Tales from the Therapist's Couch

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"...the tension gets unbearable, and all I can think about is the razor. When everything is just a huge scream inside of me, it's all I want to do... while I'm cutting there's just this swell of relief."

"...the tension gets unbearable, and all I can think about is the razor. When everything is just a huge scream inside of me, it's all I want to do... while I'm cutting there's just this swell of relief."

A young woman sits across from me in my consulting room. Her words send a shiver down my spine. I've listened to such confessions more times than it's comfortable to remember. In my clinical experience, it's women who cut. And increasingly, it's women barely out of girlhood.

The young woman opposite me is in her twenties. She started cutting when she was 14. Unlike many woman who cut themselves, she has been no victim of physical, emotional or sexual abuse. Her life story bears no scars that warrant the neat criss-cross of cuts etched into her arm and stomach. So why does she do it?

She tells me she remembers the first time as if it were yesterday. She was sitting in her bedroom "feeling like shit". She had a period. She had spots. She was revising for an exam she didn't understand and knew she would be put into a lower set if she didn't pass. The boy she fancied was in the top set. Her best friend was in the top set. They were both cleverer than her. She went to the bathroom, and seeing herself in the mirror, angrily squeezed a spot. It made it worse. She was filled with tension. She picked up a razor and, without thinking, cut into her arm. The relief was immediate and enormous.

Psychoanalytic theories about self-harm focus on how an early abusive experience becomes self-perpetuated. The violence that has been dealt out to the victim becomes the violence she repeats on herself. People who have been cut down, cut out, verbally abused by a cutting tongue, turn the anger inwards in a terrible misdirection of aggression. In my practice I have worked with women whose self-mutilation has been triggered by appalling suffering and abuse. Their cutting frequently goes hand in hand with an eating disorder, and both symptoms can be as difficult to shift as any tenacious addiction.

But increasingly I am meeting teenagers who have more in common with the young woman above: seemingly trauma-free life histories, with cutting starting in their teens. A recent survey based on a school questionnaire suggests that the number is swelling into a national epidemic.

One common denominator in all their stories is a self-imposed and relentless pressure for high achievement, with anxiety about academic success causing the most stress of all. Often these young women describe their teenage world as worryingly busy with internal and external pressures. Freud's notion of "free-floating anxiety" comes to mind, as does the restless discontent of so much in our culture. Many youngsters have to sit through over 100 exams before they finish school. They struggle with trying to fulfill the conflicting expectations of both parents and peers, expectations that are mostly internalised and made their own. Mix this up with the insecurity and turbulence that is normal to adolescence, add an "off day" and you get the fit-to-burst pressure that triggers much cutting.

Most adolescents eventually outgrow self-harm. But of course, as Freud knew so well, symptoms don't just disappear unless the underlying causes have been exorcised. The socially-accepted habits that frequently replace cutting are less likely to cause parental alarm: overworking, overeating, overdrinking; undereating, chain smoking, obsession with dieting and exercise. But aren't these simply a new set of symptoms, muted expressions of earlier adolescent anguish?

So maybe when we cringe at the desperate self-mutilation of this growing number of teenagers, we need to think again. Maybe the causes are not always within and between the child and her family, but are to be found in the madness of our pressure-cooker world. And maybe we should acknowledge that this teenage epidemic of mutilation is self-harm with a bang, whereas we adults prefer to do it with a whimper.

Elizabeth Meakins is a psychoanalytic psychotherapist in private practice. None of the clinical material above refers to individual cases