The consensus of several dictionary definitions describes mutilation as “the act of damaging seriously by cutting off, or altering an essential part.” In most cases of self-mutilation, the “essential part” of the self that is damaged is the skin, which is cut with a knife or razor blade, or scraped with an abrasive material—scissors, bottle cap, etc. Sometimes the skin is burned. In the course of treating self-mutilators, I have seen what a hot teakettle, a match, or a lit cigarette can do to the flesh. Sometimes the skin is chafed with detergent or other irritating chemicals.
The damage is rarely life-threatening, and the location of the wounds is usually on an easily hidden part of the body, though not always. Since it is the skin that is damaged, and not veins, arteries, tendons, or ligaments, the long-term harm is usually restricted to scarring.
Nonetheless, self-mutilation is a truly gruesome behavior accompanied by cosmetically gruesome results. It is the extreme nature of these external acts of self-harm that causes us to consider them worthy of psychological examination, and urges us to uncover the mental and emotional desperation they suggest.
It is important to understand that these forms of self-mutilation are not part of group rituals, not just an adolescent trend. They represent, rather, individual psychopathology: mental illness. For the purposes of this book, the current trend of piercing the skin on various parts of the face and body, ranging from the ears to the nose, nipples, navel, genitals, eyebrows, and tongue, is not self-mutilation. This behavior, although repugnant to some of us, falls into the category of adolescent trendiness (which also includes larger and more outrageous tattoos). Although such behavior alone does not constitute psychopathology in an individual, it may however create psychopathology in his or her parents.
The reason I distinguish between similar behaviors—one “sick” and the other “goofy”—is that their origins stand in sharp contrast. The “sick” behavior is a manifestation of severe psychological illness, whereas the “goofy” behavior complies with certain socially accepted norms. There are significant differences in the psychological motivation behind the respective actions of each group, as well as in the actual experience of the individual who alters his or her skin.
An analogy to conventional dieting versus anorexia nervosa is useful here. When most of us diet, we feel deprived, annoyed. When the anorexic is starving herself, she feels satisfaction, even though she is suffering pain and may be in danger of losing her life.
When someone decides to pierce or tattoo a part of his or her body, he or she feels pain, and dislikes it. Some people even do it feeling terrified, but it’s a package deal: if you want the tattoo, you have to endure the pain. When the self-mutilator cuts herself, on the other hand, she is usually in a trance state, seeking out the pain and blood. She is far less concerned with the resulting change her skin will undergo. Self-mutilators are not acting within the norms of any cultural microcosm; they do not plan their activity, but rather are overtaken by a compulsion to commit these acts, which are not about conscious intent. For the self-mutilator, it is the experience of physical pain—for its calming effect on her more painful psychological state—that is being sought.
In the Introduction, I described a seventeen-year-old girl who called to tell me her sister wouldn’t stop crying. You’ll recall Eileen, my patient, told me that her younger sister was crying because Eileen was cutting her own hand with a knife and it was bleeding. Eileen was baby-sitting for her sister at the time. You may also recall that her tone was flat, disengaged. It was almost as if she were watching a boring movie and commenting on it. Her style of reporting did not at all reflect the actual nature of the situation. Her voice did not resonate as that of a girl who was drawing her own blood with a kitchen knife.
We might say that Eileen was out of touch with reality at the time, certainly the reality of her responsibility to her younger sister. She was also out of touch with the reality of her actions, and with her feelings about what she was doing to herself. Eileen was in fact devoid of any emotional response to what was going on.
Regardless of whether we term Eileen’s condition as being out of touch with reality, psychotic, or in a dissociated state, the scene constitutes severely disturbed psychiatric behavior. This is the element that must be present in order to meet the criteria for self-mutilation as I define the term in this book. “Severely disturbed behavior” does not mean hopeless, but it does mean that it will take a long time, lots of focused attention, and an intense emotional bond between helper and sufferer in order to repair the damage.
At present, self-mutilation is not officially recognized as a disorder and is therefore not listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.* Though briefly mentioned as a behavior sometimes seen in borderline personality disorders, it is cited only in its capacity as a feature of a larger disorder. When I use the terms feature and disorder in this book, I am treating self-mutilation in the same way that obsessive-compulsive disorders (especially trichotillomania or the pulling out of one’s hair) are treated in the diagnostic literature.
In the most severely pathological forms, self-mutilation can be classified using the following diagnostic criteria:
• Recurrent cutting or burning of one’s skin.
• A sense of tension present immediately before the act is com mitted.
• Relaxation, gratification, pleasant feelings, and numbness experienced concomitant with the physical pain.
• A sense of shame and fear of social stigma, causing the individual to attempt to hide scars, blood, or other evidence of the acts of self-harm.
Of course, what is not mentioned here (and usually isn’t in the psychiatric definitions) is “Why does such disordered behavior happen?” “What does it mean?” and “What does it tell us about other coexisting personality or mood disorders?”
As in the case of so many other disorders, and features of those disorders, the answer to these questions is that we won’t know without understanding much more of the individual than just these acts of cutting or self-harming alone.
Our first task, then, is to interpret the act of self-mutilation. Is it a love of pain? Does the cutter enjoy pain? Is this like masochism, where the pain alone is the end in and of itself? No. Self-mutilating behavior is different. We have to put ourselves inside the head of a cutter to comprehend the personal value and meanings that pain holds for her. Let’s use another patient’s report of her experiences as an example.
Annika’s Story
“I was home alone. There was something both wonderful and terrible about the privacy. I walked from room to room, glad that each one was empty. No one could nag me, bother me, or scare me. I was feeling safe. After an hour of looking at magazines, I started to feel frightened of nothing in particular. I wanted the fear to go away. I tried to tell myself that there was nothing wrong; school was okay, my oboe playing was good, I had parties to go to. But the fear wouldn’t go away. I banged my forehead against the wall of my bedroom. My head stung, but only for a moment. As the stinging diminished, I knew that I needed something that would last much longer. It had to last so long that by the time it went away, my feeling of dread would be gone and wouldn’t come back, at least for a long time.
“I left my bedroom and went into the kitchen. No sneaking around this time. I would look at the knives on the rack as if I were shopping in a department store, leisurely. No sneaking into a stall in the ladies’ room with a small sewing scissors this time. I could feel the fear refusing to leave me, but I knew I could get rid of it at any second. I chose the sharp serrated knife we use for frozen foods. The serrations would make the most jagged, roughest cuts of all. It would hurt the most, bleed the most, and take the longest time to heal. I would make the cut slowly, getting the most pain from each millimeter.
“I placed it across my left forearm on the underside—easy to hide. Easy to explain as an accident from a fall. I slowly made a one-inch cut. I thought I could feel each tooth of the knife’s edge bite into and tear a little piece of skin.
“It wasn’t pain I was feeling, it was like an injection of Novocaine that the dentist uses; it makes pain go away even though the needle ‘pricks’ as the dentist puts it in. And because I controlled the pain, there was no fear with it. So maybe it’s not real pain. When I finished the inch, blood ran down the side of my forearm in a neat stream onto a folded paper towel. The stream was dark red and thick, but I wanted to see more, so I tilted my arm and the stream broke into three rivulets and the rivulets broke into a wash that was three inches wide and turned my forearm red.
“That was enough for me to see. The fear and dread were gone. I washed my arm under cold water from the tap and used hydrogen peroxide to stop the bleeding. I put a gauze pad on with adhesive tape. I went back to my bed and fell asleep. It took me two hours to remember the details, though I knew what I had done when I woke up in the morning.”
I could see Annika’s mood change as she recounted this incident. As she was describing the cutting and bleeding, she went into a trancelike state as if she were reliving it all. This kind of trancelike state is typical of cutters. I asked Annika to tell me what the experience meant to her, its value. She said, “It was like medicine for my fears.”
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Annika’s explanation made me wonder why it was that inflicting pain on herself and causing herself to bleed felt like medicine; why it felt like caring for herself. Most self-mutilators give similar explanations about the “rewards” of such behavior. This suggests that somewhere in the past, pain was somehow connected to the idea of home and comfort. These kinds of associations—pain with comfort—are alien to most of us.
It is important to remember that people will generally seek the familiar, the repetitious, rather than what is new and constructive. If the familiar happens to be painful or harmful, that rarely stops someone from seeking it out. Otherwise we would never do what is not in our own best interest—especially during those times when we are aware that it’s not—with regard to our own health, welfare, financial well-being, and healthy relationships. When the familiar is grotesque, a person seeks out the grotesque. We call such behavior a disorder.
Shila’s Story
Let’s take the case of Shila, whose father stopped being close to and supportive of her when she reached puberty and developed breasts. As she hit adolescence, Shila’s father backed away from her in terms of affection, communication, and conversation in general. He may have been under the impression that such interaction was inappropriate now that Shila was a teenager, but the result was that she felt both punished and abandoned by her father. In response, she dressed boyishly, avoided makeup, and did her cutting on her breasts, blaming her body and the onset of puberty for driving her father away.
The anxiety that Shila felt but couldn’t identify was a result of her father’s separation from her. Unconsciously attacking the cause of his unwitting abandonment was Shila’s only means of quelling her fear. This behavior, and the feelings of abandonment that caused it, is not the sort of thing most teenagers can talk about, within the family or without. With no verbal outlet, Shila’s behavior grew stronger, developing a life, an energy, and a rationale of its own.
Self-Injury as Protest
To help us further define what self-mutilation is, we can take a look at what does not constitute such behavior.
Maria acted out consciously on her family by holding her success and safety hostage in order to punish her overprotective parents. As long as she was sick, doing badly in school, having trouble with friends, she was rewarded with lots of supportive attention from her parents. The more care she received at home, the less equipped (and more afraid) to cope with anyone outside the family she became. At this point, Maria resented her parents and their love deeply.
When she was feeling this resentment, Maria would up the ante. She would feign illness, and when more care came (feeding into the cycle of her resentment), she would become more extreme, purposely falling down or even cutting herself. But her self-injury was a protest that she broadcast loudly to the rest of her family. She did not keep it a secret, hated doing it, and blamed everyone around her for her injury. Even her cutting was a conscious manipulation to frighten her family.
Maria had a hostile dependence on her family, which made her increasingly unfit to cope with the rest of the world, but because her behavior was directed at others, she was not a self-mutilator. Maria was atypical in the spectrum of self-mutilators; typical self-mutilators are not as consciously deliberate.
Diagnostic Factors
As we learn more about self-mutilators, new diagnostic subcategories may emerge, based on certain additional factors:
• other mental health problems;
• the frequency and severity of the acts of self-mutilation;
• internal versus external stress factors;
• the patient’s state of mind when such acts are executed (i.e., whether or not the person is aware of what he/she is doing at the time); and
• the types of personality disorders that drive someone to commit these acts.
This type of understanding is crucial for determining the treatment that will be most helpful in each case, and the prognosis or chances for recovery.
*This failure on the part of the Diagnostic and Statistical Manual to consider a severe, physically endangering, and sometimes life-threatening psychological behavior as a disorder means that clinical efforts to understand the problem are in danger of remaining on the back burner. For victims and their families, this means that most who suffer will continue to do so.