Self-injury is rapidly increasing in the adolescent population, with cutting being the most common form, followed by burning, scratching, pinching and not letting wounds heal. These injuries are superficial and are not intended to do any lasting harm. It's difficult to get exact figures, but a conservative estimate is that 4 to 10 percent of adolescents engage in this behavior, which is more common in girls than boys. School personnel have reported seeing this behavior not only with adolescents but also with upper elementary children. It can be difficult for adults to understand cutting, and they are often very critical of the self-injurer. Students have shared with me the following reasons why they cut:
It discharges my anger and tension.
I was able to shut out the argument that my parents were having.
When my boyfriend calls me a slut, I have an immediate urge to cut.
It is a way of punishing myself.
My body expresses what my words cannot.
I get an immediate release that is addictive.
Why Do They Do It?
There are several common explanations for this behavior: it is biological, as endorphins are released; it is psychological, as it regulates emotions; it is psychoanalytic, as it is a way to punish oneself. Research documents that young people who engage in this behavior often have a significant trauma history.
Self-injury used to be associated with severe psychiatric disorders and hatred of body image, but a new breed has emerged. Many cutters could be described as likeable, functional and intelligent, but they break down under stress. The behavior is often precipitated by an argument with parents or friends, or by a disappointment or humiliation. Many self-injurers are ashamed of this behavior and hide it well. Often parents first find out after their child has made a suicide attempt and is hospitalized.
Some professionals believe that those who self-injure and those who are suicidal are two different groups. My experience is that it is not unusual for a cutter to at some point attempt suicide.
Cutters can be very convincing that their injuries are the result of accidents, and they often hide their forearms-the most common part of the body to cut.
How Should Schools Respond?
1. Administrators need to increase awareness among school staff of cutting and to make sure that all teachers, when they see a student with marks and/or bandages, to either inquire privately or refer the student to a nurse or counselor.
2. Nurses and counselors can form a partnership to support cutters, with the goal being not to stop the behavior immediately but instead to recognize their struggle and help diminish the behavior. It is important not to promise to keep the behavior a secret from parents. One school counselor was recently sued over the issue of parental notification. It is important to get a supportive and understanding reaction from parents so they will follow through and get mental health treatment for their child.
3. School nurses, and other school personnel, need to be familiar with community mental health resources. Nurses and counselors can also make referrals to physicians. The most common form of treatment is to prescribe antidepressants, but not all cutters are depressed. The most promising treatment is Dialectical Behavior Therapy. This is a very intensive treatment that requires the victim to keep a journal of the events that trigger his or her impulse to cut. The therapist must be available to the young person multiple times each week.
Some young people have found substitute strategies useful to distract them from the urge to cut. These strategies are important for nurses and counselors to be aware of; they include writing with red marker on arms or on paper, brushing hair or teeth over and over, cutting a phone book, snapping rubber bands on arms, or sucking on hot candy. Nurses and counselors can assist the cutter to develop substitute strategies to reduce the incidence of self-injury.
4. Administrators can form a task force to research this behavior and to develop local guidelines for education and intervention that address the issue of parent notifi cation.
Scott Poland is the co-author of a chapter on self-mutilation in the National Association of School Psychologists' publication Children's Needs III (2006).