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Section 4
Cutting Voices: Self-Injury in Three Adolescent Girls: Part I

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This article focuses on self-injury, in the form of cutting, in adolescent girls, and is based on in-depth clinical interviews and case study analyses of three girls who participated in a larger research project examining suicidal and self-Krystal Understanding Motivation to Self-Mutilate psychology continuinginjurious behavior in adolescents (Machoian, 1998). The inquiry was guided by the following research question, "What do adolescent girls know about why they inflict harm on themselves?"

Adolescence marks an increase in symptoms of psychological distress in girls (Gilligan, 1991). Self-mutilation and suicidal behaviors are forms of self-injurious behavior prevalent in adolescent girls; yet, minimal research has been conducted directly with adolescent girls who self-mutilate (Suyemoto &. MacDonald, 1995; Walsh & Rosen, 1988). Adolescents who injure themselves often have histories of relational-based trauma including sexual and physical abuse, neglect, family violence, out-of-home placements, abandonment, and family alcoholism (Levenkron, 1998; Machoian, 1998; Simpson & Porter, 1981; Suyemoto & MacDonald, 1995).

The average age of onset of self- mutilation in girls tends to be early to mid-adolescence - ages 13 (Favazza & Conterio, 1988) and 15 (Suyemoto & MacDonald, 1995). Similarly, girls' depression and suicidal behaviors tend to begin in early adolescence (Angold & Rutter, 1992; Kovacs, Goldston, & Gatsonis, 1993; Velez & Cohen, 1988). Girls who engage in self-mutilation may also be suicidal (Simpson & Porter, 1981), and they are described as outgoing, likable, high achieving, and as having many problems (Levenkron, 1998).

Walsh and Rosen (1988) reported that adolescents who self-mutilate have childhood experiences "replete with dysfunction and psychopathology," (p. 66) often enduring both sexual and physical abuse, repeatedly witnessing violence, alcohol abuse, and impulsivity. Family alcohol abuse is strongly associated with adolescent self-mutilation. Relational losses, conflicts, and instability are reported to be precipitants of self-mutilation in adolescents, and their self-mutilation has been described as both interpersonal manipulation and as a way to modify uncomfortable affective states (Rosen & Walsh, 1988).

THEORETICAL FRAMEWORK: GIRLS' PSYCHOLOGICAL DEVELOPMENT

Researchers focusing on girls' and women's psychological development report that human relationships are of central importance in girls' and women's psychological health and development (Chodorow, 1978; Gilligan, 1993; Miller, 1986). In early adolescence, girls resist fraudulent relationships and fight for authentic or "real" relationships - relationships in which girls feel free to express the full range of their thoughts and feelings, and know that the person is listening (Brown & Gilligan, 1992; Rogers, 1993). Adolescent girls tend to equate caring with listening.

Thus, if girls feel someone is not listening, they may conclude that the person does not genuinely care. Relationships in which girls feel free to express themselves honestly have been found to be important in assessments of girls' overall psychological health. Not being listened to increases girls' risk for psychological distress (Brown & Gilligan, 1992; Gilligan, Rogers, & Tolman, 1991; Rogers, 1993; Taylor, Gilligan, & Sullivan, 1995).

THEORETICAL PERSPECTIVES ON SELF-INJURY
Biological theory provides physiological explanations for self-injurious behavior; cutting is understood to be similar to a drug to which people can become addicted. The addiction hypothesis posits that cutting is maintained through the functions of the endogenous opioid system. Cutting is thought to increase the levels of endogenous opiates in the body, which results in feeling high. Consequently, one needs to cut repeatedly to maintain this high feeling (Simeon ét al., 1992). Behavioral and teaming perspectives focus on the theory that positive and negative reinforcement maintain self-injurious behavior (Bennum, 1984; Carr, 1977).

Psychoanalytic theory supports that self-injury has its roots in childhood developmental processes gone awry (Rosen & Walsh, 1988). Self-mutilation becomes triggered by loss and abandonment and represents aggression directed toward the self. Aggression becomes directed toward the self because of the loss and blaming one's self for the loss. Self-mutilation represents punishment, self-blame, and self-loathing (Rosen & Walsh, 1988).

Object relations theory, which focuses on borderline personality disorder, a diagnosis common in chronic self-mutilation, suggests that self-injury may represent anger toward another person; it may be a cry for help, or it may represent an effort to coerce or force compliance from another person (Gunderson, 1984).

Trauma theory and research suggest that adults who were abused and neglected during childhood self-mutilate in an effort to regulate unbearable and overwhelming internal affective states, thereby providing relief from numbing, dissociation, depersonalization, and agitation (Herrrian, 1992; van der Kolk & Fielet, 1994; van der Kolk, Perry, &Heitìbn, 1991).

Krystal (1978, 1988) described a syndrome common m trauma survivors, alexithymia, which is the inability to recognize differentiate, identify, and name internal affective states. Emotions are experienced as undifferentiated due to the person’s inability to verbalize or describe affective states. People with alexithymia may experience somatic, distressing reactions instead of discrete emotions. Psychosomatic reactions may result (Krystal, 1978, 1988). Miller (1994) suggested that self-injury in women represents the psychological and physical reenactment of childhood traumas, expressed in self-harming behaviors. Women may experience the self-injurious behavior in and of itself as a relationship.

While the theories mentioned above focus on adults, this article focuses on the developmental time of adolescence and presents an explanatory, developmental, theoretical interpretation that posits that an additional factor may increase the risk of cutting in adolescent girls - namely, the experience of not being listened to. This interpretation is guided by a theoretical framework regarding girls' psychological development (Brown & Gilligan, 1992; Rogers, 1993; Taylor et al., 1995), the data from this research (Machoian, 1998), and clinical case study (Gilligan & Machoian, 1996, 1998, in press).

METHOD
The method of inquiry was case study analysis using in-depth, semi-structured clinical interviews. This research was conducted at a private psychiatric hospital on an unlocked, voluntary adolescent residential unit. Participants were identified through consecutive hospital admissions and purposeful sampling. Purposeful sampling is based on the assumption that if one wants to discover, understand, and gain insight into a particular phenomenon, it is necessary to select a sample from which one can learn the most (Miles & Huberman, 1994 Strauss, 1987). Selection criteria included girls, ages 12 to 17 who currently engaged in self-mutilation or suicidal behavioir. This article reports on three girls who participated in the larger study.

Potential participants were informed verbally of the research project by the principal investigator during the girls' free time on the unit. If they met selection criteria and chose to participate, their hospital case manager was contact' ed. Arrangements then were made for the author to meet with the girls' parent(s); explain the study, and obtain informed consent. An interview then was scheduled in coordination with the hospital unit. The interviews were audiotaped and then transcribed. No remuneration was offered. The girls volunteered to participate, which helps address validity. Confidentiality was maintained by changing identifying information and using pseudonyms selected by the participants.

The three girls discussed in this article are White and are from working class to upper middle class families.

GIRLS RESPONSES
When analyzing the data within and across cases, three prominent themes emerged*:
* Cutting gained a response when the girls' speaking voices failed.
* Communicative cutting leads to affect regulation.
* Adults listening is very important.

Each girl reported a trauma history and familial alcoholism.

Skylar, age 17, always does well in school. Her parents are both alcoholics and are divorced. She reported being sexually abused by a male extended family member, several years older than she, during her childhood.

Regarding her cutting, she explained,
"When they see it, like actually see it (a cut), they're like, wow, maybe something is wrong. It's like yes, you [expletive] idiot something is wrong. I've only been saying it for the last 17 years."

She elaborated, "People won't believe that something is wrong," but when she cuts, Skylar notices that, "it's like people can't really use words to deny what I just did." She continued;
It's, it's an actualization of pain, you know... The most basic is that even if you tell people that something is wrong, a lot of the times, they won't, they won't know how wrong. But all they'll do is see a cut along a vein, and they get the message right away.

Skylar observes others and learns that people do not respond to her words, but they take her self-directed violence seriously.

Seventeen-year-old Harmony was exposed to her father's alcoholism and physical violence throughout her childhood. Regarding cutting, she said:
Like people don't listen to you. Like me, I cut when people don't listen. And then, of course, people are going to notice it, and, of course, people are going to ask you why. Of course, they are. I mean nobody really looks at somebody with scratched up marks on their arm and ignores it. Of course they're going to ask you why. And, of course, it's obviously a sign of trouble.

Harmony, like Skylar, discerns a difference in how others do and do not respond and what it is that gains a response.

Noel, age 14, also was exposed to alcoholism in her extended family and violence from her stepfather, and recently was raped. She explained, "My mom never thought, she never took me being depressed seriously or anything She just said it's normal adolescence..."

Noel said, "I made it [cutting] really noticeable-because I needed people to notice me, you know, I have a problem here, help." Expressing her frustration, she explained, "It was really aggravating, I was just trying to get my point across. And no one would hear me."

Noel then explained a shift in her cutting behavior:
Now it's due to anything that triggers emotional pain, I just cut. Because I feel having physical pain that doesn't have an emotional pain, it feels better. That's why I still do it.
Noel unwittingly describes the risk of incipient cutting as a communicative gesture and how it can lead to regulation of unbearable affect.

Similarly, Harmony, described a shift, leading her cutting beyond communication, and said that sometimes she cuts because of the physical sensation:
"I don't always cut to make point, I cut because I 'need to...when I cut, when I see the blood, and I feel it rushing, it's such relief. I can feel it; it's like everything that is [bad] is just going out. Skylar also described a feeling of release:  It was a way to get out the pain that was inside of me. You know, like if I'm watching my blood sort of leave me, it was like that would be some of the pain leaving too. "

These descriptions emphasize how cutting can become a way for girls to cope with psychological pain and try to regulate their painful affective state through the act of cutting.
Skylar described a relational dilemma posed by her cutting, "I think it's a form of manipulation, of manipulating other people, and I hate that. And I hate to think that I do that, but I know I do."

She explained, "in some ways I have used it to get the support that I need at that moment in time. And I think that's manipulation. And I hate that." The dissonance of her feelings is evident in the disdain she feels for having to manipulate to obtain the help she knows she needs. Skylar said, "I mean, I guess sometimes that you go about things the wrong way to get to a certain point."

Continuing, she added:
"Well, I don't know what to say, other than that eventually you learn that you have to do sort of obscure things in order to get what you need. And even if you don't like what you have to do, or don't, or wish you didn't have to do those things for those reasons, you know, I guess self-preservation kicks in at some points and you're going to get the help however you can. "

When asked what advice they would give to adults who want to help girls who hurt themselves, the girls emphasized the importance of adults listening.

Skylar explained:
"Like be compassionate. Be empathetic. Listen, but also like don't take on the real adult-child separation. You know roles...You know, like try to relate more on like a personal level. "

Harmony, too, stressed adults listening:
"Well, first of all, to talk and really listen. Really listen. Don't like give out this advice until you know what's really going on. And then help them figure out exactly why they cut.. .just give them lots of support. And make sure that they always remember, make sure they always have somebody to talk to when they're about to cut. "

Noel also supported this advice:
"Sit down and talk to girls and get to know the experiences as you can. And you have to be open-minded about everything, too... And, most of all, you have to be totally open to listen. "

The word "listen" was articulated by each girl.

- Machoian, L. Cutting Voices: Self-Injury in Three Adolescent Girls. Journal of Psychosocial Nursing & Mental Health Services; Nov 2001; 39,11; 22-29

Personal Reflection Exercise #4
The preceding section contained information about self-injury in adolescent girls. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 4
What do self-mutilators consider the most important piece of advice they would give caregivers? To select and enter your answer go to CEU Answer Booklet

Excerpt of Bibliography referenced in this article

 
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