Dear Dr. Wes & Marissa: My friend and I were fighting yesterday on instant messenger. Then we both came to our senses and said sorry and said how we feel. Since last week, she keeps thinking of doing bad things to herself because she thinks she is disappointing everyone. She has an X on her waist and hand. She’s not cutting, but she uses a needle and gently scrapes it against her skin until it’s like someone scratched her in the shape of an X. I haven’t talked to her since yesterday, but she said she might need help. I am worried about her. – 14-year-old girl

Dr. Wes: We haven’t discussed cutting in a while, so it’s a good time for this letter. The problem continues among teens, and you’re right to be concerned about your friend. It’s not clear if you think your argument provoked the cutting or if your friend simply has become self-destructive. Regardless, you are not responsible for her behavior.

Broadly speaking, cutting teens can be divided into two groups, and it’s important to understand into which your friend falls. The first are similar to anorexics in that they tend to be “repressors,” keeping problems bottled up and taking them out on themselves. They tend to come from families that have high expectations, which they feel they can’t meet. Sometimes that’s accurate and sometimes the teen is just insecure, but either way she feels she doesn’t measure up. Your friend gives a hint of this by mentioning that she feels she is “disappointing everyone.”

She also may be cutting secretly on hidden areas of her body. Cutters also deal poorly with conflict at home or school, preferring to avoid upsetting anyone and turning their anger and teen angst inward. Many times they’re seen as “perfect children,” easy to get along with, mild-tempered, obedient – all the things parents adore. But that’s not because they’re well-adjusted. They simply hide their pain. In fact, one of the principal goals in treating cutters is helping them be more like normal teens – expressing their mood swings, showing anger and getting into conflict. That’s often hard for families to take, but it helps the teen find a far better way to deal with the struggles of growing up.

The good news is that cutters are not likely to commit suicide. The bad news is the lifelong scarring that becomes an unfortunate reminder of all the pain the teen was trying to get rid of in the beginning.

The second group includes those who get into cutting because their friends do it, or they want to gain the attention of others. These kids are harder to treat because they are acting out, not turning inward. They will persist long after the other kids have found a resolution and moved on. They’re actually kind of rebellious when compared to the first group, tending to cut in very obvious places and doing so in the company of others.

Of course, kids can get started in one group and end up in the other, so these categories are just a way to understand the basic dynamics of cutting. In either case, getting your friend to go to therapy would be an important first step, maybe even offering to go with her.

Marissa: Cutting became pretty abundant among the group of people I knew when I was in junior high (at age 14 or 15). The two groups of cutters that Wes describes are pretty accurate. I saw both kinds. There were the kids that hid it, and then there were the ones who did it openly. It seemed like they wanted to intimidate others. There were also a few people who really just did it for attention. Those were the ones I found it hardest to sympathize with. They would barely scratch themselves and then parade it around as if it were some medal of honor. It seemed almost like an epidemic, but from what I can tell, it was something that most of my friends were able to stop doing with help.

What you need to do depends on how severe you think the situation is. If I were you, I would first try to convince her to talk to her parents to help her find some treatment or someone to talk to. Cutting can become very addictive. But from what you’ve said, it doesn’t sound like it’s terribly serious … yet. Putting a stop to it early is really important.

I have confronted a few of my friends on the topic, and it’s not easy. But if you’re worried about her cutting, I really think it’s in her best interest that you say something. You don’t have to play the role of savior here, just be a friend. Beating around the bush won’t do you any good.

As Dr. Wes indicated, the worst thing about cutting or other self-mutilation is the lifelong scars it can leave behind. Because it seems that she is only doing minor damage, now is an ideal time to point out these cosmetic ramifications. I don’t think any teenage girl wants to knowingly create big gnarly scars on her body for the whole world to see. If the vanity angle won’t work, try something else. But remember, you don’t have to be the only one involved here. Just because you’re her friend doesn’t mean you’re responsible for what she does. Above all, be there for her, and try to give her support.

Next week: An update on sexually transmitted diseases.

Contest: Marissa’s job is up for grabs in fall 2006. We’re taking essays for the next three weeks in response to the challenge question published in last week’s Journal World. You can find the question at www.ftimidwest.com.

– Dr. Wes Crenshaw is a board-certified family psychologist and director of the Family Therapy Institute Midwest. Marissa Ballard is a Lawrence High School senior. Opinions and advice given here are not meant as a substitute for psychological evaluation or therapy services. Send your questions about adolescent issues to doubletake@ljworld.com. All correspondence is strictly confidential.