The Cruelest Cut

By Jeffrey Kluger/ Cambridge

Vanessa's arms no longer show the damage she once did to them. That's saying something, given that the damage was considerable. The college freshman, 19, started with just a few scratches from a sharp piece of plastic. Later came the razor blades and then the kitchen knives. After a time, she took to wearing bracelets to cover her injuries; when that wasn't enough, she began cutting less conspicuous parts of her body. "I was very creative," she says, with a smile.

Vanessa needn't be so clever anymore. In the past 18 months, she has cut herself only once. She was pleased and surprised to find that she didn't enjoy it a bit.

For most people--and especially most parents--the idea that anyone would tolerate the sting of a razor blade or the cut of a knife, much less enjoy it, is unthinkable. But maybe they are just not paying attention. Vanessa is not a member of some remote fringe of the emotionally disabled but part of a growing population of boys and girls for whom cutting, burning or otherwise self-injuring is becoming a common--if mystifying--way of managing emotional pain.

Nobody knows how many cutters are at large, but psychologists have been conducting surveys and gathering data from clinics, hospitals and private practices, and they are shocked by what they are finding. According to one study in the Journal of Abnormal Psychology, from 14% to 39% of adolescents engage in self-mutilative behavior. That range is suspiciously broad, and other estimates have put the figure at just 6% or below. But with more than 70 million American kids out there, that's still an awful lot of routine--and secret--self-mutilation. "Every clinician says it's increasing," reports psychologist Michael Hollander, a director at Two Brattle Center in Cambridge, Mass., an outpatient clinic that treats cutters. "I've been practicing for 30 years, and I think it's gone up dramatically."

The good news is that even as the population of cutters grows, so does the legion of professionals working on new ways to unravel and treat the problem. The first step is to understand why kids do this to themselves.

Overwhelmingly, self-mutilators say they began cutting for one of two reasons: to feel less or to feel more. Some kids suffering from such problems as anxiety, depression or borderline-personality disorder--a condition characterized by explosiveness and unstable relationships--find their pain so overwhelming that they simply shut off their emotional spigot. Cutting, they find, is a way to kick-start feelings when the numbness becomes worse than the pain. Other kids say the opposite--that their emotional turmoil is so great that they need something to serve as a bleed valve to calm them down in times of crisis. "I would do it when things got me upset," says Brittany, 17, an outpatient at the Vista Del Mar clinic in west Los Angeles. "At the time it was a relief, until you wake up the next morning, look at your arms and think, s___, what did I do?"

The population of kids who wake up this way is becoming increasingly diverse. The stereotypical cutter is a girl in her young teens suffering from discord at home and doing poorly at school, and there is some truth to that cliche. "Girls have a more conflicted relationship with their bodies," says Wendy Lader, clinical director of Self Abuse Finally Ends, a treatment program in Naperville, Ill. "They go after it and hurt it when they're angry." While such traumas as sexual abuse don't always precede cutting, they often do appear to be risk factors.

But cutting is becoming an increasingly democratized disorder. By some estimates, up to 30% of self-mutilators are boys, and many cutters of both sexes come from apparently stable, two-parent homes in which there is no evidence of abuse. Some of the kids have a history of suicide attempts, but many have no interest in ending their lives, no matter how self-destructive their behavior seems to be. How often they injure themselves generally depends on how acute the underlying psychological pain is. In one study, kids self-mutilated anywhere from once to 745 times a year. "They do it because it works better than anything else they've tried," says Hollander.

Few researchers doubt that there is a certain trendiness to cutting and that that is driving the numbers up. Celebrities including Angelina Jolie and Fiona Apple have confessed to past self-mutilation. Though it's true that such public disclosures encourage ordinary kids to come forward, it's also true that when glamorous people suffer from something, a bit of the glitter rubs off on the condition. "Cutting grew into a huge fad at school," says Michelle, 13, who is being treated at the Vista Del Mar clinic. "In seventh grade it seemed every single girl had tried it--except the really smart ones." Then there is the Internet, where cutting chat rooms are just a keystroke away. Many offer support for kids who want to stop, but just as many wink at the problem and even subtly encourage it.

The neurological roots of cutting are a mystery, but several theories have been put forward. When the body is injured, it releases natural opiates that help dull pain--a process that is behind the fabled runner's high. Cutting inflicts a very real injury, and self-mutilators may be seeking the neurochemical kick that follows. "When I would cut myself deliberately, I didn't even feel it," says Emily, 16, who is in her third week of treatment at Two Brattle Center. "But if I got a paper cut I didn't want, that would hurt."

The problem is that any time you chase a high, you risk getting hooked on it. "The longer kids cut, the more they need it," says psychologist Jennifer Hartstein of the Montefiore Medical Center in Bronx, N.Y., where Vanessa was treated.

Overcoming self-mutilation turns out to be less tricky than explaining it. Perhaps the most effective treatment is dialectical behavior therapy (DBT). Developed by psychologist Marsha Linehan of the University of Washington in Seattle, DBT is used as a frontline therapy for borderline-personality disorder. Because there appears to be a very significant overlap between borderlines and cutters, Linehan and others wondered if the same treatment might work equally well for both. It does.

DBT is built around the idea of encouraging the cutters and members of their family to accept the kids as they are while encouraging them to change. "We embrace two seemingly contradictory philosophies," says Hartstein. "That teens are doing the best they can and that they can also do more." With the sense of judgment lifted, children are more receptive to learning a wide range of new coping skills, such as impulse control, distress tolerance and contemplation of consequences.

The treatment at Two Brattle Center is typical of what's offered at most clinics. Cutters start with intensive DBT and coping training, attending sessions from 9 a.m. to 1 p.m., five days a week, for at least four weeks. When they are ready, they graduate to individual and group therapy, once a week each. All the kids have paging privileges, giving them a round-the-clock hotline to their therapists when the urge to cut hits. They are also taught to reach out to family and friends and answer the cutting impulse with some other activity.

"When Melanie wanted to cut, she learned to find something else to do," says the father of a 20-year-old Two Brattle graduate. "She'd be stressed, and the next thing we'd know, she'd be cleaning her closet."

Parents who are worried that their kids are cutting should look for a few red flags. If a teen wears long sleeves and sweatpants in hot weather, there's a chance something is being hidden. Temperamental behavior, intense anger and changes in eating and sleeping patterns may also be warning signals--but they are also part of the ordinary storms of adolescence, so it's wise not to overinterpret. Less ambiguous are sudden shifts in mood. "If a kid is mopey at 5 and much better at 5:30," says Hartstein, "you may want to know what happened in that half-hour." Parents should also keep an eye out for hidden stashes of blades or bandages.

More important than advice for parents is advice for the kids. Almost all former self-mutilators agree that one of the best things cutters can do is come forward--talk about their problems with parents, teachers and friends. It's equally critical for the kids to talk honestly with themselves. "Take a step back," advises Jen, 17, a Two Brattle patient. "Look at the long term. Who's in control of your life, the cutting or you?" Self-mutilation may thrive on secrecy and fear, but as with all wounds, a little fresh air can help speed the healing. --With reporting by Jeffrey Ressner/ Los Angeles