What is Cutting?

Written by: Shannon O'Brien, M.S., LAPC, NCC

The frequency of young people engaging in self-harm appears to be increasing, with one source estimating the current prevalence to be around 1 in 15 (Hall & Place, 2010).  This is a growing concern for parents, teachers, caregivers and those who are trying to overcome their own desire to cut. 

What is cutting and how does one recognize it?

Cutting is classified as a form of non-suicidal self-injury (NSSI) and can further be defined as a self-inflicted and deliberate destruction of body tissue without conscious suicidal intent.  

Self-inflicted wounds:

• Have sharp geometric borders typically surrounded by normal looking skin 

• Tend to appear asymmetrically and usually in areas easily accessible to the person cutting

• Are usually light and superficial without harm to the arteries

• Can present as parallel hatch marks or words which are often representative of the issues the person is dealing with, such as “hate” or “ugly”

• May involve razors, knives, scissors, glass, paper clips, sharp fingernails or any other sharp object (Fischer et al., 2013).

What leads to cutting?

• Childhood Trauma – This can be physical violence, sexual abuse, or psychological neglect/conflict (Gmitrowicz et al., 2014).  As a result, children and adolescents may not learn how to cope leading to high impulsivity, anxiety, poor self-identity and ambivalence towards themselves and others (Yip, 2005). 

• Psychiatric Conditions - Self-harm occurs in 70–80% of clients who meet criteria for borderline personality disorder (Yip, 2005).  Self-harm is also associated with eating disorders, mood disorders, personality disorders, disruptive, impulse control and conduct disorders, body dysmorphic disorder, substance-use disorders, trauma and stressor-related disorders and schizophrenia (Fischer et al., 2013).

• Family Conditions - Growing up in a generally unstable, unpredictable or unsupportive home can stifle a child’s basic abilities of verbalization and adequate expression of personal emotions.  Additionally, disturbed family relations, alcohol abuse by one or both parents, and even a history of mental illness or suicide within a family can be predictors of self-harm.

• Disassociation – Common in those who self-harm, a dissociative experience can be best described as a detachment from a physical or emotional experience.  The state may allow the act of cutting or it may act as a method for ending the dissociative state, enabling people to reconnect with their identities.

• Sexual Impulses – Cutting may be used as a substitute for masturbation, especially in instances where sexual exploration is frowned upon.  It has been shown that adolescents with psychiatric problems seem to have a poorer capacity to mentally process the ongoing physical and sexual maturation of their bodies - finding themselves unable to integrate these changes into their self-identity.  Girls are commonly more dissatisfied than boys with their changing body and more vulnerable to different stressors (Laukkanen et al., 2013).

• Past Suicide Attempts and Suicidality - Youth who had attempted suicide in the past year were twice as likely as non-attempters to report cutting in order to feel relief from cutting (Nickels et al., 2012).  Additionally, suicidality within peer networks is an indicator.

Statistically, who is likely to engage in cutting or other self-harm behavior?

• Rates are highest among adolescents and young adults ranging from between 12 and 21.

• The age of onset of self-injury is consistently reported to be between 12 and 14 years of age and typically occurs during a relatively brief developmental period though there are instances where cutting will continue or re-occur in young adulthood (Laukkanen et al., 2013).

• Within the LGBT community it is noted that more openness and younger ages of disclosure of sexual orientation may be correlated with increased risks of self-harm because of the increased levels of rejection and bullying experienced by these youth, at a time when peer acceptance is critically important developmentally (Nickels et al., 2012).

• Regarding gender, girls have been reported to cut themselves more frequently than boys and this is usually attributed to the finding that girls are more likely to internalize whereas boys tend to externalize.  It was also found that girls are more likely to view self-harm as an act of self-punishment and to self-blame (Hall & Place, 2010).  Research suggests that boys and girls may differ in regards to the form and function of self-harm.

Is cutting influenced by the media and peer pressure?

Trends highlighting violent and self-injurious behaviors have been identified as possible influences. Disturbingly, there are internet web sites and chat rooms dedicated to self-injury, some of which glorify cutting as cool or a source of strength. Some schools even have peer subgroups in which cutting is a requirement for becoming a member. (Dyl, 2008).  

Peer influence and peer acceptance are also factors leading to cutting as it’s often seen as being representative of a youth culture or counter-culture.  Within groups identifying as “goth” or “emo” cutting is seen as an expression of rebellion and self-identity.   Some use cutting as an expression of anger and frustration towards an adult oriented society.  Those who have friends that self-harm are more likely to engage in cutting especially if the behavior is socially reinforced in their network or symbolic of courage or rebellion.  People with no history of trauma or presence of psychological illness at all, often cut due to social pressures.

Is cutting an indication of a future suicide attempt?

There is a likely association between cutting and suicide - with rates increasing between 30 to100 times compared to the general population depending on the study. Furthermore, approximately half to two-thirds of people who die by suicide have been found to have a history of self-harm.

Most people who self-harm do not seek professional treatment. In fact, less than 50% of persons reported seeking help (Ross, 2014).  With suicide as the second leading cause of adolescent death, reducing self-harm repetition is of utmost importance (Ougrin, 2012).

There are those who view self-harm as being a distinct condition, separate from suicidality, used as a mood regulation strategy.  Self-harm in adolescents is likely to be associated with a spectrum of suicidal intent with purely suicidal and purely non-suicidal groups at each end of the spectrum (Ougrin, 2012).

It should be noted that some research indicates that although some teens that cut have a history of suicide attempts. Cutting is not always an indication that a teen is considering or attempting suicide. In fact, some research indicates that engaging in cutting may serve a protective function in helping people cope and thus preventing suicide attempts (Nickels et al., 2012). The motivation behind the cutting may need to be assessed by a professional to determine what the person’s goals are.  With this in mind, the severity should not be overlooked as the majority of research indicates that self-harm is considered to be a risk factor for suicidality. 

Why do people cut?

Generally, cutting can be lumped into two categories: those who are emotionally troubled with no effective way of coping and those for whom cutting is part of the youth culture to which they belong (Hall & Place, 2010).

Those who cut are typically attempting to manage negative cognitions about the self, avoid or minimize negative emotions, generate positive feelings and remove feelings of numbness.  It is also suggested that self-harm may be an attempt to self-punish or cope with feelings of self-loathing.  It is also seen as a way to translate emotional pain into physical pain, which the person may view as easier to cope with.  One person was quoted as describing her desire to cut as the following: “I felt lonely, I needed stimulation, I hated myself, cutting made me feel something, and cutting gave me an emotional release” (Nickels et al., 2012).

 

The feelings derived from cutting vary, however, it is known that relief is short-lasting, and is often followed by emotions such as self-anger, a sense of guilt, a sense of helplessness, as well as sadness and self-complaining that leads to repeated episodes and the creation of a vicious cycle (Gmitrowicz et al., 2014).

Is there meaning behind the location of the wound?

The location of the wound does have significance.  

Placement elsewhere than on the arms is found to be more common in girls and is also associated with more serious psychiatric symptoms including disassociation and suicidal ideation, often followed by attempt.  Those who cut elsewhere on the body experienced greater relief, were less bothered by their scars and, as a result, became more dependent on cutting than those who cut only on the arms. Those who cut on the arms only, are likely doing so as a means of social signaling to peers or help seeking from others (Laukkanen et al., 2013). 

What can I do as a parent?

Supportive parental response helps adolescents ease frustration and reduce the possibilities of further cutting. Alternatively, inappropriate parental response such as outburst of anger, frustration, or blaming tends to increase the possibilities of further self-cutting of adolescents. 

 

Helping teenagers establish supportive peer groups, find volunteer opportunities, engage in meaningful social and recreational activities, and engage in creative work can help teens to develop a healthy self-image and competence in facing external difficulties and problems. 

Treatment

An evaluation from a psychiatric professional is recommended.  It is imperative that teenagers dealing with such issues have an adult with whom they feel safe disclosing any stressors.  Parents may often benefit from information from a professional regarding self-cutting and assistance in processing their own emotions evoked by their adolescents’ cutting (Rissanen et al., 2013).

 

According to adolescents with a history of self-harm, maintaining a long-term relationship with a professional with whom they have a safe place to express feelings about the past, explore underlying issues, sort through current problems and to be accepted non-punitively, have been rated overall as the most helpful methods of managing cutting (Huband et al., 2004).  

 

There are several therapeutic approaches that are effective in dealing with those engaging in cutting, notably Cognitive Behavior Therapy, Narrative Therapy and more recently, Dialectical Behavioral Therapy (DBT) are all proven to help people work through their desire to cut.  Through therapy, teenagers can explore the beliefs and stressors they have, while learning skills to deal with the desire to self-harm in the moment, and begin to challenge their own negative feelings and cognitions.  

 

In looking for a therapist, it is particularly important that the therapist’s personality, experiences, and point of view fit well with those same factors in the patient. In fact, the relationship between the patient and therapist is likely the most important factor in any psychotherapy (Ruberman, 2011).

Citations

1 Dyl, J. (2008). Understanding cutting in adolescents: Prevalence, prevention and intervention.        Brown University Child & Adolescent Behavior Letter, 24(3), 1-6.

2 Fischer, G., Brunner, R., Parzer, P., Resch, F., & Kaess, M. (2013). Short-term         psychotherapeutic treatment in adolescents engaging in non-suicidal self-injury: a       randomized controlled trial. Trials, 14(1), 1-7. doi:10.1186/1745-6215-14-294

3 Gmitrowicz, A., Kostulskik, A., Kropiwnicki, P., & Zalewska-Janowska, A. (2014). Cutaneous      Deliberate Self-harm in Polish School Teenagers – An Interdisciplinary Challenge. Acta        Dermato-Venereologica, 94(4), 448-453. doi:10.2340/00015555-1690

4 Hall, B., & Place, M. (2010). Cutting to cope – a modern adolescent phenomenon. Child: Care,      Health & Development, 36(5), 623-629. doi:10.1111/j.1365-2214.2010.01095.x 

5 Huband, N., & Tantam, D. (2004). Repeated self-wounding:Women's recollection of pathways to              cutting and of the value of different interventions. Psychology & Psychotherapy: Theory,          Research & Practice, 77(4), 413-428

6 Laukkanen, E., Rissanen, M., Tolmunen, T., Kylmä, J., & Hintikka, J. (2013). Adolescent self-       cutting elsewhere than on the arms reveals more serious psychiatric symptoms. European         Child & Adolescent Psychiatry, 22(8), 501-510. doi:10.1007/s00787-013-0390-1

7 Nickels, S., Walls, N., Laser, J., & Wisneski, H. (2012). Differences in Motivations of Cutting        Behavior Among Sexual Minority Youth. Child & Adolescent Social Work Journal,      29(1), 41-59. doi:10.1007/s10560-011-0245-x

8 Ougrin, D. (2012). Commentary: Self-harm in adolescents: the best predictor of death by    suicide? - reflections on Hawton et al. (2012). Journal Of Child Psychology &             Psychiatry, 53(12), 1220-1221. doi:10.1111/j.1469-7610.2012.02622.x 

9 Rissanen, M., Kylmä, J., Hintikka, J., Honkalampi, K., Tolmunen, T., & Laukkanen, E. (2013).       Factors helping adolescents to stop self-cutting: descriptions of 347 adolescents aged 13-                   18 years. Journal Of Clinical Nursing, 22(13/14), 2011-2019. doi:10.1111/jocn.12077

10  Ross, A., Kelly, C., & Jorm, A. (2014). Re-development of mental health first aid guidelines for     non-suicidal self-injury: A Delphi study. BMC Psychiatry, 14(1), 120-135.       doi:10.1186/s12888-014-0236-5

11 Ruberman, L. (2011). Girls who Cut: Treatment in an Outpatient Psychodynamic Psychotherapy    Practice with Adolescent Girls and Young Adult Women. American Journal Of    Psychotherapy, 65(2), 117-132. 

12 Yip, K. (2005). A Multi-Dimensional Perspective of Adolescents' Self-Cutting. Child &      Adolescent Mental Health, 10(2), 80-86. doi:10.1111/j.1475-3588.2005.00122.x