been avoided by professionals and the public alike.
My purpose in devoting a whole book to one type of pathological behavior is threefold: first, to invite its victims to come out from their emotional hiding places and disclose who they are; second, to encourage more interest (and discourage revulsion) on the part of the mental health community so that more research will be done; and lastly, to help those afflicted, their families, friends, and the general public to see this behavior for what it is. Self-mutilation is a frightening barrier that keeps us from seeing a person who is lost, in pain, and in desperate need of help.
Cutting takes the reader through the psychological experience of the person who seeks relief from mental pain and anguish in self-inflicted physical pain; the person who finds solace in the letting of her own blood. In the same way that anorexia and bulimia manifested in behaviors that seemed at first incomprehensible to the public, later to be explained by patiently examining these apparently bizarre behaviors, the behaviors of the self-mutilator are similarly unraveled step by step. Although some of these strategies are directed toward the therapist, any way that the parent can augment this therapeutic style will hasten recovery.
At this time we are woefully short on statistics, but it is infered that the percentage of cutters in our society is similar to those who have anorexia, one in every two hundred and fifty girls.* The number of those who have permanently impaired themselves as a result of a self-mutilating act is equally difficult to determine. And the death rate is blurred by our inability to distinguish between those diagnosed as suicides versus accidental death from self-mutilation. The language of this book reflects the fact that so many more girls than boys manifest these behaviors. However, I want to stress that boys, too, can be at risk.
Self-injury is not a new phenomenon. There are numerous historical accounts of self-flagellation, for example, promoted apparently to relieve religious guilt. Christian flagellants, both clergy and laity, have flogged themselves as a means of penance since shortly after the death of Christ. In the mid-thirteenth century, flagellant brotherhoods composed of laymen and women as well as clergy arose in Italy, and the practice spread into Germany and the Low Countries. The scourge of the Black Death increased the fear of guilt and sin, yet by the fourteenth century the moral corruption of the church made it impossible for many religiously sensitive people to turn there for relief. Flagellants sought by their own efforts to mitigate the divine judgment that was felt to be at hand, forming groups that traveled about the country on foot.
In reading these accounts, one can see a parallel between failed faith or trust in the church and the failure of trust in one’s own family in contemporary life. Perhaps we are talking about a universal defense mechanism to which people have always resorted in order to avoid a sense of dread—whether in terms of believing themselves literally damned or feeling emotionally tormented.
The greatest fear we all carry within us is the fear of self. We worry about losing our temper, about our violence emerging and hurting others—especially those we love the most. Regularly in television and newspaper accounts we learn of husbands beating or murdering their wives, of parents beating or killing their children. Such news sends a shudder through us all. We don’t want to believe that members of our own species are capable of such terrible acts.
Just as we fear the human potential for violence against others, we may also fear the possible impulse to hurt ourselves. When we see the wounds or scars of a cutter, do we, just for an instant, fear that we could harm our own skin by attacking it with a sharp instrument? The act of deliberately causing oneself to bleed frightens us in many complicated and varied ways. Clearly, people who harm or inadvertently kill themselves create in us a very uncomfortable mix of fear, guilt, anger, and frustration.
In order to understand and treat self-mutilators, we have to understand enough about ourselves so that we can become effective in helping those who feel abandoned, without confusing our own fears with theirs. Each of these self-harming people has a different history, a different motive, a different state of mind before, during, and after harming themselves. As their helpers, we will have to overcome our own feelings of discomfort. This book proposes to take the mystery out of the frightening phenomenon known as “self-mutilation.”
*All the names in this book have been changed and situations disguised to protect patient confidentiality.
*Based on an informal survey by the Canadian Broadcasting Company, in which five hundred school psychologists were asked if they had seen cutters in the last year. They indicated an incidence of two to three cutters per school.