When Pain Is All You Have

Last Editorial Review: 1/30/2005

Some people in great emotional pain turn to cutting, burning, and other types of self-abuse. How can you recognize this cry for help?

WebMD Feature

Aug. 28, 2000 -- Lauren McEntire was 17 the first time she intentionally cut herself. She was sitting in a darkened movie theater next to a boy who was her best friend. On the other side of him sat his new girlfriend. "I was jealous. I was scared he wouldn't be my friend anymore," she says, two years later from her home in Austin, Texas. "But I didn't know how to tell him how I felt."

Instead, fidgeting nervously in the quiet theater, she yanked the tab off her soda can. Without much thought, she pressed its sharp edge deep into the flesh of her thumb. The pain and blood that followed made her feel, for the first time, as if she were in control. But with the blood came something more: anger. "A lifetime's worth exploded in that one minute," says McEntire. Within a month, she was a full-fledged self-injurer, graduating to a single-edged razor blade and using it to carve deep grooves into the skin of her arms and legs.

Long misunderstood by outsiders, self-injury (also known as self-mutilation and self-abuse) is finally being taken seriously, and a growing crop of books, television programs, and even a recent made-for-TV movie are spotlighting this surprisingly common phenomenon. The audience is certainly out there: Although few firm statistics are available, those who have treated self-injurers estimate that about 2 million people in the United States engage in some form of this behavior. Cutting is the most common expression of this disorder, but burning, self-hitting, hair-pulling, bone-breaking, and not allowing wounds to heal are other variations.

While more than 70% of self-injurers are women, mostly between the ages of 11 and 26, they come from all races and social classes, says Steven Levenkron, MS, a psychotherapist in New York and author of Cutting. What self-injurers have in common, says Levenkron, is that they are often children of divorce, and as many as 90% grew up in homes where communication between parents and child was lacking and where messy problems were ignored, avoided, and ultimately left in silence.

Cuts Run Deep: Understanding Why

About 50% of self-injurers have a history of sexual or physical abuse, says Wendy Lader, PhD, a psychologist who co-founded and is co-director of SAFE (Self-Abuse Finally Ends) Alternatives, the nation's only in-patient center for self-injurers, in Berwyn, Ill.

Heather Collins, a 26-year-old from Oregon, says the physical pain she inflicted with her own hand for nearly a decade -- using razor blades to cut herself and smoldering cigarettes to burn her flesh -- helped her forget the emotional pain of a childhood marred by sexual abuse. "After I [cut or burned myself,] I felt better," says Collins. This kind of nonverbal expression of anger and frustration is common, says Levenkron. "Many cutters simply lack the language skills to express their emotions." Instead, they feel only self-loathing, alienation, and an intense desire to do themselves harm.

Self-injurers turn to cutting as a way to avoid feelings of worthlessness, numbness, and detachment. They come to appreciate the raw pain of injury; finally, they can feel something. "Self-injurers would rather feel the physical pain than the emotional pain," says Lader.

At the heart of self-injury is control, says Lader. As with eating disorders, self-abuse is a way to take charge of your body. That's one reason many people who self-injure -- an estimated one-half to two-thirds, according to Lader -- also suffer from conditions like anorexia or bulimia. "Self-injury has a hostage-taking effect," says Lader. "It's a way to control parents and friends whose attention you want, or who are worried about you." Whereas the cutter may have previously felt invisible and insignificant, she (or he) is now getting noticed like never before. Self-injury makes others pay attention.

Healing the Wounds

Just as those with eating disorders tend to shroud their activities in secrecy -- anorexics who wear baggy clothes, bulimics who purge in private -- self-injurers often injure places that can be easily hidden by clothing, such as the arms, upper chest, and upper thighs.

Yet, Levenkron says, "Self-injurers are not suicidal. They're pretty careful. They don't intend to destroy themselves, so they quickly figure out how deep, how long, they can safely cut." The wounds are usually quite short (only an inch or so, usually on the non-dominant forearm) and very controlled. Nevertheless, tragedies -- including serious medical complications or death -- can and do occur.

Until recently, self-mutilators like Lauren and Heather were bounced from emergency rooms to mental hospitals with little hope for complete recovery. Mental health professionals simply didn't know what to do with them. Even today, says Levenkron, emergency room doctors sometimes dismiss them, suggesting that they'd rather treat "real" patients, or they simply treat the surface wound and send them on their way. But thanks to increased media attention (the teen drama Beverly Hills 90210 featured a self-mutilation story line), the disorder is finally coming out of the shadows. Now a combination of techniques, including psychotherapy, antidepressant medication, and stress-tolerance and stress-management therapies, are being tried and found to help.

Helping Those Who Are Hurting

At Lader's program, she and her colleagues take a "tough love" approach with their patients, refusing to treat them like potential suicide cases, and ignoring the scars (they don't want the focus to be a show-and-tell of the patients' wounds). Instead, they use talk therapy to help them learn to take responsibility for, and control of, their actions.

The program is a last stop of sorts: SAFE patients have been hospitalized an average of 21 times before they get to Lader; one recent patient had been in and out of hospitals 200 times for treatment of self-inflicted wounds. Despite the odds, Lader says the intensive program has a 75% success rate two years after treatment. "Cutting is a way to be temporarily distracted from real feelings," says Lader, "and we help [cutters] learn to put a thought between the impulse and the action, to learn to deal with their feelings without 'self-medicating.' " The program seeks to uncover the motives behind the self-injury; one technique the program uses is having patients reach for a pen instead of a blade and write about their feelings.

As treatment for self-injurers becomes easier to find, friends and family can play a more active role. If you suspect someone you know is a self-injurer -- say you notice a series of similar scars in various stages of healing -- don't just ignore it. "Be direct but empathic," says Lader. "React in a caring way by saying something like, 'I've noticed scratches (or scars) on your body. Did you make them? I'm worried about you and want to help you get help.' " Don't minimize their seriousness, thinking the whole thing is just a harmless fad and that the wounds will heal with time. "Self-injury was my way of telling people that something was wrong," says McEntire, herself a "graduate" of the SAFE program, "but now I use my voice."

Dana Sullivan is a freelance writer based in Reno, Nev.

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