VOL: 98, ISSUE: 02, PAGE NO: 38
Jacqueline Freeman, BSc, RN(MH), is a staff nurse at the Early Onset Unit, Lambeth Hospital, LondonCutting of the skin has been carried out for centuries in rites and rituals. However, in contemporary Britain, cutting oneself is usually regarded as a sign of mental instability.
Cutting of the skin has been carried out for centuries in rites and rituals. However, in contemporary Britain, cutting oneself is usually regarded as a sign of mental instability.
There is little epidemiological information on the prevalence of self-harm, of which cutting is a common form. Favazza and Rosenthal (1993) reported a prevalence of between 400 and 1,400 per 100,000 of the population per year for all self-injurious behaviours; yet many instances go unreported and undetected. In an unpublished thesis in 1994 Harrington reported an average of 5.5 self-harming incidents each week in secure psychiatric hospitals, with almost two-thirds (63%) of female patients self-harming during a one-year period (Jones and Hughes, 1998).
Cutting often involves the arms and hands. However, the legs and, less commonly, the face, torso, breasts and genitals are cut. Razor blades, shards of glass and knives are typically used, although the range of potential tools is as large as the self-cutter's imagination.
The number of people arriving in A&E departments as a result of deliberate self-harm has increased significantly in recent years (Greenwood and Bradley, 1997). These people may be classified as having attempted suicide, but this is not the case. People who self-injure may be depressed or distressed, but usually are not trying to kill themselves. Solomon and Farrand (1996) describe the link between the two acts as one (self-injury) being an alternative to the other (suicide); thus self-injury can be seen as a form of self-preservation.
Nevertheless, it should not be assumed that patients who repeatedly harm themselves are never suicidal. Hawton et al (1999) identified that 45% of people committing suicide before the age of 25 had a history of self-harm. Earlier statistics also show that 1% of those who deliberately self-harm kill themselves within one year, a rate 100 times greater than in the general population (Williams and Gethin Morgan, 1994).
The nature of self-cutting
Common triggers for self-cutting are interpersonal conflict (Morgan et al, 1975) and overwhelming emotional pain or anger (Arnold, 1995). The process of cutting is often experienced in a dream-like state, which may be comforting as well as feeling magical or special. People often report feeling little or no pain during the act and great relief with the decrease in tension that follows (Feldman, 1988; Macleod et al, 1992). This relief seems to drive the addiction, leading to long-term continuation of cutting.
Self-cutting is sometimes described as an impulsive act (Mansell Pattison and Kahan, 1983), perhaps because it is preceded by a compelling drive to relieve tension. However, evidence suggests that it is more likely to be organised and ritualised as a coping strategy (Babiker and Arnold, 1997). For example, people who cut often carry blades, or store them as a contingency; as a way of feeling safe and in control should the urge to cut arise.
A key approach to understanding the addictive and long-term qualities of self-cutting is to look at the historical antecedents to the behaviour. Cutting is a clear expression of psychic pain and its repetitive and chronic characteristics speak volumes about the depth of that pain. Familial and personal circumstances may persist for years and be reflected or re-enacted in continued cutting.
The background to self-harm
Abuse or maltreatment are common experiences as well as bereavement and loss (Babiker and Arnold, 1997). In particular, childhood physical and sexual abuse are recognised antecedents of self-mutilation (Tantum and Whittaker, 1992). In a major study, 62% of repetitive self-cutters reported a history of childhood sexual and/or physical abuse (Favazza and Conterio, 1989).
Favazza (1990) suggests there is a broad link between self-mutilation and 'stressful situations', including physical/sexual abuse, early hospitalisation and medical procedures, institutional care and parental alcoholism and depression. These all involve some degree of maltreatment, neglect, loss of autonomy and/or isolation, leading to feelings of helplessness and anger. Such experiences force the child to encounter complex, distressing emotions and self-injury may develop as the only alternative to the feeling that they may not survive the experience, and so provide some control over the body and its pain. Alternatively the maltreated child ends up with feelings of low self-worth which may create a tendency towards self-destructiveness.
The expression of trauma through cutting the skin suggests a specific relationship between the self and the skin. The skin is the boundary between inside and outside. It visually communicates inner states, for example through blushing. Abuse frequently involves breaking or wounding the skin. Cutting the skin may serve to re-establish the skin as a boundary, or re-enact boundary violations in an attempt to understand or resolve the experiences. The caring for the skin that follows cutting may provide longed-for soothing.
Self-cutting is rarely a one-off event and its addictive nature means that it cannot be halted easily. Like most addictions, cutting induces physical and psychological gratification.
Cutting through layers of meaning
It is commonly assumed that people who cut themselves repeatedly with no suicidal intention are communicating feelings such as violent anger, hatred, distress, loneliness, shame or guilt to others. Reder et al (1991) propose that it is primarily an interpersonal transmission that one is in crisis, 'This is how bad I feel'. This view is validated in certain contexts, such as psychiatric inpatient and prison environments, as well as when the purpose of the injury is to manipulate, blackmail or deliberately offend others. However, labelling all self-mutilating acts as 'attention-seeking' or cries for help can be trivialising, superficial and unfair.
Self-inflicted cuts are frequently hidden from view and performed in private (Roy, 1978) and many studies suggest that the overriding meaning is self-reflective. Experiences of dissociation are commonly relieved through cutting, which makes the person feel 'real', alive and grounded in the moment, terminating feelings of detachment (Solomon and Farrand, 1996; Barstow, 1995; Tantum and Whittaker, 1992; Allen, 1995).
Cutting as an expression of self-hatred or anger against the body is also a recurrent theme. This can be understood in the context of the high proportion of sexually abused people who self-injure. In this sense, injuring the body is reminiscent of ancient and diverse cultural practices used as punishment to atone sin. In particular blood-letting is often referred to as purifying. Many cutters report that seeing the blood and feeling its warmth is the sensual highlight of the experience.
Self-harm can also be a way of controlling relationships and the ambivalent feelings they arouse; it distances others and allows individuals to protect themselves against rejection (Lemma, 1996). The sense of control borne from cutting may also be linked to feelings of security reported by regular cutters (Favazza, 1989).
Biological causes of self-harm
Some researchers have concentrated on the biological aspects of self-injury. Van der Kolk et al (1991) propose that a biological predisposition can be set up by early experience and maltreatment. It is also suggested that self-mutilation is a form of self-medication, because cutting causes endorphins to be released, providing analgesia, reducing anxiety and decreasing dysphoria (Favazza, 1989).
Some researchers propose that some people have impaired opiate systems and need to externally simulate the release of opiates in order to feel emotionally balanced. Winchel and Stanley (1991) found the exact relationship to be unclear, but favour the theory that self-injury is a disorder of impulse control caused by impaired serotonin levels. Recent biological research supports the hypothesis that repetitive self-cutters have an increased serotonergic hypofunctioning (Simeon, 1992; Herpertz et al, 1997; Loughrey et al, 1997). Such findings have led to the administration of serotonin reuptake inhibitors to repetitive cutters (Favazza, 1998).
The erotic associations of recurrent self-harm have been discussed in the psychoanalytical literature. The combined sensations of pleasure and pain may relate to early experiences of sexual abuse. The element of control in cutting and the ensuing relief of tension can be seen as auto-erotic, and similar to orgasm following masturbation. One survey of adolescent girls with mental disorders found that many equated the experience of cutting to orgasm (Ross and McKay, 1978).
Daldin (1988) proposes that cutting represents a self-stimulating masturbatory activity, involving both sexual gratification and punishment for the impulse to self-stimulate. He highlights the fact that the onset of cutting during adolescence is linked to the importance of masturbation during this phase of development. The perceived deviant nature of self-harm and the secrecy around it may also add to its erotic component.
Alvarez (1997) suggests that an erotic association may become a secondary motivation for cutting. She proposes that its original motive may have been some attempt to solve an unconscious internal problem but, over time, the person may begin to cut even when not particularly distressed, and thus self-cutting may become exciting and gather sexual associations. Alvarez (1997) also notes that some people who self-harm want others, typically a therapist, to know that they enjoy hurting themselves.
Repetitive self-cutting should be taken seriously, as it demonstrates psychic pain and could be a prelude to suicide. It is imperative that health care professionals move away from accepting such behaviour as chronic and attention-seeking, and towards a sensitive and empathic understanding of people who self-harm.