Vol.2, No.4, 366-375 (2010) Health
doi:10.4236/health.2010.24055
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Cutting and other forms of derma-abuse in adolescents
Hari D. Maharajh1, Rainah Seepersad2
1Department of Clinical Medicine, University of the West Indies, Trinidad, West Indies;
2Psychologist, Department of Clinical Medicine, University of the West Indies, Trinidad, West Indies;
Received 22 November 2009; revised 25 December 2009; accepted 28 December 2009.
ABSTRACT
Cutting or self inflicted epidermal damage
(derma-abuse) describes a number of blood-
letting behaviours among adolescents. Unlike
suicidal behaviour, it is associated with low le-
thality and the absence of suicid al attempt s. The
purpose of this study is two-fold: Firstly, to
present and discuss vignettes of four young
adolescents and secondly, to study the dynam-
ics and characteristics of six derma-abusers
who have attended Dual Group Therapy (DGT)
concurrently with their parents for a six month
period. Our findings suggest that patients in-
volved in derma-abuse are generally non-sui-
cidal but engage in comfort cutting for the
psychological release of pain, tension reduction
and anger management. There is a preponder-
ance of females (80%) with an over-representa-
tion of mixed origin and borderline cultural
states. In this small group, males amounted to
20% and were more bizarre, gruesome and bru-
tal in their self-abuse. Of the total sample, 10%
were of African origin, 60% were of Indian de-
scent and 30% were of mixed ancestry. Psy-
chodynamic factors explored in Dual Group
Therapy (DGT) are the emphasis on non-suici-
dal intent, association with tension reduction,
reclaiming power and mastery over self and
others, life and death instincts, the significance
of bloodletting in a socio-cultural context, trans -
generational conflicts, dysfunctional family dy-
namics frequently with parental separation and
sexual abuse and early sexual induction.
Keywords: Derma-Abuse; Cutting, Self-Harm;
Adolescents; Non-Suicidal Intent
1. INTRODUCTION
Self-inflicted epidermal damage, referred to as derma-
abrasion and derma-contusion are common practices
among young adolescents. There is much confusion in
the classification of su icidal behaviours with the general
view that self-inflicted human blood release is equated to
suicidal behaviour. The literature is replete with de scrip-
tive terminologies: Suicide and parasuicide [1] suicide
and deliberate self poisoning/injury [2], and Non-fatal
deliberate self-harm [3]. Other synonyms are “self in-
jury” (SI), “self-harm” (SH) “self-mutilation,” “deliber-
ate self-harm”, (DSH) “self injurious behaviour” (SIB),
and “self inflicted violence” (SIV) which are used inter-
changeably to explain common patterns of behaviour
where demonstrable injury is self inflicted [4-9].
Self-mutilation has its origin in many cultures around
the world. In ancient Mayan civilizations, Sadhus or
Hindu ascetics and early Catholic and Jewish Canaanite
rituals, all involved some form of bloodletting or self
flagellation that are associated with great religious and
spiritual sacrifice or rites of passage [10]. In the 1880’s,
this form of behaviour was the norm among cultures and
was not distinguished from other behavioural problems.
In 1935 and 1938, an important distinction was made
with a modification of the term self-mutilation that was
initially introduced by L. E Emerson [10]. This differen-
tiation considered the view that suicidal behaviour and
self-mutilation were two separate entities. As Menninger
stated in his book “self-mutilation was a non-fatal ex-
pression of an att e nuat ed death wish” [10].
Internationally, the most common form of clinically
determined self-harm is skin cutting. This occurs in
70% of the individuals that harm themselves, followed
by the act of banging or hitting oneself (21% to 44%)
and lastly 15% to 35% of persons who engage in acts
of burning themselves [11,12]. In non-clinical popula-
tions such as college samples, the most common form
of self-injurious behaviour was severe forms of scratch-
ing and pinching which results in bleeding and scarring
(51.6%). This was followed by acts of hitting objects to
the point of blood release (37.6%), then cutting (33.7%)
followed by acts of punching and banging with blood
release (24.5%). Body surface areas targeted by self-
harmers are the areas that are of easiest access such as
arms, hands, wrists, thighs and abdomen [13-15].
However, there seems to be no agreement on findings
of deliberate self-harm since similar rates have been re-

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Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
367
ported in both institutional and community populations.
In non-clinical populations, 4% of the adult population
had engaged in deliberate self-harm with a similar find-
ing of 4% in military recruits, (33). College populations
as a rule have reported higher rates of DSH, ranging
from 14%-38% [4,12,16,17]. In Europe, for persons over
the age of fifteen (15), there is an average rate of 0.14%
for males and 0.19% for females [18].
In the local setting, self-harm has been on a steady
rise over the past decade. A conservative estimate of the
incidence rate of students referred to a psychiatric clinic
is about 0.5% percent of secondary school students in
Trinidad. Approximately four cases per month are re-
ported at the Eric Williams Medical Sciences Complex
at Mt. Hope with an emphasis on derma-abuse or skin
cutting. In comparison to larger countries such as in
England 6.9% of students’ ages 15 and 16 in a cross sec-
tional study of 41 schools reported acts of deliberate
self-harm, [19].
In 2007, a newspaper report on ‘cutting’ among girls
in Trinidad sparked the issue of a mental health crisis
[20]. Further, two recent surveys conducted on non-
clinical populations have revealed high rates of self-
harmers. In a sample of 215 students at the University of
the West Indies, the overall prevalence of self-harmers
was found to be 24.2 percen t with 9.3 p ercent notated as
recent self-harmers and 14.9 percent engaged in self-
harming behaviour over the past year [21]. Among the
students reporting recent (within the past twelve months)
self-harm, the most frequently utilized methods were
cutting (70%), sticking oneself with sharp objects (50%),
and scratching oneself (45%). Students invariably util-
ized multiple forms of derma-abuse.
Analysis of the self-harmers over a one year period
revealed that those who reported recent self-harm be-
haviour had an average of seven times as many (M =
35.6 s.d = 54) incidents than those with a past history of
self-harm behaviour. In another study of 174 students,
[22] there was an overall prevalence rate of 31.6 percent
with a history of self-harm. In terms of recent self-harm
11.5 percent indicated this in comparison to 20.1 percent
who engaged in self-harm behaviour more than a year
ago. Within this sample 8.6 percent reported cutting, 8.6
percent indicated severe scratching and 6.9 percent, nee-
dle sticking. Of interest, 9.2 percent admitted to con-
suming pills, consumption of excessive amounts of al-
cohol, hair pulling (trichotillomania) and food refusal,
[22]. An interesting find ing is that although these studies
were conducted at the same University in Trinidad dur-
ing the same year, differential rates of 31.6% [22] and
24.2% [21] were recorded for self-harm behaviours.
It is evident that many researchers have described a
medley of behaviours that have been categorized as life
threatening and equated with suicidal intent. While some
authorities [19,23,24] have commented on the low lethal-
ity of derma-abusers, the boundaries appear to be blurred.
The purpose of this study therefore is two- fold:
Firstly, to present and discuss vignettes of four young
adolescents and secondly to study the dynamics and
characteristics of six derma-abusers who have attended
group psychotherapy for a six-month period with em-
phasis on their suicidality and treatment.
1.1. Theories of Self Harm
There are many explanatory models of self-harm that en-
compass various theories in psychology. Self-harm has
been described through Behavioral and Systems theories,
Psychodynamic and Psychoanalytical models as well as
Interpersonal and Object relations approaches [25,26].
Behavioral and Environmental models theorized that
self-mutilation creates internal or environmental re-
sponses that are reinforcing to the individual. The Drive
models purport a psychoanalytical understanding of the
self-harm behavior, specifically with the Anti-suicide
and Sexual model. The Anti-Suicide model claims that
self-mutilation is a suicide replacement, an attempt to
avoid suicide, a compromise between life and death
drives, and a sort of ‘microsuicide.’ The Sexual model
states that self-mutilation stems from conflicts over
sexuality, sexual development, masturbation, menarche
and menstruation [25,26].
The Affect Regulation Models offer a psychodynamic
explanation through the affect regulation model and the
dissociation model. Th e Affect Regulation model claims
self-mutilation stems from the need to express or control
anger, anxiety, or pain that cannot be expressed verbally
or through other means whereas the dissociation model
states that self-mutilation is a way to end or cope with
the effects of dissociation that results from the intensity
of affect. Many self-harmers report that they want to feel
alive again and acts such as skin cutting removes their
feelings of numbness [25,26].
The Boundaries Model which builds it explanatory
power on interpersonal and object relations theories state
that self-mutilation is an attempt to create a distinction
between self and others. It creates boundaries or an iden-
tity to protect against feelings of being engulfed, on the
other hand a fear of loss of identity. It reinforces self-
mutilation as evidence of familial or environmental dys-
function [25,26].
1.2. Objective
In this clinical study, prefaced with a comprehensive
review of the local and international literature, four vi-
gnettes and six patients and their families in Dual Group
Therapy (DGT) are studied over a six month period. The
purpose is to define socio-demographics characteristics
and to understand the dynamics of derma-abusers in the
context of interpersonal, trans-generational and envi-
ronmental factors. An appropriate management strategy
is devised.

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368
2. RESULTS
2.1. Vignette 1
I. S. is a 13 year old female student, of Caucasian de-
scent, who resides in Singapore. She was born in Flor-
ida, of mixed origin and of the Roman Catholic faith.
She came to Trinidad for treatment since she could not
be contained in Singapore. She has Trinidadian roots
as most of her family is originally from the island.
The patient has been reportedly skin-cutting since
2007 when she was eleven years old. She reported that
she had accidentally cut herself with a broken tea cup
during one of the many arguments of her parents. She
further stated that her ‘accidental injury’ had allevi-
ated her emotional confusion and made her feel re-
laxed. In 2008, she was hospitalized for a two (2)
week period after a cutting incident while in Singa-
pore. On her release, it was discovered that she smug-
gled a piece of glass into the hospital by concealing it
in her clothing and had continued cutting herself on
her thighs and was further warded at the facility. In
July, in Trinidad, she became so distraught and tense,
she begged her Aunt who was visiting from Florida to
allow her ‘to make just a little nick on her wrist to
alleviate her confusion’. Her most recent episode was
in September 2009. She presented for cutting her left
wrist at the Health Facility and subsequently taken to
the University Hospital and warded at the Paediatric
Ward. The patient with a history of skin cutting and
burning indicated her most recent cutting was not a
suicidal attempt but was used to eliminate stressors in
her life, inclusive of a strained relationship with her
cousins. In a review of her developmental, personal
and family history she has had somewhat of a tumul-
tuous past from an early age. As a toddler, she exhib-
ited temper tantrums at age 3, her parents divorced
when she was age five (5), and she reported that her
mother has been in abusive relationships, not only
with her father, resulting in her having to move be-
tween Malaysia and Singapore.
Her developmental milestones were normal but early
visits to her Paediatrician had shown evidence of pre-
cocious development. At a routine pediatric checkup at
age 6, the patient was noted to have a unilateral breast
bud and pubic hair. The pediatrician referred her to an
Endocrinologist where FSH, LF and other hormonal
levels testing were done. They were all within normal
range. A bone age scan was also done which showed
that the age of her bones were consistent with her
chronological age. Subsequently, a unilateral ovarian
cyst was discovered via ultrasound. This was monitored
for six months and at the second ultrasound no cysts
were found. The endocrinologist has since discon-
firmed precocious development despite her advanced
sexual development. In Trinidad, brain scans CT and
MRI were found to be normal as well as Electroen-
cephalographic (EEG) studies.
In her personal history, she has shied away from her
usual extracurricular activities such as netball, football
and swimming when she started cutting. Her attempts to
conceal the scars have resulted in her lack of interest in
other activities but she still con tin ued in th e school ch oir.
I.S. described herself as always being below average,
and always had difficulty concentrating since very
young expressing that she has always been taken long
periods to complete assignments. She has never got into
any physical fights at school or otherwise. Her history of
friendships has been mixed with some “bad” friendships,
but presently she has trustworthy friends. She lives with
her mother, her mother’s fiancée and his children and
will be returning to Singapore soon. Her maternal aunts
and mother are being treated for depression.
2.2. Vignette 2
M. A is a 16 year old female student of East Indian de-
scent who resides in Trinidad. She is the youngest of
three children. She presented on this occasion with in-
gestion of six (6) Painol tablets and two (2) painkillers.
The incident occurred in August 2009 and was precipi-
tated by an argument with her current boyfriend who is
eight years older and a friend of her brother. She de-
scribed herself as feeling depressed, hopeless and frus-
trated, with loss of interest in activities. She normally
enjoyed listening to music and watching television, but
did not have any intent to die. After this incident, she
reported feelings of sadness for long periods over the
next two days. M. A has a prior history of skin cutting
which had started two years ago.
Her first incidence of skin cutting was in early Form 3
(age 13). She described feeling angry but cannot re-
member the details of the incident. She also stated that
she engaged in banging her fists against the walls in her
bedroom when she felt upset and frustrated due to argu-
ments with her parents surrounding incidents with her
boyfriend.
Both her parents’ family has a history of depression.
Her father’s two cousins have depression and one of
her mother’s brothers has been committed to a mental
institution following a nervous breakdown. One has
also committed suicide. The patient herself has also
been treated for depression on her initial visits to the
psychiatrist.
Her developmental history was insignificant as de-
velopmental milestones were reported in congruence
with her age. She began puberty at around age twelve
(12). She has had no major accidents or illn ess to requ ire
hospitalizations. She has visited a psychologist fo r a few
sessions after she broke school on the first occasion. Her
relationship with her parents and brother has been
somewhat average since the incidents occurred but

H. D. Maharajh et al. / Health 2 (2010) 366-375
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
369
presently the family ties are improving.
In terms of her personal history, M. A has reported to
having two previous relationships from the age of 12
which lasted two (2) months, and then at age 13 with a
twenty one (21) year old man, which lasted one (1) year
and eight (8) months. M. A’s current boyfriend is twenty
five (25) and this relationship developed as she enjoyed
conversing with him as well as being a family friend.
She expressed that she enjoys school very much and gets
along with everyone including her friends. She has no
history of aggressive behavior. Her performance in
school is fair, but her grades have been falling due to her
involvement with her boyfriend.
Both her parents family have a history of depression.
Her father’s two cousins have depression and her
mother’s family has depression. One of her mother’s
brother has been committed to a mental institution fol-
lowing a nervous breakdown and one committed suicid e.
The patient herself has also been treated for depression
on her initial visits to the psychiatrist.
2.3. Vignette 3
S. M is a fourteen year old Secondary School student who
was referred to the Psychiatric Services for self- harm,
following a self infl icted t att oo whi ch he carved on hi s l e ft
arm with a symbol of his initial S. He did this without the
permission of his parents because “he wanted to feel pai n”.
He mutilated his forearm with a razor blade and covered it
with ink in order to ma ke a tattoo.
In addition, the school guard found letters in his pos-
session written in blood and ink which were messages of
hate. He stuck a fountain pen into the v a in of his forearm
thereby withdrawing blood and wrote a letter to his al-
leged girlfri e n d.
In his past history, at the age of five years on a school
excursion he was separated from the class and claimed
that people stamped on his chest. He was found by two
strangers who carried him back to school. At the age of
nine years, he received electric shocks from open wires
with no serious injuries. It is not known whether these
were accidental.
Both his parents are alive and he will drink with them
on special occasions and will even smoke cigarettes. He
has no sexual relationship but claims that he has many
girlfriends, defining a girlfriend as “someone to be with
when feeling down.” At the age of fourteen, he suffered
a fracture of the radius due to a fight at school. He was
close to his grandfather who recen tly died.
On interview, he was properly groomed adequately
clothed with a relaxed behavior. His affect was appropri-
ate and speech fluent. He said he did not believe in God.
He gave no reasons for his behavior and appeared to be
smug about it.
2.4. Vignette 4
A. P is a thirteen (13) year old male Form 3 secondary
school student of Indo-Guyanese descent. He was re-
ferred by the school guidance officer with a two month
history of carving a tattoo on his left forearm with the
inscription ‘Sasha’ his girlfriend. He painted it with ink
creating a self- made tattoo. His mother reported that he
is aggressive at home, stealing jewelry and money al-
legedly giving it to his girlfriend. He spends a consid-
erably amount of time at night speaking to the girl on the
phone which his mother attributes to his poor perform-
ance at school.
He was born in Guyana and was kept at the hospital
for an extra week due to an infection. His developmen-
tal milestones were normal but his mother noted that he
is extremely short tempered and responds with rage at
the slightest provocation. He is the last of three (3) sib-
lings with an older sister and brother. He does not get
along with his brother and recently pulled a knife at
him.
He came to Trinidad six (6) years ago with his mother,
who has been separated from his father for nine (9) years.
Presently he lives with his grandmother, grandfather and
brother aged seventeen (17). His mother is now in a sec-
ond relationship with a new husband for the past eight (8)
years. A. P does not get along with his stepfather and
accuses him of stealing the lost money and jewels. All
members of his family except his stepfather are of Guy-
anese origin. He denies the use of tobacco, alcohol and
drugs. He was diagnosed as having an impulse control
disorder in his first contact with the psychiatric services
on the island.
With respect to his derma-abuse, he feels no pain on
carving and is supported by his girlfriend who is ex-
tremely thrilled at his show of love. His mother has con-
tacted her on this issue and she has denied receiving
money and stolen rings from him but is adamant that no
one can stop him from seeing her.
3. ANALYSIS OF STUDIED GROUP
3.1. General Classification of Suicidal
Behavior with and without Intent
In the figure below, a classification based on a small
sample of ten (10) derma-abusers is presented. Pa-
tients involved in derma-abuse are generally non sui-
cidal but engage in comfort cutting for the psycho-
logical release of pain, tension reduction and anger
management. In this small group, males amounted to
20% and were more bizarre, gruesome and brutal
in their self-abuse. Females accounted for the major-
ity of the sample (80%) and among these; approxi-
mately 38% were of mixed origin. Of the total sample
10% were of African origin, 60% were of Indian de-
scent and 30% were of mixed ancestry. The high
percentage of abusers of mixed origin was unex-
pected and a plausible explanation is that these ado-
lescents find themselves in a borderline cultural state.

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These are individuals who are unable to conceptual-
ize which culture they belong to and consequently
develop identity issues in their attempts to please
both parents. The value assigned to each parent is
often based on stereotyped racial pecking order and
the environmental influences of parental dominance
and autonomy.
In this small sample of ten derma-abusers, patients
were categorized into three groups: those without suici-
dal intent, those with suicide in mind and a third cate-
gory of delayed onset, secondary suicidal thoughts. It is
noteworthy that in more than 80% of the sample, suicide
or thoughts of death was not the initial inten t and appar-
ently developed following intervention, after the pa-
tient’s discovery of its importance as a powerful ma-
nipulative tool. (Table 1)
In Table 2 below, a number of characteristics of
derma-abusers are outlined. These are observations taken
from group psychotherapy and concurrence with the
group therapist following the sessions.
In Table 3 above the socio-demographic character-
istics of adolescents in group psychotherapy were
tabularized to highlight commonalities among derma-
abusers.
Figure 1. General classification of derma abusers.
Table 1. Categorization of derma abusers in trinidad.
Derma-Abusers
Without Suicidal Intent With Suicidal Intent Mixed Group with later su ic id al o nset
 Chronic Harmers
 High Predictability
 Low lethality
 Intense family
Pathology
 Low impulse
control
 Harmer usually fits the criteria
below:
Plan-distinct
Lethality-High
Intent-High
Method
Timing
 Intense personal
Pathology
 Chronic attempters
 Any available method
 Family pathology
 Personal Pathology
Suicidal Behaviour
Suicidal Behaviour
without Intent
Suicidal Behaviour
with Intent but
without success
Suicidal Behav-
iour with Intent
and with Success
Suicidal Ideation
and Parasuicide
Non fatal deliberate
self harm
Attempted Suicide
Complete Suicide
Derma-abrasion and
Derma-contusions
Skin Cutting,
Piercing, Carving,
Banging, Burning,
Punching, PIcking
May progress to

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Table 2. Characteristics of derma-abusers as recorded in group psychotherapy.
Psychodynamics of adolescent Derma-abusers in Trinidad
1. Emphasis on non-su ici dal in ten t
2. Associated with tension reduction
3. Spontaneous overflow of emotion with low impulse control
4. Rejuvenation of loss of emotional resonance
5. Life and Death instincts- Eros and Thanatos considered
6. Reclaiming power and m astery over self and others
7. Significance of blood le tti ng i n a s oci o-cultural context
8. Transgenerational dysfunctional family dynamics frequently with parental separation and sexual abuse
9. Physical and developmental disor ders in early childhood
10. Morbid relationship with creativity with respect to body carving and architectural designs
11. Conte mporaneous influences of y outh c ulture
12. Reinforcement by family and help-seeking services
Table 3. Socio-demographic characteristics of the four (4) Patients presented in the vignettes and six (6) in group psychotherapy.
Vignettes* and Group Psychotherapy Cases
Demographics I. S* M. A* S. M* A. P* R. A K. E A. M O. M A. T T. S
Sex F F M M F F F F F F
Ethnicity Mixed East Indian East Indian East IndianMixed East IndianMixed East Indian African East Indian
Religion Roman
Catholic Roman Catholic Hindu Hindu
Roman
Catholic Hindu Roman Catholic Roman Catholic
Christian
(Pentecos-
tal) Pentecostal
Educational
Level Secondary (Junior) Secondary (Senior) Secondary (Junior) Secondary (Junior)
Tertiary
(Univer-
sity)
Tertiary
(Univer-
sity)
Secondary
(Senior)
Tertiary
(Univer-
sity)
Secondary
(Senior) Secondary (Junior)
Family
Structure Single
Parent Nuclear Nuclear Single Parent Nuclear Single Parent
Single
Parent
(father
died)
Adopted
blended Single Parent
Nuclear
dysfunc-
tional
School
Performance Borderline Fair Fair Poor BorderlineGood Poor Poor Poor Poor
Intermarriage
by race/relig-
ion/nationality
Caucasian
white &
Indian
Hindu &
Muslim Presbyterian & Hindu Guyanese & Trinidadian Indian & African
Guyanese
&
Trinidadian
Indian &
African
Muslim &
Roman
Catholic No No
Method Skin Cutting Banging &
Cutting Carving Carving Skin Cutting Skin Cutting Skin
Cutting Skin Cutting Wrist/Skin Cutting Skin cutting
Onset of self
harm 11 13 13 15 20 16 13 18 16 13
Co morbidity Depression Depression Non Family
Dysfunction Depression Depression
Childhood
Epilepsy &
Conduct
Disorder
Borderline
Personality
Disorder
Conduct
Disorder &
Hyper-
sexuality
Conduct
Disorder;
early
sexual
induction
& Somatic
complaints
Family history
of Psychopa-
thology
Bipolar
disorder Depression Non Non
Depression
& Alcohol
Depend-
ence
Alcohol
Depend-
ence Non
Personality
Disorder
(mother)
Psychopath
(brother)
Non Nervous disorder
(mother)
3.2. Profile of Adolescent Derma-Abusers
From the sample investigated, a general profile was de-
duced to represent the description of a typical derma-
abusing Trinidadian adolescent. Eighty percent (80%) of
the cases in Trinidad appear to be adolescent girls, rang-
ing from ages 11 to 16 years with onset of self harm in
early teenage years. They appear to be of East Indian or
mixed descent of both the Roman Catholic or Hindu
faith and attending Secondary School. The derma-abus-
ing adolescent seems to have an equal chance of coming
from either a nuclear or single parent family (absence of

H. D. Maharajh et al. / Health 2 (2010) 366-375
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372
father figure), though, within the nuclear family there is
usually a dominant parent, the mother. Their family
background seems to be of mixed origin, either by relig-
ion, race or nationality and there is a history of family
dysfunction and instability. Their performance at school
spans the poor to borderline ranges and the individual is
usually diagnosed with a depressiv e disorder due to rela-
tional conflicts. In some cases there is a history of Con-
duct Disorder in childhood.
Associated psychosocial factors are low self-esteem,
body image and identity disturbances and early cour tsh ip
and sexual induction. This is on a background of Trini-
dad and Tobago having the second highest rate of suicide
in the Caribbean region and may be a precursor for such
behaviour in adulthood. Different forms of derma-abra-
sion and derma-contusion observed among the sample
were skin cutting, banging, scraping, carving, burning
and branding, picking at the skin and removal of blood
with instruments (pen and needles). Skin cutting was
more prevalent amongst the female sample and carving
with tattooing was present in all the male derma-contu-
sion cases. It seems the intensity of the latter paints a
more bravado picture of sacrifice to a loved object when
compared to skin cutting by the females. Sexual drives
are a major operative factor in both male and female
derma- abusers.
4. DISCUSSIONS
An examination of the four (4) vignettes and six (6)
cases treated in Dual Group Therapy (DGT) highlights
significant commonalities in the life histories and pre-
senting concerns of all patients. The vignettes and group
psychotherapy cases presented are of adolescent indi-
viduals who began self-harm between the ages of 11 to
20, with a mean of 14.8 years and 80% between the
11-16 age group. According to the literature, studies
have reinforced that individuals aged 11-25 have been
known to self-injure [27].
Eighty percent (80%) of the cases discussed here were
children of intermarriages by race, religion or nationality.
It raises the issue of identity confusion and misunder-
standing of culture and practice as it starts at the family
level. The author is of the opinion that these individuals
suffer from a borderline cultural state which results in
their poor conceptualization of which culture they be-
long to. This cultu ral confusion in ethnicity, religion and
nationality is often stratified by the environment in
which one lives and can result in identity splitting and
confusion. In psychodynamic terms, blood- letting can
be viewed as an individual attempt to remove the bad
blood or bile of their mixtures in a purging process.
Durkheim’s theories of anomie, egoistical and altruistic
behaviors and Erikson’s stages of development are ap-
plicable here.
On closer inspection, the precipitating cause of self-
harm is strongly associated with the establishment of
early relationships with sexual induction as evid enced by
70% of the cases. This holds commonalities as those
purported by the Sexual Model of self-mutilation.
Among the teenage population, sexual experimentation
and risk taking behavior is a common aspect of this age
group. With numerous coping strategies to aid in the
tension reduction n eed ed, caused by volatile p artnersh ip s,
derma-contusions seemed to be prevalent. Within the
present sample of self-harmers skin cutting was ob-
served in all of the females and carving, being the
derma-contusion of choice among the male cases. It
seems the intensity of the latter paints a more bravado
picture matching the male image, in comparison to ‘skin
cutting’ portraying a slightly less gruesome, ‘romantic’
sacrifice. Though two different forms, both make the
assumption of the ultimate sacrifice, bloodshed.
The cases presented underlie the occurrence of trans-
generational dysfunctional family dynamics as shown in
Table 3. Approximately 60% of cases report family
separation, divorce, transcultural differences and family
psychopathology. In the nuclear family there was in-
variably the presence of a dominant parent which served
as a major stressor in the individuals’ life. In addition,
there were high rates of psychiatric disturbances (80%)
and psychosocial difficulties (100%), especially the
prominence of mood disorders (40%) in individuals who
self-harm within the present sample, as reported by pre-
vious studies [28]. It is likely that a substantive propor-
tion of these patients will progress to Bipolar disease.
Aggressive tendencies, emotional disorders, temper tan-
trums, conduct disorders and teenage angst were preva-
lent. The aggregate of emotions that are expected of this
age group coupled by intense family psychopathology as
expressed by 60% of the sample and personal psycho-
pathology as indicated by 90% of the cases seem to be
antecedents of self-harming behavior. Most of the indi-
viduals in the vignettes and group therapy cases have
stated that they use these behaviors as a way of express-
ing anger and frustration when emotions are at a high
and the overflow is unbearable, whereas some individu-
als self-harm to prevent suicide, or escape unwanted
feelings, as indicated by the Anti Suicide Model [25,26].
As expressed by Vignette 2, she was unable to explain
the situations surrounding her first skin cutting episode
but was certain of the fact that she was extremely over-
whelmed by anger. Since banging her fists on the wall
ceased to work anymore, she upped the ante to a more
punitive method that she felt helped at stressful times. In
a recent interview with M.A she stated that she was
faced with a situation concerning an assignment, in
which she had to redo a portion that she assumed was
finished. She reported that for a brief moment she
thought of cutting but reconsidered her actions. M.A’s
behavior seemed to hold commonalities to the Affect
Regulation Model of self-mutilation as she was over-
whelmed by emotion. The extent of the behaviors and

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Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
373
meaning of their acts are unknown to them and are often
given interpretative credence in treatment. Also, their
behavior is significantly different from suicidal behavior
with intent as the individuals in these cases have made
their scars public. As suggested by Hawton [29] self
harm behavior is distinctly suicidal if the act is “planned
for, carried out and followed through in such a way as to
keep it from the notice of others.” Even though derma-
abusers may try to hide th eir wounds the target areas are
easily noticeable despite concealment with hand bands
or clothing.
The new found control that has been indicated by
some of the above cases and vignettes has been the main
function of the deliberate derma-contusions that are self-
inflicted. It may be apparent that the manifestation of
family psychopathology and family strife is showing
itself in adolescence as creative forms of ‘bloodletting’
as it parallels Hippocrates early assumptions of ‘purging
of bad humors.’ [30]. Seventy five percent of the cases
report their bloodletting as an addiction that they desper-
ately need to engage in with the likes of alcohol and
drugs. It seems that a derma-contusion returns it users to
an equilibrium state that is required for their existence.
This supports the underlying commonality among the
cases with the lack of suicidal intent. They perceive their
self-harming behavior as a form of rejuvenation by let-
ting the bad blood out rather than as a destruction of
body tissue.
An important observation is the predictability and
chronicity of the self-harming behavior without suicidal
intent. In most of the vignettes derma-abusers repeated
these behaviors as certain events presented in their lives,
indicative of maladaptive coping mechanisms as well as
a need to remedy the situation at the moment, suggestiv e
of perhaps a hopeful future. An emphasis here can be
placed on a compromise being made between life and
death instincts of psychoanalytical theory, specifically
the Anti Suicide Model. They derive pleasure not from
stereotypical pleasurable behaviors but rather from ag-
gressive, self punitive behaviors that widens the power
differential between themselves and others. In an effort
to heal, they set themselves apart from normal methods
of remedy, lending resemblance to the Boundaries model
of self-mutilation. In Vignette 4, A. P felt that he was
showing his commitment to his cause when he carved
the name of his girlfriend along his forearm. He seemed
to be giving of himself wholly in a way he probably
could not express in words as proffered by the Affect
Regulation Model of self-mutilation [25,26].
The excessive compulsion and obsessive psychologi-
cal dependence of derma-abusers seems to be cognizant
of its chronicity a mong the individu als inflicted with the
addiction. Fifty percent of them seem to experiment with
different methods of self-harm before the addiction of
the tool of choice develops. It seems though, when in
desperation the tool of choice may best be substituted
with an available option . As illustrated by Vignette 1, I.S
went to great lengths to conceal a piece of glass within
her clothing, and thought nothing of it as she continued
to deliberately harm herself at the hospital, even though
she found comfort using razorblades. Prior evidence of
this kind of dependent behaviour can also be seen where
she begged a relative to allow her to cut her wrist in an
attempt to equilibrate herself again.
In this study, derma-abusers were not generally in-
volved in acts with suicidal intent (Figure 1, Ta b le 1).
The ten patients were categorized into three groups,
those without suicidal intent, those with suicide in mind
and a third category of delayed onset, secondary suicid al
thoughts. It is noteworthy that in more than 80% of the
sample, suicide or thoughts of death was not the initial
intent. These thoughts apparently developed following
intervention, on discovery that their behaviors were en-
meshed with the feelings o f power and mastery over self
and others, effects on tension reduction and as a form of
revenge and hostility directed against family members.
The act itself became the most powerful manipulative
tool reinforced in a Caribbean setting with a history of
aggression, violence and more recently high murder
rates in Tr inidad (Table 2).
The treatment of derma-abusers is difficult and pre-
sents a major challenge. After failure of individual ther-
apy designed along the lines of Linehan’s Dialectical
Behaviour Therapy model (DBT) [31] another method
was employed. DBT was unsuccessful for the following
reasons: Patients were too young and disturbed to ac-
quire what Linehan calls wisemind. With respect to the
‘what’ and ‘how’ skills, they could not focus on mind-
fulness. They could not develop interpersonal effective-
ness to say no, or resist their urges of cutting and had
little distress tolerance and emotional regulation.
A novel system of Dual Group Therapy (DGT) was
devised. This is the simultaneous occurrence of two
group sessions of one and a half hours held concurrently
in two adjoining sound proof rooms of the same building
once per week. The following screening process was
instituted. First the initial interview with the patient and
the attendants in the presentation of the problem (30
minutes). In the local setting, it is customary for the en-
tire extended family, caretakers and friends to accom-
pany the patient. In the second stage, the patient was
interviewed individually (45 minutes) being allowed to
tell her story and assessing significant others in her life.
In the third stage, two significant others, determined by
the patient and therapist were asked to be seen together
with the patient. In a client centered approach, the dy-
namics of interaction of family members and patients
were observed. The therapist had to be cautious in not
ascribing blame to anyone person, attempting to avoid
confrontation and acting-out behavior commonly found
in our setting. Information on ethno-historiography, that
is, the characteristics of origin, race, culture, religion and

H. D. Maharajh et al. / Health 2 (2010) 366-375
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
374
lifestyle were sought. This socio-cultu ral academic exer-
cise presented little threat to those involved. In the final
stage, an agreement (non-signed contract) was reached
by the parents (caretakers) and the patient to attend two
concurrently run groups namely ‘The Adolescent Group’
and ‘The Parent Support Group’. They were asked to
attend for a twenty four sessions (six months) period.
The third and fourth stages lasted approximately one
hour with a total assessment time of two hours. Parents
were given the charge of bringing the patients to the
groups. Two trained psychologists conducted the groups
and met together with two co-therapists who also were
in the group and the psychiatrist for weekly review s fol-
lowing the meetings. With shared information and emo-
tions from both groups, a tailored management approach
was devised for each patient introduced within the dy-
namics of group therapy.
This study investigates derma-abuse in adolescents.
However, two other studies done on adults in Trinidad
indicate that this practice continues into adult life. In the
University sample [21,22], students in the psychology
field were more prone to self-harm than those in natural
sciences and engineering fields of study. It seemed the
trend of cutting and derma abuse has continued into the
tertiary level institution and it may be useful to investigate
whether these students were derma abusers during their
secondary school life, or has the behavioural pattern
emerged during their University life. If the former is sug-
gested, a reduction in numbers may be expected if early
detection plans by appropriate service providers and per-
sonnel are put into place at the secondary school level.
The cases and vignettes presented are individuals who
have used maladaptive coping in an attempt to remove
dysfunctional events in their life. The adolescents have
challenged the status quo of ‘normal behavior’ in the
hope of normalizing their own lives. Their commonal-
ities are striking and lend itself to distinct characteriza-
tion of the phenomena of derma-abusing in Trinida d.
5. CONCLUSIONS
This is a preliminary study that highlights a growing
problem among secondary school children in Trinidad.
The author works closely with the School Supervision
Unit of the Ministry of Education in Trinidad where a
number of s tude n ts ar e r efe rr ed by th e Gu idance Officers
who are not equipped to deal with the intensity of prob-
lems encountered. The behavior of these students are
devastating to both fellow students and staff members
alike and can undermine the spiritual and moral values
of the schools’ discipline. The fact that there is an ele-
ment of contagion or copy cat behavior has led many
school authorities, especially those of the denomina-
tional Christian schools to perceive the problem to be
one of demonical possession and it is not unusual to
have these students ostracized and referred for exorcism
and spiritual healing.
In the presentation of this small sample of ten patients,
the intention is to demonstrate the similarities of behav-
ior, personal and family psychopathology and dynamics.
The psychopathology of the individuals and their fami-
lies must be emphasized as these may be major precur-
sors to their condition. While there is room in any insti-
tution for pastoral care and counseling, the presentation
of four (4) vignettes and study of the dynamics of six (6)
students in group therapy provide a better understanding
of these patients and prov ide a psychological framework
for treatment. While this paper does not address their
outcome in treatment, it is necessary to recognize th at in
group therapy, the inclusion of non-derma abusers in
groups can lead to the recruitment of deviants. Family
involvement is mandatory since disturbed kids invaria-
bly come from disturbed families.
Notwithstanding the limitations of it being a small,
descriptive observational study, it is however the first
clinical study of this nature coming out of the Caribbean
region. As highlighted in a daily newspaper two years
ago as ‘a mental health crisis’ [20], it is understandable
that this will be a major public health issue of adoles-
cents in the future, especially in Trinidad and Tobago
now on the threshold of first world status.
The increased attention to derma-abusing cases may
be an indication of additional adolescents engaging in
the behavior. So too, it can be attributed to the chang-
ing attitudes of adolescents in today’s culture as they
freely engage in risky behavior. As previously stated
[32], service providers may now have a more keen
ability to recognize and report derma-abusing behav-
ior with a better understanding of the dynamics in-
volved.
6. ACKNOWLEDGEMENT
I wish to thank Dayna Mohammed of the Psychology Department of
the University of the West Indies and Katija Khan, Psychologist of
University of Hull in England for their useful comments and contribu-
tion to this paper.
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