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Section 5
Cutting Voices: Self-Injury in Three Adolescent Girls: Part II

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These three girls described not being listened to or responded to, and not receiving help for their psychological distress until they inflicted harm on themselves. Therefore, they discovered the language people take seriously is the language of violence. Directly verbalizing their emotional pain did not result in a response from others, whereas self-inflicted injury did. They reported efforts to tell others "something is wrong" but explained that "no one would hear me" and "people don't listen." The girls' familial circumstances of parental alcoholism may have contributed to the lack of responsiveness they described.

These girls did not give up hope for a relational response, and their refusing to accept not feeling heard is evidenced by their violence. Through their self-inflicted injury, they are asking in effect, "Does anyone notice me? Does anyone care?" and they have learned that people do notice violence. Their unheard speaking voice has become visible or visual actualization of pain-through acts of self-harm that others cannot deny. The girls' self- injury becomes a relational strategy in service of self-preservation, wherein, paradoxically; they hurt themselves in an effort to help them.

Implications for Girls' Development
An important developmental and relational implication then becomes the importance and necessity of listening to adolescent girls who are suffering from psychological distress. Being listened to is crucial for girls' healthy psychological development. Not being listened to increases girls' risk for problems and psychological distress. If adolescent girls feel they are listened to and responded to only when they use violence and harm themselves, this may have damaging future implications.

For example, it may lead to an exacerbation and increase in cutting, resulting in chronic cutting, an unhealthy progression described by the girls. Given what is known about trauma and escalating, unbearable, and overwhelming affect, nascent cutting as a symbolic and communicative visual voice can evolve into a developmental pathway to chronic cutting as a form of affect regulation. Therefore, not being listened to increases the risk of cutting for adolescent girls, specifically those with a trauma history.

Consequently, if girls begin to use violence and cutting in adolescence as a communicative gesture, immediate intervention becomes crucial as a preventive measure to curtail the development of this behavior as a pathway to chronic cutting. Self-injurious behavior that begins as a signal of distress but that becomes chronic has the tendency to alienate people, whereas it is genuine human connection and therapeutic help that the girls are seeking.

A catch-22 for girls who cut is that, although their self-directed violence may have its onset in the service of "self-preservation," it can lead them to be pejoratively labeled as manipulative in mental health settings, which may perpetuate further dismissal. The girls have "discovered how to manipulate" in a desperate effort to obtain response and intervention amid situations of familial alcoholism, violence, sexual and physical abuse, and experiences of depression, suicidal ideation, and post-traumatic stress.

Despite the awareness that self- injury has been in the service of "self-preservation," Skylar articulated disdain that she "used it to get the support I need at that moment in time." Although she acknowledged a relational or emotional neglect of not beings listened to for 17 years in an alcoholic family, this pejorative undertone of being "manipulative" and hating it has the propensity to contribute to or exacerbate preexisting feelings of self-blame and self-loathing, which have been reported in self-destructive adolescent girls (Noam & Borst, 1994).

Identity development is an important task of adolescence (Erikson, 1968). Defining one's self as manipulative may have implications for the development of negative identity, which is already a risk for traumatized children. Although it may be helpful for girls to know that cutting tends to be construed as manipulative^ without validation of the context that has led to the need to "manipulated the pejorative label may increase risk, interfere with or lead to negativity with treatment providers, arid may perpetuate a cycle of using violence.

Intervention requires building a therapeutic relationship, as well as other relationships. While the author does not espouse that chronic cutting will be ameliorated immediately by listening, for girls who have just begun to cut to be heard, having someone who listens may halt their behavior, thereby curtailing its evolution. The author has observed this clinically.

In addition to establishing a trusting therapeutic relationship, which is the necessary foundation for treatment, clinical intervention needs to include an assessment of post-traumatic sequelae, including dissociation and alexithymia, as well as techniques in grounding (e.g., ways to orient one's self to the present time and place, staying embodied versus dissociation) and knowing, naming, and regulating unbearable affective states.

Initial interventions optimally will include psycho-education for girls regarding post- traumatic sequelae and symptoms, self-harming behaviors, and working together to develop coping skills and strategies. Exploring the meaning of and reasons for the cutting, including the precipitants and triggers, and developing a plan for what to do when the need or urge to cut arises are important. The statement articulated by Harmony, "make sure they always have somebody to talk to when they are about to cut," underscores the importance of the relational context needed for intervention.

Van der Kolk (1989) wrote that in asking adults what was most helpful to them in overcoming the impact of childhood trauma, including self-mutilation, he found that:
"All subjects attributed their improvement to having found a safe therapeutic relationship.. . . All subjects reported that they had been able to markedly decrease a variety of repetitive behaviors, including habitual self-harm, after they had established a relationship in which they felt safe to acknowledge the realities of both their past and current lives (p. 404). "

Resiliency studies report that the strongest protective factor for children under stress is having a good, confiding relationship with an adult (Rutter, 1987).

For girls to use direct speech, there needs to be someone listening, for "speaking depends on listening, it is an intensely relational act" (Gilligan, 1993, p. xvi). Although the signal(s) adolescents may use to indicate their distress may become complex, dangerous, desperate, or seemingly dramatic, adults need to learn, understand, and heed the language in which the distress is being conveyed to abate the escalation of violence.

The girls' insistence on being heard took them into the realm of increasingly life-threatening behavior. Taking seriously what the girls said emphasizes the importance of listening and responding, which has the potential to curtail violence, a problem endemic in our culture and one that has become increasingly widespread in the lives of adolescents.

1. Adolescent girls with a trauma history discover that violence, in the form of cutting themselves, heeds a response from others when others do not listen to their speaking voices.
2. Cutting may begin as an effort to communicate psychological distress and a plea for relationship but becomes a developmental pathway to cutting as a form of regulating unbearable affect, indicating the need for early intervention.
3. Adults actively and genuinely listening to girls are a critical component for both prevention and intervention of cutting.

Girls who engage in self-mutilation may also be suicidal..., and they are described as outgoing, likable, high achieving, and as having many problems.

Human relationships are of central importance in girls' and women's psychological health and development.

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.

Self-injurious behavior that begins as a signal of distress but that becomes chronic has the tendency to alienate people, whereas it is genuine human connection and therapeutic help that the girls are seeking.

- 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 #5
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.

Peer-Reviewed Journal Article References:
Knutson, D., Jacobs, S. C., Hakman, M., & Milton, D. C. (2021). Profiles of distress and self-harm among LGBTQ+ transitional youth in a rural state. Journal of Rural Mental Health, 45(2), 107–120.

Sansone, R. A., Sellbom, M., & Songer, D. A. (2018). Borderline personality disorder and mental health care utilization: The role of self-harm. Personality Disorders: Theory, Research, and Treatment, 9(2), 188–191.

Witt, K., & Robinson, J. (2019). Sentinel surveillance for self-harm: Existing challenges and opportunities for the future [Editorial]. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 40(1), 1–6.

Online Continuing Education QUESTION 5
What is the catch-22 for girls who cut? To select and enter your answer go to CE Test

Excerpt of Bibliography referenced in this article

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