Health: When mental scars lead to physical wounds: Why do thousands of women cut or burn their own bodies? Sarah Lee explains how pain drives them, and how sensitive treatment can help

It started suddenly when Kim was 17. 'I was in a state of extreme anxiety and began to build up this urge to put my fist through a window. I couldn't stop thinking about it - about how the blood would be pouring down my arm from the cuts.

'Then one night I did it accidentally. I was knocking on a friend's window when my arm went through the glass. When I took my arm out there wasn't a mark on it. So I just picked up a bit of shattered glass and cut my hand with it a few times. Physically it was absolute agony, but I also felt a strange sense of relief.

'After that it became my secret. I'd make cuts on my arms with broken glass and razor blades. I'd use anything I could get hold of - like a nail file or screwdriver - and just cut and gouge until a decent size wound appeared. Afterwards I'd be upset and frightened by the injuries, but I was also satisfied with them.'

Kim is now a 28-year-old local authority Women's Education Officer from Newcastle upon Tyne. For more than seven years she carried out deliberate acts of physical damage to her own body. Self-injury is a term that encompasses a broad range of behaviour. In its milder forms it can include nail-biting or persistent scratching. It can also, however, refer to acts of severe self-mutilation such as cutting, banging and burning - or, at its extreme, gouging out eyes or driving nails into the forehead.

More than 100,000 cases of self-injury are reported every year in hospital accident and emergency departments in the UK, but it is estimated that at least 10 times as many people disguise what they do as accidents or care for their own wounds. It is believed that self- injury is twice as common among women as men.

Despite its prevalence, it remains one of the least understood conditions within the field of mental health. Consigned to brief chapters in obscure psychiatry books, it is often misdiagnosed as failed suicide attempts or manipulative attention-seeking - and can create confusion, fear and even revulsion among the public and medical profession.

For Kim, a graduate in politics, self-injury was the culmination of a prolonged emotional crisis. Throughout her childhood and teenage years she appeared part of a perfect middle- class family - a bright, happy girl with loving and supportive parents. The reality was quite different:

'In fact my mother was very ill and depressed and my father - the 'responsible, kindly breadwinner' - used to get very angry and violent. And he was abusing me sexually. I couldn't say what I was feeling in words, so the cutting and scars became my language. They expressed feelings that didn't have anywhere else to go. Beforehand I'd be feeling utterly desperate - like my feelings were running away from me and I was slipping down a slope. Cutting myself stopped me going down that slope.'

Like many women who injure themselves, she says: 'There was a disparity between how I appeared and how I felt inside. In my breaks at work I'd go into the toilets and cut myself. Then I'd hide the wounds, go back to my job and carry on being 'successful'. Sometimes I'd cut myself about once a fortnight, but when things were really bad I'd do it up to twice a day.'

Kim says that when she was injuring herself what she needed was 'a place to talk'. What she received was completely different: 'Psychologists and psychiatrists treated what I was doing with contempt - like a 'loony' sign that I was deeply disturbed. I'd get told off in hospitals and people would freak out if they saw my scars. They said I was just being childish and gave me major tranquillisers, which just made me feel completely unable to cope.'

According to Mind, the London-

based mental health charity, her experiences are typical of an approach that emphasises the restraint of self- injury. 'The distress of women who self-harm is often compounded by hostility, judgemental attitudes and coercive methods of management on the part of staff,' says Alison Cobb, Mind Policy Officer. 'These women don't need punishing again in their lives. Since feelings of powerlessness and lack of control exacerbate self-

harming behaviour, the focus of professionals should instead be on empowering the woman and enabling her to take control over her life.'

An astonishing 53 per cent of calls received by the late-night Bristol Crisis Service for Women - a national support phone-line for women in crisis - relate to self-injury. The service has found that many women believe it is socially unacceptable to express anger overtly - and instead turn it in on themselves. Self-injury is a way of releasing the overwhelming tension that builds up inside. Counsellors at the service say it is just one of a range of coping strategies that include alcoholism and eating disorders. These may be more 'socially acceptable', but are equally damaging in terms of a woman's self-image.

However, the question remains as to what triggers this mutilating expression of personal crisis. Hilary Lindsay, co-ordinator and counsellor at the Bristol centre, says there is a clear link between self-injury and abuse: 'More than half of the women who call us about self-injury go on to say that they have been sexually abused. For them the only way of dealing with their continuing emotional trauma is to transfer their internal pain to external, physical pain on their bodies.

'Some talk about damaging relationships that have left them emotionally scarred. But we believe that the number who experienced sexual abuse would prove higher, if we asked them directly.'

In an attempt to close the gap between the needs of women and their treatment, the Bristol centre is launching a two-year research programme focusing on the experiences of women who injure themselves and will culminate in a national conference and training programme for health professionals. The aim, says Ms Lindsay, is to put self-injury on the mental health map.

Kim says: 'I eventually found what I needed - a place to explore the reality of my past. Being listened to took the place of having to cut myself. I've reached the stage where I can say I'll never do it again.'

Bristol Crisis Service for Women: 0272 251119; Friday and Saturday 9pm-12.30am.

Write, in confidence to: Research Project, BCSW, PO Box 654, Bristol BS99 1XH.

(Photograph omitted)