Helena was 13 when she first took a razor blade and cut a vertical line, about three inches long, on her wrist. She stared at the gash as blood oozed and spilled off her thin, pale arm. Without a sound, she wrapped her wrist in a towel and crawled under her bed covers. After 15 to 20 seconds of excruciating pain and what seemed like endless throbbing, she fell into a peaceful sleep.
She said she felt no remorse — only release. Finally, she embraced relief instead of the anxiety that had been mounting for months. That was her first time, four years ago, but not her last.
HELENA, WHO attends a Loudoun County high school, talked about her "addiction" to pain last week. Her actual identity will remain anonymous. She is one of a number of students, mostly girls, who cut themselves to supplant their intense emotional feelings with physical pain.
Anne Lewis, supervisor of the school district’s Guidance and Health Services, said the problem is so prevalent that the school district invited a national author, Kaye Randall, last spring to provide a full day of training for about 100 guidance counselors, nurses, social workers and other school personnel. Randall and Susan Bowman wrote "See My Pain! Creative Strategies and Activities for Helping Young People Who Self-Injure."
"There are very few things we use as a one-day topic," Lewis said. "But we are seeing a large number of girls and it’s not limited to girls."
Lewis said Loudoun County Public Schools bought copies of the book and placed one in every middle- and high-school guidance office. Guidance counselors have not kept track of how many students are cutting, but the number is growing, she said. Nationally more than three million people, generally between puberty and the early 30s, are hurting themselves by cutting, burning, hitting, pulling hair, breaking bones and employing other destructive behaviors.
Wendy Lader, co-author of "Bodily Harm," said in a telephone interview from Illinois that the age range can be even wider. "I’ve talked to kids in elementary school and women who have been told by their doctors they are too old for this," she said.
Why would anyone go to such extremes? "Why do some of us choose to smoke, to gamble, to self-medicate with alcohol?" Lewis asked. "It’s hard to know why."
HELENA HIDES HER cuts by wearing a sweatshirt to school everyday. "I’m not scared about anyone finding out," she said. "I just don’t want people to give me a hard time. A petite, 5-foot-2-inch brunette with a bob haircut, she plays softball year round.
"This summer, I cut every night. Now when I want to cut and I have a game the next day, I scrape the razor across my wrist without cutting. It helps take the edge off."
Helena, 17, admits that cutting provides only temporary relief. "Nothing changes. You just have something on your arm," she said.
She cites arguments with her boyfriend, her friends or her mother as reasons for the behavior. "Whenever I’ve been going through a bad situation, when a boy or my mom are driving me crazy, I get the urge or anger to take it out on myself," she said.
Helena has used razors, hairdresser sheers, nail clippers, scissors and box cutters.
Karen Conterio, the other author of "Bodily Harm," said that child abuse, divorce, a disability in a family or overprotective parents can be contributing factors. "Often there is smothering or overprotectiveness going on," she said.
John Walker, coordinator of Loudoun County Family Connections, said people who cut themselves come from a variety of economic and social backgrounds. "These girls don’t necessarily come from chaotic homes," he said. "They can be real high achievers."
Family Connections is a county Department of Social Services parent education program for "extreme teens" who are out of control and demonstrating risky behaviors.
HELENA’S MOTHER discovered the wounds in September. Helena said she had been "hanging out" with older friends and smoking. She had sprayed perfume to hide the odor, but eventually she didn’t bother with the fragrance. She said she also used to sneak out of the house between 11 p.m. and midnight. "Then it got earlier and earlier," she said. "I let things slide. I would just be careless."
Her mother began to wonder what else was going on. When she learned about the slash marks, she took Helena to the doctor’s office. "I would have needed stitches, but it was too late. My wounds were healing," Helena recalled. "Mom thought it was a sign of depression."
Walker said depression often precedes self-injury. "I would be very worried if I were a parent with a girl who was cutting herself," he said. "It starts with depression, anxiety, which is linked to suicide attempts and cutting." A teenager who cuts, however, is not trying to end his or her life. "There is no intention to kill themselves. … If they were suicidal, they would try something drastic."
Lewis recalled seeing a woman in her 20s recently with scars from cutting on her neck and arms. "It was almost as if she had been in a fire," Lewis said. "She could have had a sign that said, ‘I’m in agony,’ and it would not have spoken any louder. It is a cry for help."
Walker said cutting shows the level of desperation these teenagers feel. "It shows you these girls are getting more and more out of control."
CONTERIO SAID CUTTING often goes hand-in-hand with other addictive behavior, such as eating disorders. Many teenagers have a poor image of themselves and suffer from anorexia, bulimia or obesity, she said.
Madison, a 15-year-old Loudoun County high-school student, contemplated suicide last year. When she stepped in front of a moving car, the driver swerved and missed her. She started cutting three years ago and her depression led to two suicide attempts. With therapy and medication, she abandoned the plans to kill herself. But she continued to cut, eventually switching from knives to razor blades.
Cutting her thigh and wrist made her feel better, albeit temporarily, she said. "It’s just that the physical pain is better than my emotional pain."
Lewis called the self-injury a "coping technique" that helps the teenagers when they cannot soothe their inner emotions. She said these students have trouble expressing their feelings. "They can gain balance and control over their emotions … by taking care of the external wounds," she said.
Walker said cutting releases endorphins that provide a euphoric feeling.
Some people don’t even feel pain, just as trauma victims in a car crash, said Lader. The endorphins take over and they are pain free. Some girls disassociate themselves, almost as though they have an outer body experience and are watching the cutting, she said. They feel the pain later.
"In the beginning, they want to feel something," she said. "After awhile, they have been stuffing their feelings for a long time, and they end up not feeling it."
The danger is that girls can cut too deep, she said. "People can accidentally kill themselves. A lot of people have come to us and said they almost died and they didn’t mean to and it scared them."
Madison said she worries about cutting too deeply. She started the behavior after seeing a television show about a summer camp for troubled teenagers who struggled with cutting behaviors, eating disorders, drug-abuse and other problems. She doesn’t even remember the incident that triggered her first cut. She only knows that it made her feel better.
Madison plays soccer. Her quick smile and a slender, 5-foot-8-inch frame belies the troubles underneath — pain that she does not care to explore. Why does she cut? With a shrug, she says, "I don’t know."
BUT SHE ADMITS every slice comes with a serving of shame.
Randall, in "See My Pain," said that shame and guilt are common among people who cut, and those feelings cause them to repeat the behavior.
Experts disagree whether cutting is addictive. Conterio describes it as an "addictive-like" behavior rather than an addiction. She maintains that people who cut can "unlearn" the behavior.
Lader said she doesn’t label it an addiction, because Alcoholics Anonymous (AA) maintains "once an alcoholic, always an alcoholic."
"We don’t feel that way about self-injury. Once they get in touch with their feelings, they don’t feel the need to self injure anymore," she said. "There are underlying issues and once you deal with those and your fears, head on, you can stop."
Research conducted by Bessel van der Kolk, a New England psychiatrist, said cutting may seem addictive, because of the endorphins released. People may have trouble abandoning the behavior, because of the elation, according to his research.
"It’s like an addiction," said Helena, who said she has thought about quitting. "But I’ve thought, ‘What can I do instead?’ Nothing else would work.
"It’s a way to get my extreme, deeper feelings out. I don’t have to hold them in."
She said she got the idea from her classmates in eighth grade. "For a while, a fad at school was you had to carve someone’s initials in your arm," she said. "I realized it helped me cope and it progressed over the years."
Lader said people who self-injure often believe they will be in more pain if they give up the behavior. She compared the argument to a cancer patient who does not want to undergo chemotherapy because he or she will suffer a lot of pain. "At that point, you have to recognize that you are going to feel worse before you get better," she said.
Teenagers will experience additional pain when they stop cutting, she said. "They now have to deal with the underlying reasons for that pain, to go through the pain to get better."
LADER SAID patients can recover without therapy, but she asserts it is the most effective treatment. "Adolescence is a very difficult time. Maybe once they get past that, they can learn how to deal with their emotions. But therapy is a faster way to deal with it.
"If it were my child, I wouldn’t want to leave it to chance. There are people who have cut for years and years and it has gotten worse."
So far, Helena is not persuaded. Her cuts have deepened in the past year, sometimes right down to the muscle. "It’s how I’m feeling at the time, when I’m ready to cut, as to how big or deep the cuts are," she said. Often she cuts three lines instead of the one slice she made that first night.
Madison cuts herself up to four times a month. She uses Vitamin E to reduce the scarring. She used to hide the wounds with long-sleeved shirts, sweatshirts, terry cloth wrist bands and ace bandages. Lately she does not try to mask them. "Everyone knows we do it," she said.
Jayne Fonash, the Potomac Falls High School guidance counselor, said some students have a tendency to minimize the problem, if they even admit it, she said. "They’ll say, ‘It’s really not anything. I only did it once.’"
They also confess to being frightened by their own destructive ways, she added.
Lewis said guidance counselors often find out about the cutting from a student who says he or she is worried about a friend.
Walker said teenagers draw attention by cutting. "People … don’t get mad at them, they get worried," he said.
Loneliness is another trait of the teenager who cuts, he said. She shares a commonalty with other teens who self-injure. "It’s a way of solidifying yourself into the peer group," he said. "Kids are all worried about each other. It keeps them together in a tight network."
Fonash said the guidance office provides resources and recommends therapy once the problem is reported. "We try to educate the students about the resources they have if they are in any kind of pain.
MADISON SAW a therapist, who suggested journaling. Madison’s voice was fraught with sarcasm. "I’m supposed to write and talk to people and tell them how I truly feel," she said.
She eventually stopped going to therapy. "It doesn’t work," she said. "I’d rather just talk to my friends."
Helena said she is taking medication. With a tone of mockery, she added, "It’s supposed to be making everything all better."
She is seeing a therapist, who recommended writing three reasons to be grateful on a daily basis. "It’s such an idiotic idea," she said, rolling her eyes.
Helena said she occasionally follows the therapist’s recommendation to journal.
Conterio said opposition to therapy occurs frequently. "I have parents sobbing on the phone, "How do I get them to treatment? Grounding them would alienate them more. … The more you oppress them, the more they act out."
She recommended putting the responsibility on the teenager. "How is it you are not finding counseling helpful? What do you want out of therapy?"
She also would ask the teenager if he or she would talk instead to a trusted adult.
Walker said parents need to approach the topic carefully, perhaps explaining that they know a therapist could do a better job of helping the child than they could themselves.
Fonash said the teenager might consider seeing a different therapist if the first one is not a good match. "I would hope they would keep trying," she added.
Lader said "Bodily Harm" contains suggestions for parents grappling with this issue. She suggested that parents insist on their child at least attending family therapy. "It’ll be difficult for them to be silent when everyone else in the family is talking, especially if she gets angry," she said.
"Family therapy is important," Conterio said. "Parents should not hold back if they suspect, if they think their child is self-injuring."
Teenagers usually try to hide their wounds from their parents, because they don’t want to upset them, she said. "Parents say, ‘I want to know.’ They are not on the same page.
CONTERIO SAID teenagers have to reach their own decision to stop. "They quit because it is interfering with friends, they are fearful of dying and often times with younger people, there is a pressure for them to get help," she said. Unfortunately, the latter motivation is not always effective, because it comes from parents, she said. "They are not as willing to do it as they would have if they had decided on their own."
Madison kept her secret from her mother for two and a half years. By then, she had tried to quit twice. She said she is ready for another attempt. "Maybe three times a charm," she said. "I want to stop. I hope I can."
The key motive is a close friend who has refused to have anything to do with her as long as she continues to cut. "It’s bad for you and it upsets other people," Madison said.
Meanwhile, Helena said she has no plans to stop. "That’s part of me," she said. "It seems to help at the time, so why should I? I’m not hurting anyone."
Lader countered, "First of all, you are someone. That’s number one, and you are hurting yourself."
In addition to wounding relationships, "your mind and body become increasingly disconnected, because cutting takes the place of genuine emotion and direct communication with other people," she said. "Every time you injure yourself, you are getting rid of a feeling. And feelings are a way of understanding how people and events are affecting us, so we can deal with them directly.
"Otherwise, you become a doormat. People can keep upsetting you and they don’t even know the effect they are having on you. The anger keeps building up."