T(w)eenage Parenting #17: Cutting and Self Injury

The thought of a t(w)een who is self-cutting evokes the image of gothic adolescent listening to The Cure all alone with a razor blade. However, when we really look at the behaviors and emotions that surround a t(w)een who is cutting, we see that these stereotypes don't apply to all t(w)eens who cut.

What is Cutting?

Cutting is a self-injurious behavior in an attempt at body-mutilation.  While cutting is typically done with sharp objects, such as knives, razors, or scissors, it can also be done by repetitively rubbing any object over the same area, including zippers, erasers, and pen caps.  The cutting is not done with the intent to commit suicide, although it may seem like it due to cuts that accidentally go too deep.  There is also a different psychological drive than those who attempt suicide by cutting their wrists.

The psychological differences between self-injury and suicidality are different enough that the American Psychiatric Association is likely to create a new diagnostic category in 2013 for Non-Suicidal Self Injury. The proposed diagnosis uses criteria that the injuries are not caused with the intent of suicide as either reported by the patient or by looking at the patterns of the injuries over the course of the last year (the proposal suggests a minimum of five such injuries over the past twelve months).  Another distinction is that the t(w)een engaging in the acts knows that the method being used does not have lethal intention, which is often seen in the superficial depth of the wounds, as opposed to the deeper wounds associated with suicide attempts.

Research from the 1990's suggested that less than 3% of all 10-18-year-olds engaged in cutting behaviors. Most current research investigates cutting behaviors in t(w)eens as a demographic, but does not examine differences between genders. The few reports that do separate males and females suggest that while only 8-10% of males engage in cutting behaviors, as many as 20% of females in this age range are cutting themselves with sharp objects or burning themselves with matches or lighters.  A 2008 study from Yale University found that 56% of 10-14-year-old females had engaged in self-injury, including 36% in the past year. But these gender differences only tell part of the story.

Who is Cutting?

While females are more likely to cut, there are even more specific demographics and behaviors that may dictate who is most likely to engage in self-harming behaviors. Caucasian females who are in middle or high school who come from in-tact, middle or upper class families are the most likely to cut.  Typically, but not always, the t(w)eens who engage in this type of behavior are high-achievers who attempt to maintain a picture of perfection surrounding them and their achievements.

Why is this group so prevalent? The t(w)eens who engage in these behaviors have a difficulty expressing their feelings, which can lead to extreme emotional reactions to minor occurrences, such as a small argument with a parent or friend. These girls also have the most to lose socially by having emotional blow-ups. Cutting allows for a physical release of the built up emotional pain without creating a scene that would risk a loss of social status. This is also why wounds are most often hidden; in order to protect their social status and image of perfection, t(w)een girls will conceal the evidence.

Males tend to not have the same repercussions for emotional blow-ups. Sometimes, these are encouraged, such as using the emotion in football or other aggressive arenas. The general idea is that males act outwardly, where females act inwardly. Males who usually engage in cutting behaviors tend to have few friends or are otherwise considered outcasts by their peers. The behavior may also be an act of aggression toward someone else.

What to Watch for

T(w)eens who engage in cutting typically exhibit certain behaviors or signs to hide the marks left from their injuries.  Signs that a t(w)een is cutting include wearing long-sleeve shirts or long pants during warm weather, wearing thick wristbands or watches that are never removed, having unexplained marks on the body, reports of being clumsy that lead to suspicious scrapes or bruises, spending lengthy periods of time alone, having friends or peers who are reportedly cutting, and the disappearance of items that can be used for cutting (knives, razors, safety pins, etc.).

Cutting can take on addictive qualities, both physically and emotionally.  From a physical standpoint, the body produces a rush of endorphins, which are the body's "feel good" chemicals that counteract the initial pain. Emotionally, however, it becomes a habitual way to tolerate difficult emotional responses to stressors. In these cases the addiction to cutting isn't for the physical rush, but as the "go to" response for stress relief, which can be anything from too much homework to breaking up with a boyfriend. Eventually, if left untreated, the t(w)een feels the need to cut more frequently as it does not produce the same emotional release as before.

A few months ago, I had a client in my practice that reported cutting behaviors. The client reported engaging in the behavior during school with friends, purely as a social activity.  In these cases, cutting can be seen as attention-seeking from peers.  What may have started with one person who has deeper psychological problems has turned into a social status symbol.  Much in the same way that peer groups can go through eating disorders at the same time (binge groups or restricting groups), cutting can become a fad, too.  In these groups, the cutting can escalate much more quickly as the scars become signs that state, "Look how much pain I can tolerate."

How Parents Should Respond

If you suspect or know that your child is engaging in cutting, your response can dictate the course of the treatment. Many parents initial reactions range from disbelief to outright rage.  I find that many parents try to rationalize with their t(w)eens, making such statements as, "What were you thinking? Didn't you know it was going to hurt for days afterward?!", or "Don't you know what you are doing to your body long-term?!" While these are completely normal emotional reactions from parents, they aren't necessarily the most productive from the t(w)een's standpoint, and can actually make the cutting behaviors worse. Remember, the t(w)eens who engage in these behaviors typically have difficulty expressing their feelings, so putting them on the spot with a barrage of questions isn't going to provide them with a safe, emotional atmosphere to open up to you.

You may not realize that you could be contributing to the problems at home. Pushing kids to be high achievers or to avoid showing weakness can have negative effects. If your response in the past has been to dictate and control aspects of your t(w)een's life, you may want to give more emotional space to your t(w)een to let her speak up about her own experiences. While it can be anxiety-provoking for parents to hear what is happening with their t(w)eens, it is important for parents to keep their own emotions in check. This means accepting that you are having an emotional reaction and admitting that you are having the emotion to your t(w)een. For instance, this can sound like, "I'm afraid of what you're going through."

Some parents fear that if they are too supportive of their t(w)een, then the t(w)een will take it as permission to continue cutting. While this may be true in some cases, you really want to establish open communication between you and your t(w)een about cutting behaviors. From a purely risk-reduction standpoint, you are better off knowing about the cutting than having your t(w)een continue to hide the behavior from you. By acknowledging that there is an issue, you and your t(w)een can begin finding appropriate ways to handle responses to stress.

The best thing that you can do is to learn more about cutting and have your t(w)een evaluated by a therapist for the severity of the cutting behaviors and any underlying factors. Know that not all cutting behaviors need to be treated through prolonged therapy, as in the cases of social cutting. These behaviors occur on a spectrum and can range from very serious to somewhat benign. The best way to find out is through open communication.