The sleeve slips up, and then there might be a glimpse of red slash marks on a student's arm. Alarm sets in.

Faced with a lack of information for "front-line professionals" such as school counselors and nurses called on to respond to students who cut themselves, Amelio D'Onofrio wrote a book.

Making room in the heart to understand a difficult situation helps, said D'Onofrio, a clinical professor and director of the Psychologist Services Institute at Fordham University.

He began with a quote from Karl Marx: "The only antidote for mental suffering is physical pain." D'Onofrio led a workshop at the NYSUT Professional Issues Forum on Health Care last month.

Self-injury, he pointed out, has been around for thousands of years, including with religious groups who used it for ritual.

But in the last 10 years, there has been what he called "an explosion" of young people in emotional pain cutting themselves. It gives them a feeling of being in control, jolted back into reality.

The practice, he said, "has moved from the clinical population to schools." Causes include sexual abuse, depression, disgust with physical appearance, problems with sexuality, loss or deprivation of a parent, and stormy relationships with families or peers. Today's multi-tasking, high-pressured and competitive lifestyles can also manifest persistent stress and anger, D'Onofrio said, citing the raised level of competition just to get into college.

Often, he said, the cutters have a disassociated quality of being outside their bodies, and self-injury brings them back into feeling alive again.

Many people judge them as manipulative, attention-seeking and having borderline personality disorders. Some clinicians react with disgust, helplessness, guilt or the need to rescue.

Cutters have difficulty soothing themselves, D'Onofrio said. Pharmacology messages blasted all over television push the message that "an outside agent can fix an inside problem." Meds promise to alter moods, induce sleep, achieve desired feelings.

Listen and understand

Caregivers such as school counselors and nurses, he said, should foremost "listen with the intention to understand." The goal when dealing with self-cutters should be to be consistent, attentive, nonjudgmental and trustworthy.

The assessment checklist, he said, should include:

• is this a crisis?
• is medical attention needed?
• what should be done about notifying others (parents, administrators)?
• do colleagues dealing with this student need attention?

Most importantly, he said, the frontline responder should be dispassionate, firm, confident and knowledgeable. It is important to communicate interest and develop a collaborative style.

First contact might include: "I'm glad you told me what you did to your body. Are you feeling okay about having told me? ... I noticed scars on your arms. I hope it's OK that I'm saying that. I'm interested in knowing if you want to tell me about it ... I'm glad you told me about it. If you want to tell me more or feel like saying more sometime in the future, I'm interested in hearing about it."

If a known cutter says he or she is going to cut again but wants to stop, a response might be: "How else can you release the tension? Walking, listening to music? What happened to make you want to do this right now? What are your feelings?"

Helping a person to heal, D'Onofrio said, "starts with your interest in their internal life."

— Liza Frenette