Living under the knife

Steven Levenkron's book "Cutting: Understanding and Overcoming Self-Mutilation" casts an eye on the emotional pains behind a dark adolescent practice.

Published June 6, 1998 3:56PM (EDT)

One windy afternoon I sat on a bench behind my high school and watched kids playing soccer in the yellow grass. I was 15. My head was clouded with anger at everyone around me. The targets kept shifting from my family, which was actually stable and supportive, to my friends, who were dealing with their own personal and academic problems, to the pretension and hypocrisies of my Southern prep school. None of these things on its own was particularly remarkable, but that didn't keep them from being any less intense. One moment I was furious at these people, the next desperate to protect them from my illogical rage.

I was sick to death of my feelings, but I did not want to die. (Deep down, I knew if I could just graduate from high school, everything would be all right.) I pulled a box of matches out of my bag and set a binder up over my knees to shield me from the wind. One by one, I lit each match and extinguished it on a patch of skin in the crook of my right elbow. With each match in hand, I mustered the nerve to ignore my instincts and hit the already-pink, stinging spot, feeling the pain wash through and fade out again in a finite wave. When the box was empty, I was calm. Endorphins pumping through my body made me feel more awake. I stopped needing to cry.

Years later, that patch of skin is healed into a slightly bumpy oval a shade lighter than the rest of my arm. It looks something like a track mark, and thus still occasionally elicits surprised revulsion. I have other little pale marks on my wrists and arms and thighs, standard spots self-mutilators choose, as they are sensitive and easy to hide. But that's all that's left of those impulses. I have two college degrees, a terrific job and lots of friends. I have a great relationship with my family and big plans for my future.

Steven Levenkron's "Cutting: Understanding and Overcoming Self-Mutilation" lacks any uplifting story of resolution such as this. Rather than following a set of patients through life's trials to a promising future, Levenkron ends most of the case histories after the first few sessions, with a brief account of how long it took to elicit a thorough confession. Like most pop psychology books, "Cutting" begins with widely applicable insights that read something like a horoscope for teenagers: The self-mutilator feels misunderstood, lacks self-esteem, does not possess the maturity required to express her feelings, is likely to have experienced physical or mental abuse. But by Chapter 3, the sensitive healing language that marks pop psychology vanishes into a clinical explanation of the complex emotional machinations behind the behavior.

The book does not sentimentalize or dramatize self-mutilation in the way most media treat teenage problems. Levenkron, a psychotherapist in New York, estimates that about one in every 250 girls is a self-mutilator, roughly the same percentage as those who suffer anorexia, which is Levenkron's other area of expertise. He mercifully avoids waving red-flag words like "addiction" and "suicide," stressing instead "removing the drama and replacing isolation with sharing." Levenkron's calm tone throughout the book portrays a professional disposition that seems to answer his personal call to compassion with level-headed action and listening.

Unlike Mary Pipher's popular "Reviving Ophelia," which spoke to the average Middle American parents, "Cutting" mainly targets therapists, a group that, according to Levenkron, is still unfamiliar with ways of dealing with the phenomenon. While Levenkron explains the various terms -- dissociative, symptomatic, disorder, etc. -- as clearly as possible, one can practically hear the frightened mother worried about the cuts on her daughter's arms screaming at his picture on the book jacket, "But what do I do?"

Self-mutilation was common at my high school; we called it "masochism" and among our circle of masochists we allowed for certain exhibitions. During geometry class, we'd have contests to see who could endure rubbing an eraser across their skin the longest. In a competitive environment, the most screwed-up person was the one who got the most credibility. Yet outside of our circle, we hid the marks on our bodies with long sleeves and lied about their causes. I was ashamed because the effects of my venting were sickening to look at. My pain was self-inflicted, an outward proof of my illogical feelings. There seemed to be no reasonable justification for my emotional turbulence, or for my way of dealing with it.

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Most of my friends and I were on the mild end of the spectrum. "Cutting" tells many stories of extreme cases -- where victims of incest and other physical abuse attempt to use self-mutilation as a means of treating their problems. Over time, this strategy only makes things worse. The behavior collapses into a full-blown dissociative disorder and the victims lose contact with reality. They fall into trances or periods of amnesia in which they inflict physical harm on themselves without consciously knowing what they're doing. Over time, these flights of amnesia can evolve into permanent psychosis.

Levenkron explains that for kids who have suffered mental or physical abuse by parents and caretakers, pain is fused with their sense of security. Children are unable to judge their parents, he says, and even an abusive parent is better in a child's mind than none. To decide that mom or dad is a bad mom or dad would cause a separation anxiety much more unbearable than any harm that parent might inflict. So to cope with what feels like inexpressible "crazy" pain, they invite physical pain. They take out on themselves the anger they are afraid to take out on other people. (This introversion of anger probably accounts for the fact that the overwhelming majority of cutters are female; male depression usually expresses itself as outward rage.) It falls along the same logic as chopping off your arm to take your mind off your headache.

Cutters respond to the visual stimulus of seeing their own blood flow. They describe a sense of calm and of being grounded back to reality, since the physical pain is finite and reminds them of their physical reality. Pain is often a kind of self-medication because of the endorphins released in the brain. In essence, it's a quick fix that does mental and physical harm and not much good. Self-mutilation ultimately causes shame, which further hinders girls from expressing their feelings.

Levenkron's conclusion is obvious enough: Self-mutilators need to go into therapy ("twice a week, outpatient"). They need to develop trusting relationships with people who can handle their problems. In many of the cases he discusses, therapy is that much more vital because abuse by the parents is the origin of the children's problems. Once we accept this solution, the fact that the book doesn't specifically target an audience of parents seems less troubling. Perhaps psychotherapists need to be reached before the parents of self-mutilators can be.

My mother caught a glimpse of the gruesome red patch on my arm one day. When she asked me what it was, I nervously made up a story about a freak curling iron accident. Nearly sick, she nodded and let the issue drop. Later, she gathered up her strength to tell me I could either go to a hospital or private school, but that we couldn't afford both. This was exactly the jolt of reality I needed. I never discussed the burning with my therapists except briefly, in the past tense, mainly because it felt like a symptom rather than a central problem. Also, I was embarrassed about it, and I didn't think even a therapist could have understood. To protect herself from liability, she probably would have tried to send me to a hospital, which I didn't need.

According to Levenkron, I was probably right. +In case history after case history in "Cutting," his patients tell him they have been "too much" for their previous therapists. Even within the psychological community, self-mutilators are considered "sick cookies." A therapist needs a small amount of medical knowledge (about as much as is contained in the Boy Scout manual) to inspect the wounds for severity and medical attention. Most shrinks, Levenkron says, would rather have patients who "free-associate about their childhoods." If this is the case, "Cutting" is an important pop textbook written for an audience of professionals with a lot left to learn.

By Fiona Morgan

Fiona Morgan is an associate editor for Salon News.

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