Cutters for the Layperson

* I am writing this because I know there is a lot of misunderstanding about wrist cutting and people who cut on themselves in other locations in general and thought some people may want to know more about this phenomenon. I recall my cousin's struggles with a college roommate who cut herself on a regular basis and her difficulties in knowing whether or not to

press the panic button as it were or not when this occurred. We deal with "cutters" on a daily basis in psychiatry and are not as uncomfortable in dealing with this behavior. If anything, there is a level of frustration at it because cutting is so often used to manipulate and control other people and becomes very old after a while.

First, to clarify some misbeliefs about cutting one's wrists. It is almost impossible to die from cutting one's wrists. I have had many patients tell me that they know they need to cut lengthwise, or soak their wrists in water to keep the cuts from clotting or take rat poison (a potent blood thinner) to prevent the blood from clotting, etc. None of this is true. A healthy adult can donate a pint of blood without risking his/her life and would have to lose far more to die, and one is simply not going to lose that much blood from an incision on the wrist. If one were to cut clear down to the artery, which would in fact be straight across, maybe one could bleed out enough. The problem is cutting that deep is extraordinarily painful and most people are simply not able to do that. For someone to die of cutting his wrists, the plan must be very carefully planned and the cut must be pretty deep. The person also needs to make sure that he/she is somewhere very remote because it is going to take hours to bleed out that much. I have never seen a patient die from cutting themselves anywhere and only had one close call. Morbid to keep a head count, but that is the reality.

Cutters know that cutting is not lethal. They often say they are making suicide attempts when they cut, but in all reality, they are upset and saying something out of anger that they do not really mean. It is true that some people do intend to kill themselves by cutting their wrists, but these people are usually not chronic cutters and di not really know how unlikely it is to die from cutting themselves.

So why do they cut? Many will describe it as a release. This could be a release of anger, frustration, panic, just about any powerful emotion that the sufferer cannot tolerate. A large percentage of cutters have the diagnosis of borderline personality disorder, but this is not the case in all cutters. Certainly when this behavior becomes a pattern, this diagnosis needs to be entertained. Borderline personality disorder is a complex disorder in itself and volumes have been written but suffice to say for this piece, these people have very immature and chaotic coping mechanisms and cutting is a frequent way they turn to to deal with their frustrations. Often cutters have been victims of abuse as children and they have learned to abuse themselves when they perceive themselves as having done something wrong. This often manifests as cutting.

For others, it is a way of manipulating others. I see this more with men who cut themselves when their girlfriends break up with them to get them back. This is sadly, surprisingly effective and the men usually get their wish. These relationships are often chaotic and there is most of the time a fair amount of domestic violence involved. Drugs and alcohol usually come into play as well. They almost always make a statement about "showing her how much I love her because I cannot live without her". I usually try to point out that if this person truly loved his girlfriend, he would want her to be happy. If she is not happy with him, coercing her to go back to him is not showing love, it is showing a need to control. My confrontation usually goes unheard or receives an angry response, but I feel compelled to tell the truth in these cases. Women are certainly not immune from this behavior and can be just as manipulative but usually there is not the domestic violence element involved.

The reason that people pick up the habit of cutting is multi factorial but the element that is in these cases most often is a history of abuse, especially sexual abuse. This is probably why it is much more common in women. Other forms of abuse may be involved but for some reason, sexual abuse seems to show up most often. Behaviors in adulthood are learned in childhood as is one's view of oneself. Children who are abused regularly as children learn to abuse themselves. It is what they know, and what their "inner child" tells them should be the result of being "bad". People who cut often do so over a sense of guilt from events that may or may not have been their fault, an they are very prone to blame themselves for things that are not their fault. They probably always were as children.

There are endless aspects of cutting that could be discussed, more than could be realistically talked about in one essay so I am excluding a large amount of information simply for lack of space. Understand self mutilating is something that cannot be taught in a book and takes years of experience to fully understand and interpret but I tried to touch on some of the basics.

The biggest problem one runs into with cutters is how to treat them. There is simply no magic pill that will stop this behavior and very few therapies that are very difficult to access and get insurance companies to pay for that can effectively treat this problem. Cutting is not necessarily a sign of depression, and the cutter may not be depressed at all. Whether or not to hospitalize a cutter is also an issue. People who cut themselves superficially know they are not going to harm themselves and are just venting. Putting them in the hospital every time they cut may be counterproductive. Trying to find the balance between what was a serious suicide attempt or a serious action vs a baseline cutting behavior can be tricky. As hard as it seems, sometimes the best way to deal with the behavior is to ignore it. Maybe not when the person in question locks herself in the bathroom, texts suicide notes to her friends and shouts out "this time you'll be sorry!" But for the women who every time she gets in a spat with her abusive boyfriend makes some superficial cuts on her thighs, sometimes paying too much attention just increases the behavior. The best that a layperson can do is get the person in question to a good therapist, psychiatrist or if the person is really making a lot of suicidal threats, to hospital ER or crisis center, if available, and allow a professional figure out a treatment plan. Do not expect a miracle cure or long term hospitalization in most cases. This simply does not happen, but with the right, long term, treatment this behavior can be reigned in to a manageable level.

One caveat with this is that cutting in adults if often a long standing and habitual pattern and very difficult to stop. This is not true for children and adolescents. Cutting behavior at this age is a sign of a person who may truly be suicidal and needs to be taken seriously. Never tell an adolescent they are cutting "for attention". Sometimes once they realize that cutting does not work, they move up to more lethal measures, and a bottle of OTC Tylenol is quite lethal, and easy enought to obtain. Get them help quickly. In some cases, cutting could be a case of an evolving personality disorder that will become a lasting pattern in adulthood, but if an intervention is made early enough, teenagers can grow out of cutting patterns, so do not ignore this. It could save them a life of misery and thousands of scars. Or it could save a life.

*Photo courtesy Scott Feldstein on Flickr