helping teens who cut
helping t e en s w h o cut
U N D E R S TA N D I N G ENDING AND S E L F - I N J U RY
Michael Hollander, PhD
THE GUILFORD PRESS New York London
© 2008 The Guilford Press A Division of Guilford
Publications, Inc. 72 Spring Street, New York, NY 10012
www.guilford.com All rights reserved The information in this
volume is not intended as a substitute for consultation with
health care professionals. Each individuals health concerns
should be evaluated by a qualified professional. No part of this
book may be reproduced, translated, stored in a retrieval system,
or transmitted, in any form or by any means, electronic,
mechanical, photocopying, microfilming, recording, or otherwise,
without written permission from the Publisher. Printed in the
United States of America This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1 Library of Congress
Cataloging-in-Publication Data Hollander, Michael. Helping teens
who cut : understanding and ending self-injury / by Michael
Hollander. p. cm. Includes bibliographical references and index.
ISBN: 978-1-59385-426-3 (pbk. : alk. paper) ISBN:
978-1-59385-705-9 (hardcover : alk. paper) 1. Self-mutilation in
adolescencePopular works. I. Title. RJ506.S44H635 2008
618.92'8582dc22 2008002171
contents
preface acknowledgments introduction
KIDS WHO DELIBERATELY HURT THEMSELVES
vii ix 1
PA RT I
understanding self-injury 1 fact versus fiction
BRINGING SELF-INJURY INTO THE LIGHT
13 32 57 72
2 what sets the stage for self-injury? 3 how does hurting
themselves make some kids
feel better?
4
DBT
THE RIGHT THERAPY FOR YOUR TEEN
PA RT I I
helping your teen in treatment and at home 5 making the most of 6
resetting the stage
HOW TO HELP YOUR TEEN RESTORE EMOTION TO ITS PROPER PLACE
DBT
101 128
v
vi
contents
7 writing a better script
NEW WAYS TO DISCOURAGE SELF-INJURY
144 160 179
8 taking care of yourself to take care
of your teen
9 how to speak with siblings, friends, and the
school about your childs troubles appendix a
EFFECTIVENESS OF ADOLESCENT INTENSIVE DIALECTICAL BEHAVIOR
THERAPY PROGRAM
193
appendix b
INTENSIVE TREATMENT PROGRAMS
197 203 207 214
resources
WEBSITES RELATED TO SELF-INJURY
index about the author
preface
My interest in kids who self-injure was sparked by a conversation
I over-
heard between two adolescent girls at a hospital and school for
troubled kids. I was in my first year of postdoctoral training,
and what I heard made me think they were just striking a pose:
They were sharing with each other the benefits of self-injury.
Speaking with a kind of secret excitement, they told of how
burning themselves actually made them feel better and more alive.
As I spoke with supervisors and colleagues, my eyes were opened
to this phenomenon, and I realized that the girls had indeed been
serious. Soon afterward, I began to seek out patients who
deliberately self-harmed. Much of what I know about self-injury I
learned from my young patients. Without exception, the parents of
these patients were frightened, confused, and worried that they
had somehow failed their children. Kids who deliberately hurt
themselves need specialized treatment and, in some ways,
specialized parenting. Since I am a parent myself, I know that
parenting is a challenge even under the best of circumstances.
Once you get on that bus, you can never get off
these were my mothers words of wisdom to me
when my wife and I were about to have our first child, and she
was right. While she certainly captured the idea of child rearing
as a long-term ride, I didnt fully anticipate the bumpy
roads, the storms we would have to drive through, or the
occasional breakdowns. Raising children is very hard work. While
each developmental stage presents its own difficulties,
adolescence is certainly one of the hardest for parents to
negotiate. The journey becomes especially tortuous if our
children have emotional difficulties. Its all too easy to
get lost ourselves in the emotional storms and breakdowns that
overwhelm our kids. Our own understandable worry about our
childrens emotional states sometimes makes clear thinking
impossible. To complicate matters, our health care system
sometimes appears designed to prevent our children from getting
the help they
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viii
preface
need to move forward. I hope the following chapters will make
your journey progress a little more smoothly. I have confidence
that with a better understanding of self-injury and some new
tools to address the problem, your life will get a little easier.
My confidence arises from the program data that we routinely
collect from kids and parents who have attended our program at
Two Brattle Center and from the many conversations that I have
had over the years with parents who have tried these techniques.
If you learn these skills and begin to use them, you will be more
effective with your children. I have raised one adolescent and am
in the process of raising another. I know how challenging this
can be. My wife, who is a clinical social worker, and I routinely
use the skills outlined in this book both to be useful to our
child and to keep ourselves going in the right direction.
Thats what I hope this book will do for yousend you
in the right direction, by giving you some effective tools that
make a tough job a bit easier.
acknowledgments
t is impossible to acknowledge all the people who have influenced
my clinical thinking over the last 30 years. I have been
extremely fortunate to have had the chance to be trained at and
then affiliated with McLean Hospital. I would like to acknowledge
three master teachers: Richard Bonier, PhD, Edward Shapiro, MD,
and Shervert Frazier, MD. These three teachers, each of whom had
a very different way of approaching psychological treatment,
shaped my clinical work. The time I spent at the Adolescent Day
Service and the Adolescent and Family Treatment Unit helped me
understand what adolescents need and how their struggles affect
their parents, and vice versa. I am deeply grateful for what they
were able to teach me. My acknowledgments and thanks to Cynthia
Kaplan, friend and colleague at the McLean Hospital Acute
Residential Treatment Program. Her clarity of thought, humor, and
support have been invaluable to me over the years. I want to
thank Blaise Aquirre for reviewing the manuscript and making
helpful suggestions regarding the use of medications. Joan
Wheeliss vision for treatment has been a major influence in
my work and in the writing of this book. I am grateful to her for
pushing me to learn dialectical behavior therapy (DBT) and for
providing me the opportunity to develop an adolescent DBT program
at Two Brattle Center. I want to thank Shari Manning, PhD, for
her help in making sure the chapters about DBT were accurate,
precise, and clear. I am deeply grateful to Mathew Nock, PhD, and
Tara Deliberto at Harvard University for their willingness to
keep me up to date on the research pertaining to adolescent
self-injury. No one has done more than Marsha Linehan to
dramatically expand my clinical thinking. Her rigorous adherence
to the science of psychotherapy helped me challenge my beliefs
about the process of change, while at the same time her
compassion and kindness with patients earned my admiration and
respect.
I
ix
x
acknowledgments
My developmental editor at The Guilford Press, Chris Benton,
helped shape this book at every turn. I am immensely grateful to
her for sifting the chaff from my thoughts to identify what I was
trying to say. Her support, good humor, and keen insight were
invaluable to me throughout the writing process. I want to thank
Kitty Moore, Executive Editor at Guilford, for taking a chance on
a first-time author, and for keeping me in the game with her
irreverence and perspicacity. Thanks to my daughter, Kate, a
writer, for looking over the beginning drafts and for her
invaluable cheerleading and commiseration. Thanks also to my son,
Sam, for his excellent ear for dialogue and for keeping me
humble. I have the good luck to be married to a thoughtful and
skilled clinician, Janna Hobbs, who was truly a partner in the
writing of this book. I am grateful to her both for her
willingness to sacrifice her time to help me think through the
ideas in this book and for providing me with the kind of feedback
that sharpened my thinking. Her patience and loving support were
a critical part of this process.
INT RODUCT I ON
kids who deliberately hurt themselves
n more than 30 years as a psychologist, I have helped hundreds of
teens with all manner of problems. And I have seen that nothing
causes parents as much anguish as kids who deliberately cut,
scratch, burn, or hurt themselves in some other fashion. Parents
find their childrens self-injury to be one of the most
painful experiences they have ever had, and one of the most
confusing. If you find yourself in this situation, its only
natural for you to be frightened, sad, and sometimes angry.
Whatever you try to do to help your child may seem only to make
the situation worse. And your frustration may have created
tension between you and the childs other parent, who might
have very different ideas about how to manage the problem. My
intention in these pages is to clear up the confusion surrounding
selfinjury, to explain how it can be successfully treated with an
intense, shortterm program, and to show you what you can do to
help. This is not a book about becoming the perfect parent or
doing everything righttheres no such thing. No matter
how hard we try, we cant always provide our children with
what they need, whether it be discipline, empathy, validation, or
guidance. We fail because our timing is off, or we misread a
situation, or were tired or angry. We fail because the
world has changed so much from when we were young, or because we
didnt get what we needed from our own parents, so we just
dont know how. Children, especially emotionally sensitive
ones, have a way of bringing our parental weak spots to the
surface. I would like you to read this book with compassion for
yourself as well as your child. Self-injury is a complicated
problem with a multitude of causes. The first thing I want to
tell you is, Do not blame yourself. You will probably be able to
help your son or daughter the most if you dont try to be
perfect and instead focus on staying open to learning from your
mistakes. Dont underestimate your strengths. You may need
to
I
1
2
introduction
do things somewhat differently from other parents, but you can
learn the skills to be the parent your child needs. Getting your
child professional help will be an important component of what
you need to do. In this book I want to introduce you to a
relatively new therapy, dialectical behavior therapy (DBT), that
has been shown to be effective in helping kids to stop hurting
themselves. While it is impossible to predict how long any
particular treatment will take, DBT seems to be the shortest and
most effective route to wellness. While DBT is not a miracle
cure, Ive seen kids reduce self-injury in 3 to 6 months.
Keep in mind that any therapy is a process of a few steps forward
and a step back. It is not a smooth upward course. I also want to
offer some tips about how you can be helpful as a parent and how
to take care of yourself so youre able to tolerate what can
be a very bumpy and uncomfortable ride. I hope by the time you
finish this book, you will have a clearer understanding of
self-injury and will be armed with the tools to help get your
child back on track. The second thing I want you to understand is
that your child is selfinjuring because it calms him or
herat least thats true for the vast majority. To us,
thats a terrible solution. To your child, its one
that works. We dont know why it worksprobably because
of some combination of biological and psychological factors we
dont fully understand. One of the main purposes of DBT is
to help adolescents find other ways to calm and soothe
themselves. Rest assured that youre not alone on this
journey. Most self-injury begins in early adolescence, around 13
or 14, and affects an estimated 9% of the teenage population. Let
me share with you some brief moments in therapy with two
adolescents who self-injure. You will probably find something of
your own son or daughter in their responses. SARA : IT
CALMS M E DO WN Sara, age 15, and her parents entered my
office for their first consultation. Sara was neatly dressed, had
an easy manner, and appeared quite comfortable in this situation.
Her father had called earlier and requested the consultation on
the advice of Saras therapist. In the phone call he
reported that the therapist wasnt sure they were making any
real progress. Her father also said he thought Sara had a good
relationship with her therapist, and that Sara said she liked to
meet with him but was still cutting. Saras dad went on to
reassure me that the cutting was superficial and never required
medical attention. Sara, her father related, was a good student
who had many friends but often doubted her own abilities. Very
soon into the visit it was clear that Sara was a bright and
person-
introduction
3
able young woman. She told me that she had been cutting herself
since middle school and that she engaged in the behavior two to
three times a week, sometimes lessand in times of stress
more frequently. When I asked her what she meant by
stress, she described feeling emotionally
overwhelmed, like she wanted to jump out of her skin.
When I asked when her parents learned of her behavior,
Saras mom said she had learned of it only 8 months ago,
when the school nurse called and told her she had noticed
superficial cuts on Saras shoulders. A cloud of sadness
swept across Saras face, and tears begin to well in her
eyes. Right at this moment Saras dad quickly asserted that
as soon as this came to their attention, they found a therapist
and set up an appointment for Sara. I turned to Sara and asked
her about her work with her therapist. She told me that she liked
him very much and found him very easy to talk to. I asked what
kind of things she and her therapist spoke about. All kinds
of stuff, she said, like school stuff and friend
issues. Do you speak about your cutting? I
asked. No, not very often, she replied, but I
know the doctor doesnt want me to do it. Were trying
to understand why I do ityou know, to figure out what it
means. I asked Sara if she felt a sense of relief from
stress after she cuts. She replied that she does feel better
after she injures herself: It calms me down. I asked
her if she wants to stop cutting, and she assured me that she
did. Why? I asked. She knows its unhealthy,
Sara said, that it worries her parents, and that she doesnt
want scars on her body. I told her that while these are very good
reasons to stop cutting, in my experience they rarely have been
sufficient for someone to stop. I asked her in more detail about
the experience of being emotionally overwhelmed. She described
feeling sort of crazy on the inside, like Im about to
get out of control. She let on that cutting had been the
only thing that had helped her calm down in these situations.
How long does the relief last? I inquired. And
what happens when the relief is gone? It
depends, she replied. Sometimes it lasts a few days
and sometimes only a couple of minutes. Afterward I feel kind of
guilty. I used to tell myself I wont ever do it again, but
I dont do that anymore. I know when I get into that state I
dont have any control over myself. So cutting
really works at helping you manage powerful emotions. It is a
simple, relatively easy thing to do. Are you sure you want to
stop? I asked. Suppose I could convince your parents
not to worry about the cutting and reassure you that in the
future cosmetic surgery will probably take care of the scars?
Would you still want to stop?
4
introduction
A faint smile appeared on Saras face as she said, No.
In fact, I really dont want to stop. Saras
admission that she was not so sure she wanted to stop cutting
clearly surprised her parents. Its often the case, however,
that adolescents who self-injure have come to realize how
effectively the behavior helps them to soothe themselves.
Its not at all unusual for them to have mixed feelings
about giving it up. Saras story highlights two important
themes. First, self-injury usually serves to help kids calm down
from an intense emotional state. Second, sometimes even good
therapists, the kind who really know how to relate to teenagers
and are helpful in most situations, can miss the boat on
self-injury. Ill have a lot to say about both of these
points in the opening chapters. Your teenager may not look
exactly like Sara. With almost one teenager in 10 having engaged
at least once in what clinicians call nonsuicidal
selfinjurious behavior,its only natural that there
would be a wide variation in the behavior and the kids involved
with it. Not all teens who self-injure are girls; in fact,
theres some evidence that in the general teen population an
equal percentage of boys and girls self-injure. In research
samples of children who come to clinics, however, girls are much
more likely to be in treatment for it. Therefore, I will usually
refer to children who self-injure as females. Kids have
discovered a variety of ways to self-injure: with razors,
scissors, poptops from cans, fingernails, bits of glass, and even
broken CDs. For some adolescents it is a one- or two-time thing;
others will do it many times. As I mentioned, deliberate
self-harm often starts in early adolescence, but I have consulted
with children who started self-harming as early as 10 years old.
Without effective treatment the behavior can persist well into
adulthood. As you will come to see, deliberate self-harm is often
a solution to how your child feels in the moment. It can become a
stable way of managing painful emotions or a way to escape an
awful feeling of numbness and emptiness. Interestingly enough,
self-injury does not usually occur in the context of abusing
substances, and frequently the adolescent does not feel pain at
the moment of injury. Drugs and alcohol often serve a similar
function, which might account for why they dont often
appear in concert with self-harm. MARIE: SOMET IM ES I DO N
T FEEL ANYT HING AT ALL Knowing that youre not
alone with this issue probably doesnt make it any less
worrisome, frightening, or confusingespecially if you
cant find effective treatment, as happened to Maries
mother and father.
introduction
5
It looks like youre thrilled to be here, I said
to Marie in my office. I hate shrinks, she replied.
Marie was an attractive young woman with purple hair and several
face piercings. She was 17 years old, was date raped at 15, and
has a long history of failed psychological treatments. She had
had six inpatient admissions at local hospitals for cutting and
two for overdosing on pills. Shed gone through seven
therapists in the last 4 years. In addition, Marie had spent 9
months in one of the best long-term residential placements in the
country. When she left there, she and her parents were quite
hopeful about the progress she had made. She had stopped cutting
and no longer felt that suicide was an option in her life. The
gains she made when living away from home, however, disappeared
upon her return. Clearly everybody was disappointed that Marie
seemed to be right back where she started. Her last therapist
described her as unwilling to get better and as
someone who appeared to like the role of patient. He referred her
to me, but was clear that he felt she wasnt ready to engage
in therapy. It wasnt too hard for me to imagine that Marie
could be pretty stubborn. The therapist suggested that she cut to
let people see how awful she felt about herself, and that
self-injury had the added benefit of helping her receive
attention from her friends. So why did you come
today? I continued. With a scowl on her face she grumbled,
They made me. And you do everything they tell
you? I asked innocently. At this point Maries father
interjected that if Marie doesnt start to get her act
together, he was going to send her back to the long-term
residential placement where she had done so much better. While
clearly he was fed up and at his wits end, it also seemed
that hed be willing to do whatever it took to help his kid.
His statement was not so much a threat as an expression of his
ongoing concern, perhaps an indication of how fearful he felt
about his daughters future. Unfortunately, Marie heard it
only as a threat and slumped deeper into her chair. I asked
Maries dad how he understood her problems. Without missing
a beat he told me with certainty that her problem is that she
keeps trying to get attention. He understood that the date rape
may have been a factor in how she felt about herself, but if she
just had a little more willpower about putting the past behind
her, he said, she wouldnt allow herself to suffer so much.
Maries mother chimed in that her daughter has always been
rather dramatic and overly sensitive, and while in
some ways they are alike in that regard, she has done everything
she could for her daughter and is running out of energy. She
exclaimed that she has no idea whats going on with her
child and burst
6
introduction
into tears. Marie expressed her annoyance at having come to this
stupid appointment and threatened to leave. I asked
Marie if she could stay for just a few more minutes, as I had a
couple of questions to ask her. She reluctantly agreed to stay
put for the moment. I was relieved that Marie agreed to stay
because there were some important questions that I needed to get
answers to right up front. The first was about her experience of
cutting and of overdosing. I wanted to determine if cutting and
overdosing were similar or different ways of helping her cope. I
told her that I was going to ask her a few questions that called
for her opinion about herself, then I plunged in. When you
cut yourself, is your goal to die? No! she
replied without hesitation and with a hint of annoyance. I
didnt think so, I responded. What about when
you overdosed? Did you intend to die then? Yes,
she mumbled. I couldnt stand it anymore.
So for you, cutting serves a different purpose than
overdosing. Is that right? Cutting solves the problem of how you
feel in the moment, and overdosing is about ending it all.
Yeah, thats right. Okay, Marie, just a
few more questions. When you think about yourself compared to
others, do you think you are more sensitive than most
people? Definitely, she said. Do you
think it takes longer for you to get over an emotional situation
than other people? Do people tend to tell you things like
Get over it already, youre stewing over something
that happened days ago? The briefest of smiles and
the beginning of some curiosity crossed her face as she
responded, Yes. And finally, do you respond
really quickly to emotional situations? That is, you know what
you feel about something almost immediately, and if you
cant name the feeling you still know you feel something
very strongly? Totally, but sometimes I dont
feel anything at all. I just feel numb and empty, she
replied. I asked her when she feels numb and empty if cutting
makes her feel alive again. In other words, does it seem to bring
her feelings back? Yes! she replied. The story about
Marie highlights a couple of important points about selfinjury in
addition to what Saras story revealed. First, teenagers
often have a different intention when they deliberately
self-injure than when their intention is suicide. It is critical
that a thorough suicide assessment be conducted by a mental
health professional whenever self-injury is part of the picture.
It is equally
introduction
7
important that self-injury not get mixed up as suicide because in
some important ways each requires a different treatment approach.
The second point is the contention that self-injury is a
deliberate attempt by the adolescent to get attention. In my
experience this is one of the most frequent misconceptions about
self-injury. Parents and therapists alike hold to this
misunderstanding as they struggle to understand a very worrisome
and perplexing behavior. I discuss both of these points in
greater detail in Chapter 1.
WHY DO THEY DO IT?
If its not a cry for attention, then why do teenagers hurt
themselves intentionally? The two most common reasons for
self-injuring are (1) to control the extremely painful and
frightening experience of overwhelming emotions, and/or (2) to
escape from an awful feeling of being numb and empty.
Unfortunately, it may not be easy to see that this is whats
going on with your son or daughter. A teen who goes straight to
her room after school may not reveal the roiling emotion
thats tormenting her at the moment. And even if your teen
has directly expressed the feeling of emptiness, you may not be
able to tell exactly when shes experiencing it. So
youre left confounded by the cutting or burning, feeling
helpless and profoundly worried. The paradox of self-injury is
that what normally brings pain brings immediate emotional relief
in these cases. The key concept in understanding self-injury for
the vast majority of teens is that it is an emotional coping
strategy. (There are adolescents who self-injure for other
reasons, but they form a relatively small group.) Furthermore, as
a short-term strategy to manage awful emotional experiences, it
can be very effective. Its certainly not an acceptable
strategy, but understanding how it serves this function is a
critically important first step. When youand your
teens therapistunderstand that your teen selfinjures
to get immediate relief from emotional pain or discomfort, you
can start solving the problem. But without that understanding
therapies may move in the wrong direction, leaving even the most
competent therapist, the struggling adolescent, and the most
dedicated parent feeling hopeless and frustrated. Professional
help youve sought before may have led nowhere, and your own
repeated pleas to your teen for an explanation of why shes
doing this horrible thing to herself can lead you right down the
rabbit hole. My goal in this book is to keep you from falling
into it. Understanding your childs worrisome behavior will
help you in two im-
8
introduction
portant ways. First, it will lessen your own anxiety. When we
understand something, our fear and worry usually decrease.
Dont expect to become calm about your kids trouble,
but odds are, once you understand it, you wont panic as
much. In addition, it will help you locate appropriate treatment
and be better able to assess whether progress is being made.
WHAT YOU CAN DO
Like Sara and Marie, teenagers who self-injure often describe
feeling as if they are losing their minds or spinning out of
control. To the outside observer it sometimes seems that these
kids are being overly dramatic, throwing a tantrum, or making an
emotional mountain out of an inconsequential molehill. But being
overwhelmed by emotions or not having his or her own emotions
available to him or her can have an impact on every aspect of
your adolescents life, from friendships to a sense of
identity to what is sometimes described as impulsive
behavior. Adolescents who cut, or who deliberately self-injure in
other ways, lack the skills necessary to manage their feelings.
Furthermore, their emotional systems are more highpowered than
most peoples. They feel things very deeply. Even those who
feel numb or empty have usually unconsciously flipped a switch to
turn off the very intense feelings that tend to overtake them.
Self-injury is a way to regain emotional balanceit is a
solution to the extremely disturbing emotional problem of feeling
out of controland it works. Its critical that you
understand that fact because it explains why your teen, like
Sara, may not really want to stop the cutting. Why? Its
like aspirin. What do you do when you get a headache? You take a
pain reliever. What happens? Your headache goes away. How much
time do you spend after the relief thinking about why you got a
headache? Not much. It seems just human nature that when we solve
a problem, we dont spend too much time thinking about why
it occurred. The same is true for self-injurers: once the problem
(overwhelming emotion or devastating numbness) is solved, they go
on with their lives. All too often they dont devote any
attention to understanding what set them off and/or developing
the skill sets to solve the initial problem. It is the purpose of
this book to explain how your child can develop these skills and
how you can reinforce them at home. The first section,
Understanding Self-Injury, lays to rest several
popular myths about why adolescents self-injure and introduces
you to the facts about this worrisome practice, the factors that
lead up to it, and the treatment that works best to help
introduction
9
your child overcome it. In the second section, Helping Your
Teen in Treatment and at Home, I go into greater detail
about how DBT works and how I conduct this therapy, offering
concrete suggestions about what you can do to help your child and
to avoid making the situation worse. Ill also give you some
pointers about how to remain relatively sane through the tough
times. Taking care of yourself is a critical piece of the healing
process. Finally, Ill discuss figuring out how, and with
whom, to share the problem. DBT is not a quick fix.
Many adolescents reduce or stop self-injuring in 3 to 6 months,
but you will probably need to make a commitment of 1 year.
Whether your child stops self-injuring altogether depends on
other factors as well, such as his or her support system. As a
type of cognitive-behavioral therapy, DBT does not require any
special ability or insight. What it requires is recognizing the
purpose the behavior has been serving and making a commitment to
learning and practicing different ways of soothing a high-powered
emotional system. Armed with knowledge and willingness, your
child can learn to get past this very difficult time. And you can
help. Reading this book is an important start.
PART I
understanding self-injury
1
fact versus fiction
BRINGING SELF-INJURY INTO THE LIGHT
Caitlins parents were at their wits end. Whose
wouldnt be? Their daugh-
ter had been cutting herself several times a week for the past
year and a half. All their well-intended attempts at helping her
had failed. I just dont know what to do at this
point, said Caitlins dad. Weve tried
everything: individual therapy, family therapy, all sorts of
different medications. We even sent her to a different school. We
tried grounding her. We got so desperate we even locked up all
the sharp objects in the house. Nothing has worked. I dont
think she wants to stopshe must like the attention or
something. Caitlins mom chimed in: Shes
such a good kid. I know shes unhappy. I just wish that she
and her therapist could find the reason for her cutting. What
does it mean to her? I think if she knew why she did it,
shed be able to stop. Most of the parents who have
sought my consultation, like you, have been caring and loving
people who are frustrated and worried sick. Its hard to
stay calm when your children seem to be stuck in scary behavior.
You experience strong emotions that feel nearly unbearable. And
when youre emotionally aroused in this way, the climate is
right for you to make errors in thinking and judgment. Your need
for answers to aid you through these troubled times can lead you
to cling to erroneous conclusions that help lower your anxiety
and make sense of the emotional chaos but take you off the right
path. This atmosphere of confusion and misunderstanding has given
rise to numerous myths that circulate among lay people and in the
media. Therapists themselves have contributed to these myths in
some cases because theyve been struggling with a problem
behavior that has been illuminated by very little scientific
research.
13
14
U NDE R S T A N D I N G S E L F- I N J U R Y
Gaining a new understanding of why your children would do
something so inconceivable as cutting themselves is much more
important than you may believe right now. Of course, you may be
much more interested in getting straight to what you can do to
make this behavior stop. But acquiring a new perspective on the
purpose that self-injury serves for your child is an important
foundation for eliminating this disturbing behavior. A new
perspective will direct you to effective treatment and help you
to facilitate change in your childs behavior by doing some
things differently yourself. Thats why in this chapter we
will examine some of the myths and misconceptions you might have
about self-injury and some of the paths you may find yourself
going down that keep you from truly understanding the troubles
your child is having. The many misunderstandings that parents,
pediatricians, and therapists have about deliberate self-harm are
a primary reason why children dont get appropriate
treatment in a timely way. Consider Cynthia, a 22-year-old
college student who has engaged in self-injurious behavior since
the age of 13. Over the weekend Cynthias roommate noticed
the cuts on her arm and told the dorm counselor. Cynthia came to
my office only because her dean ordered her to get a
psychological consultation before she would be allowed to return
to the dormitory. Ive had therapy since I was a kid,
and it hasnt helped with the cutting, Cynthia told
me. Ive just become resigned to the fact that this is
part of my life. You know, when I cut myself it really
doesnt hurt, but it just seems to help. Im not even
sure I want to stop anymore. Cutting has been part of
your life for almost a decade, I said. You have been
clear with me how it helps you calm down, so I can imagine you
have mixed feelings about giving it up. Yes, in some
ways its like an old friend who is a bit troublesome but
who is always there when you need her. Cynthias a
little older than the patients I usually see. For the most part
in this book I will be talking about teenagers, because the vast
majority of people who engage in deliberate self-harm begin it in
adolescenceand thats when youre most likely to
be trying to understand and eliminate it from your childs
life. I want to leave no doubt in your mind that you should seek
professional help for your child if you know, or reading this
book confirms your suspicion, that your teenager has been
engaging in self-injury. While some kids only experiment with the
behavior, for most it will continue into the early adult years
and even into midlife and beyond unless prompt and effective
psychological treatment is sought. That can be difficult to
pursue when misconceptions get in the way.
fact versus fiction
15
MYTHS ABOUT SELF-INJURY
Please keep the following ideas in mind when you read about these
myths. First, in psychology nothing is absolute or certain, so in
a few instances what is a myth when applied to an entire
population can be a fact in an individual case. Second, most of
our behavior is influenced by many factors, including our past
history, our current needs, and our long- and short-term goals.
Not all these factors have an equal influence. Some have a minor
role in keeping the behavior going, while others exert a powerful
effect.
Myth 1: They Do It to Get Attention
According to some researchers, less than 4% of adolescents
deliberately hurt themselves to get attention. Yet its the
most common reason that parents and some therapists give to
account for the behaviordespite the fact that often an
adolescent is self-injuring for months before an adult even
notices. Misconceptions of this kind derail treatment and prolong
both the adolescents and the parents distress, as it
did for Erin and her family. ERIN: NOT FOR AT TEN T I O N Erin,
age 13, was a very likable and extremely bright girl who seemed
to have some anxiety in social situations. She had been
hospitalized numerous times over the last 6 months for
self-injury and suicidal thinking. The psychiatrist in charge of
her care reported that Erin had been cutting herself for the past
2 years, but that it had come to her parents attention only
about 8 months ago. When I asked the psychiatrist if he had any
ideas about why Erin injured herself, he replied with confidence
that he, the previous clinicians, and Erins parents were
all convinced that she did it to get attention. How could a young
girl be seeking attention through a behavior that she kept secret
for well over a year? When I posed this question to the
psychiatrist, he realized immediately that he may have leapt too
quickly to his conclusion. So how is it that smart, well-trained,
competent clinicians and caring, loving parents so often make
this mistake? Its hard to know for sure, but here are some
possibilities.
Even Delicate Cutting Is Self-Soothing
First, the majority of self-injurious behavior involves
relatively superficial wounds. Some clinicians refer to
superficial cutting or scratching as delicate
16
U NDE R S T A N D I N G S E L F- I N J U R Y
cuttinggiving the impression that the adolescent is
taking care not to hurt herself seriously, but only to cause
enough damage to get people to notice. But these superficial
wounds have the self-soothing effect that these adolescents seek.
(I discuss the smaller group of more serious self-injurers later
in this chapter.)
Parents Proximity
A second reason why parents might get off track about self-injury
has to do with the context in which the behavior occurs. Once you
realize that your child is self-injuring, you will probably
become more vigilant about her mood changes and emotional states,
thus keeping you near your child. If she hurts herself when
youre close, it would be easy to assume she did it to
capture your attention. Many parents have told me how they know
their child is having emotional trouble, but when they try to
help, the child often rebukes them or denies that anything is
wrong. The parents know that this is untrue and so they stay
close at hand. In a matter of minutes the child self-injures
right in the next room, and the parents rush in to help. The
child is a little calmer now and somewhat more willing to talk.
The parents conclude that she hurt herself to get the attention
she is now willing to accept. Parents are often both relieved and
annoyed by this sequence of eventsrelieved that their child
was open with them but annoyed because they felt manipulated by
the behavior. They conclude that the self-injury is a
manipulative ploy to get them to pay attention. Their frustration
is compounded because of their thwarted attempts to help.
Theres another explanation for this sequence of events.
Adolescents Want Privacy
The alternative explanation rests on two factors. The first is
the normal tendency for adolescents to seek privacy concerning
their emotional lives. This is especially true for those in the
early to middle stages of adolescence. For boys, early to
midadolescence ranges from 13 to 16 years of age; for girls
its a little earlier, from 11 to 15. Hallmarks of this
stage of development are the phrases I dont want to
talk about it and Everything is finethe
second of which often doesnt square with what you see. At
this point in their lives, adolescents feel a real need to be
separate and independent from their parents. As they negotiate
these new waters, they often confuse asking for help with
child-like dependency. These kids pull hard against any current
that might make them feel like a younger child. They have not
learned to differentiate between mature dependency, which
fact versus fiction
17
includes the capacity to ask for help and advice, and a
pseudoindependence that places a premium on going it alone. For
the most part, kids in this stage of development try to keep
their parents out of their business. While they At an age when
their mantras may wear outlandish clothes and beare I
dont want to talk about have in ways that are over
the top, it and Everythings fine,
they rarely intend to promote tighter teenagers rarely seek
parental scrutiny from their parents. Ironically,
attentionmuch less help. it is just such behavior that
often invites adults in to set limits.
More Emotion Than They Can Handle
The second point that supports an alternative explanation for
Erins behavior has to do with the way these kids experience
emotional distress. By and large, adolescents who self-injure are
extremely reactive people: they feel things very deeply and are
prone to becoming emotionally overwhelmed quickly. They possess
powerful emotional systems without the tools to manage
themits as if they have Ferrari engines and Toyota
Corolla transmissions. They have great difficulty harnessing
their powerful emotions in the service of clear thinking and
problem solving. When theyre emotionally charged up, they
lack the capacity to skillfully ask for help or to take in new
information that may alleviate their current distress. What they
want to solve, and to solve Kids who self-injure have quickly, is
how awful they feel in the mothe emotional engine of a ment.
Ferrari with the transmission Self-injury often provides immediof
a Toyota Corolla. ate relief from this feeling of emotional
turmoil. With that relief comes a degree of calmness that enables
them to be more available and reasonable with their parents. The
change in demeanor, coupled with the parents presence,
makes it seem as if they injured themselves to get attention, but
its almost always about getting immediate relief from
emotional distress. (Those cases where it doesnt provide
emotional relief are discussed in Chapter 3.)
Myth 2: Everyones Doing It
Deliberate self-injury has been part of the adolescent scene for
many years. My clinical experience and that of my colleagues
suggest that its on the rise, but we dont know for
sure. We are uncertain for at least three reasons.
18
U NDE R S T A N D I N G S E L F- I N J U R Y
Deliberate Self-Injury Has Often Been Mistakenly Documented as a
Suicide Attempt
Since suicide attempts appear to be on the rise, when self-injury
gets mistaken for attempted suicide, it seems erroneously that
self-injury is on the rise. Maries story from the
Introduction highlights the different experience teens have when
they are actively suicidal, as opposed to using self-injury to
soothe themselves. I cant emphasize enough the importance
of a thorough assessment by a qualified mental health
professional to sort out this issue. Most of the adolescents I
treat are quite clear about how different these two experiences
feel for them. (Often the adults around them, who are worried,
baffled, and at their wits end, are inadvertently
generating the confusion.) They tell me that they deliberately
self-injure when they just cant stand how painful life
feels a minute longer. They may wish they were dead, but they
have no intention of killing themselves. In contrast, when they
are feeling suicidal, they do intend to end their lives. But
dont try to make this distinction in your own children.
Seek a professionals help.
No Firm Criteria
Some researchers employ a rather narrow view of what constitutes
nonsuicidal self-injury while others use the broadest of
criteria. Consequently, the percentages given for adolescents in
the general population who self-injure range from 9 to 39%; for
adolescents who are hospitalized for psychiatric reasons, the
range is 40 to 61%. As clinicians and researchers
attention is drawn more and more to this area, I believe it
wont be too long before we have more definitive answers to
these questions.
Todays Kids Seem Less Secretive about It
While we dont know for sure whether self-injury is on the
rise, in my experience adolescents used to be more secretive
about it in years past; it would have been unusual for a child to
speak about such behavior even to his closest friend. Parents
often remained unaware of a childs self-injury until his
psychiatric hospitalization for some other reason. As time went
on, stories of selfinjury crept into the media, both in news
reports about teenage health issues and in the adolescent music
and movie culture. In a way self-injury has been
normalized. As a consequence, adolescents are much
more likely to disclose their self-injurious behavior to friends
and to discuss how it makes them feel better in the short run. In
addition, a number of Internet sites are devoted to
fact versus fiction
19
self-injury. We dont know whether these sites help children
to stop selfinjury or induce them to keep it up, but its
another route by which self-injury has come out of the
closet. The good news with self-injury coming out of the
closet is that researchers began to study the problem in an
attempt both to understand it and to develop more effective
treatments. The not-so-good news is that as more adolescents
became aware of the behavior, more tried it out in a moment of
emotional turmoil. Unfortunately, for a significant number of
adolescents, the behavior worked all too well in helping them
regain their psychological equilibrium. In the media and in the
adolescent culture, self-injury is often portrayed in ways that
glamorize or romanticize it rather than address its devastating
long-term consequences. You may even have come to believe from
these portrayals that self-injury is a worrisome behavior that
your children will outgrow once theyre out of their teens.
Sadly, this is not true. The child who self-injures is in
significant emotional distress and needs professional guidance.
Myth 3: Peer Pressure Is the Main Culprit
While kids who cut themselves are often friends with other
adolescents who do the same, peer pressure probably has little
effect on keeping the behavior going. For adolescents, and in
particular female teenagers, the peer group is a place to air
their problems. Its not unusual for one teenager to tell
another about her personal experience with self-injury or to let
on that another friend has tried it. Teens can also find out
about it from the media. In fact, preliminary data suggest that
about 52% of kids learn about self-injury from a friend or the
media.
Peer Pressure as Scapegoat
Peer pressure has been used to explain many kinds of adolescent
behavior, often without merit. For example, its often been
cited as a reason adolescents use alcohol and drugs. While peer
pressure can probably make someone use these substances on a few
occasions, its more typical for kids who are involved in
substance use or abuse to seek each other out, thereby creating a
new peer group. A similar pattern probably occurs with
self-injury. As adolescents describe it, only their friends have
the insight and ability to understand and help them. Its
true that cliques are an important part of adolescent life, and I
dont want to downplay the importance of a childs
feeling of belonging and support. I find, however, that a social
group offers its members an abundance of understanding and
compassion but not much in
20
U NDE R S T A N D I N G S E L F- I N J U R Y
the way of helping one another change undesirable behaviors. The
problem is more likely to be solved from the inside out: when
kids stop self-injuring, they will be more likely to find new
friends, rather than new friends in their group somehow helping
them to stop self-injuring, as Melanies story shows.
MELANIE: I LIKE T H ES E N EW FRI EN DS BET T ER
Melanie had been in treatment for 8 months and hadnt cut
herself for the past three. She started the session with an
upbeat story about a concert she had attended with some friends.
Did you go with Dee and Nick? I asked. No, I
actually dont see them much anymore, she replied.
I know your parents worked very hard to stop you from
hanging out Adolescents generally dont start with them. Is
that why? injuring themselves because of No
way, she told me. When the influence of friends. They
they wouldnt let me see them, I just are more likely to
choose friends did it behind their backs. I dont pick who
share their behavior. their friends, why should they pick mine?
They thought I was being influenced by Dee and Nick, like I
dont have a brain of my own. I dont know, I just feel
like Im changing and I like these new friends better.
Myth 4: Drugs and Alcohol Increase the Likelihood of Self-Injury
Self-injury soothes emotional distress, just as drugs and alcohol
do. So the behavior, especially in a child who self-injures as a
way to regulate emotions, would rarely be triggered by drug or
alcohol use. What happened to Vicki illustrates how they serve
the same purpose. I had been meeting in dialectical behavioral
therapy for the last 4 months with Vicki, a 16-year-old high
school junior. She came to therapy for cutting, but she often
also had problems with drinking. As we worked on reducing her
self-injury, we noticed that she began drinking more. You
know, I think I might be drinking as a substitute for
cutting, she told me in one session. I think
youre on to something, since both behaviors seem to be
geared toward helping you feel less anxious around friends,
I replied. I think we better target your drinking along
with your cutting behavior. The exception is the relatively
small group of self-injurers who hurt
fact versus fiction
21
themselves from severe self-hatred and contempt and for whom
self-injury is about relieving guilt through physical pain. These
children have often suffered sexual abuse, and theyre more
likely to harm themselves in the context of substance use. John,
a 19-year-old college freshman, came in to talk with me about his
self-injurious behavior. He had been sexually abused by a cousin
from age 7 to age 11. John prided himself on his academics and
had done very well through High School. I never cut myself
before. It just seemed to start around exam time first semester.
I put a lot of pressure on myself to perform, and I was really
stressed out, he told me. Tell me about the first
time, I prodded. I was studying for my math final.
Im usually very good at math, but I just couldnt seem
to get the concepts. One night I just got really frustrated and
began to drink in my room. The next thing I knew, I just was
feeling all this intense selfhatred. Without thinking I
picked up my X-Acto knife and began cutting.
Myth 5: Certain Kids Manage Physical Pain More Easily Than
Emotional Pain
Frequently when I ask adolescents about their self-injurious
behavior, they tell me that its easier for them to bear
physical pain than emotional pain. Like an alchemist of old, they
claim to be able to turn emotional pain into physical pain. It
does seem like a good idea to change a problem you cant
solve into one that you can. But when I ask them if their
self-injurious behavior hurts, typically the answer is no. So how
can it be easier to manage physical pain than emotional pain if
there is no physical pain? Im convinced from my numerous
discussions with these kids that they are not deliberately
distorting their experience. How can we reconcile this seeming
conundrum? When emotionally revved up, In all likelihood the
mechanism some people experience a sense that provides the relief
for these chilof calmness and relief when dren has to do with the
neuropsychothey damage their skin tissue. logical effect of
self-injury some people experience when they are in an intense
emotional state. This sense of soothing is the most common
experience that kids have at the moment of self-injury. While we
do not yet have a full understanding of how this works, it seems
that some people, when emotionally revved up, experience a sense
of calmness and relief when they damage skin
22
U NDE R S T A N D I N G S E L F- I N J U R Y
tissue. This may have to do with a kind of opiate-like endorphin
that is released at the moment of tissue damage. These kids,
however, explain their experience in a different way: they claim
that physical pain is easier to manage than emotional pain.
The Mustard Test
Psychologists and marketing professionals both know that the
reasons people give for their behavior and the true motivation
behind it are often two very different kettles of fish. If you
place a particular brand of mustard on the top corner shelf in a
grocery store, for example, and then ask people why they bought
that brand, they may tell you its because of its fabulous
taste. If you then put that brand on the bottom shelf, the very
same customers might buy a different brand now sitting on the top
corner shelf. If you ask them why they bought the second brand,
they may tell you its because of its wonderful taste.
Clearly, though, the mustards place on the shelf was what
determined which brand customers purchased. Psychologists have
developed something called attribution theory as a
way to explain this kind of behavior. Simply put, attribution
theory examines the ways in which our beliefs are related or
unrelated to why we do the things we do, and how our beliefs can
influence our behavior and our sense of ourselves. Our
attributions can be divided into two categories. Internal
attributions comprise our beliefs about what kind of person we
are, and external attributions focus on our beliefs about factors
that influence our behavior from the outside. For example, if I
run in a race and I do well, I may tell myself that I did well
because I trained hard and that I am naturally gifted. This would
be an example of an internal attribution. On the other hand, if I
tell myself that I did well because the field of runners that day
was poor, that would be an example of an external attribution. So
how might all this relate to our dilemma? When adolescents tell
me they experience no pain at the time of selfinjury but that
they self-injure because they manage physical pain better than
emotional pain, I gently point out the contradiction to help them
begin to see that other factors may be at work. These kids
believe (and its true) that they cant effectively
manage emotional pain, which they often experience as a personal
weakness. Believing that they can manage physical pain is a
positive aspect of their personality, and so they trick
themselves into believing that their self-injury is a strategy to
harness a positive aspect of their personality. They explain
their behavior based on the internal attribution that they can
manage physical pain more competently than emotional pain. While
this explanation has some validity, it doesnt accurately or
fully explain their self-injury.
fact versus fiction
23
Myth 6: Its a Failed Suicide Attempt
If I had written this book 10 or 15 years ago, Myth 6 would have
been first on the list. Thankfully, most clinicians now are
better able to differentiate selfinjury from self-harm with the
intent to die. This determination can be a complex clinical
endeavor, however, and the bottom line is that if youre
worried, you should get your child evaluated. Most kids who are
suicidal let someone close to them know about it. The notion that
if someone were really going to kill himself he wouldnt
tell anyone is a myth. Furthermore, as you well know, things can
change pretty rapidly with teenagers, so even if you had a
consultation, get another one if your worry comes back. Suicide
is the third leading cause of death among adolescents (after car
accidents and murder). While we have some clear ideas about risk
factors for suicide, many kids have risk factors and never make a
suicide attempt. What is terribly clear, however, is that the
single most powerful risk factor that predicts future suicidal
behavior is a past attempt. See the accompanying box of other
risk factors. See also the list in Chapter 3 of self-injuring
behaviors that may predispose an adolescent to suicide attempts.
More often than not, deliberate self-harm is not a failed or
half-hearted suicide attempt. But as with Marie, described in the
Introduction, some kids have both experienced suicidal thoughts
and injured themselves. And then there are kids who injure
themselves as a type of suicide prevention. As I mentioned
before, only a qualified mental health professional can make this
determination. Its critical that any child who is
self-injuring undergo a thorough suicide assessment by a
qualified professional. If your child is struggling with suicide,
your treatment team and you will need to stay vigilant about any
evidence of worsening mood, talk of hopelessness, or references
to wanting to die.
RISK FACTORS FOR SUICIDE
1. Psychological troubles like major depression, bipolar
disorder, borderline personality disorder, or anxiety disorders.
2. Substance use. 3. Severe family problems. 4. A recent
lossfor example, a break-up of a romantic relationship, a
move, or a change in school. 5. The recent suicide of another
adolescent in the community. 6. Impulsive or risky behaviors. 7.
Self-injury. 8. Struggling with issues about sexual orientation.
24
U NDE R S T A N D I N G S E L F- I N J U R Y
A NEW APPROACH TO UNDERSTANDING WHY YOUR CHILD IS SELF-INJURING
For children to hurt themselves in an attempt to feel better is
so counterintuitive that its only natural to look for an
explanation beneath the surface. Surely something elsesome
hidden, unresolved needmust be causing the behavior. But
the search for such hidden meaning has given rise to many of the
myths just discussed. It has also led therapists away from a key
concept: hurting themselves does make some kids feel better in a
very specific way at the moment they do it. Since the time of
Sigmund Freud, psychologists have been interested in the meaning
hidden in a persons actions. This kind of detective work
can be an important tool in psychotherapy, but it can lead
therapists and patients on a wild goose chase where self-injury
is concerned. Recognizing the function of these kids
self-harm, rather than trying to ferret out a symbolic meaning,
is the new understanding that makes it possible to help them give
up this behavior. When we understand the purpose their self-harm
has been serving, we can help kids find a healthier way to serve
the same purposeboth in treatment and in support of that
treatment at home. Let me give you an example. TAMAR AND T HE
PUPPY Tamar is a very bright college student who has a long
history of self-injury and eating-disordered behavior. She has
had several tries at more conventional individual talk therapies
aimed at helping her understand the meaning of her
eating-disordered behavior. Her parents divorced when she was in
elementary school. Her mother and father are two high-powered
professionals who travel often as part of their work. While Tamar
had a good relationship with her parents, she felt they pressured
her to conform to their ideas of success. Her eating-disordered
behavior reached a level where she couldnt remain at
college and had to return to live with her mother, although she
often spent time at her fathers house. After several
hospitalizations, she began outpatient psychotherapy with me. An
especially difficult problem for Tamar was binge eating in the
middle of the night. At one point she had made some gains in this
area by using skills she had learned in therapy with me, but we
were not sure what triggered the behavior or what function it
served for her. About 3 months into our meetings, she began to
backslide. It was a puzzle to both of us. She started one of her
sessions by saying, I think I know why I started to binge
again. It has to do with my father coming home from his business
trips.
fact versus fiction
25
I get really tense when hes home. I just know that he
wishes I would get my act together. He doesnt understand
how much Im struggling. As the therapy hour
progressed, I learned that Tamar had recently acquired a puppy
that she was in the process of housebreaking. As part of the
training, Tamar would get up in the middle of the night to take
the puppy outside. She told me that she was always fearful of
waking her father on these late-night trips with the puppy.
Furthermore, she complained of how intolerant her parents were of
her puppys behavior and said she would become stressed and
tense in response to their criticisms. What we learned when we
went step by step looking at what happened when she took the
puppy out was the following. Tamar would get extremely tense when
she noticed that her puppy might have to go out. As we talked,
she realized that when she went down the stairs and out the front
door she didnt binge, but when she went down the stairs and
out the back door through the kitchen, she did. It seemed that
seeing the refrigerator was the trigger for bingeing. If she
didnt see the refrigerator, she stood a better chance of
accessing her new skills to help her manage her stress. The
function of her bingeing, it became clear, was to reduce her
stress. The remedy, then, was simply to go out the front door.
This is the same type of solution that becomes accessible in
treating selfinjury when we look at its function rather than try
to discover its buried meaning. With the trigger out of the
picture and a better understanding of the function her bingeing
had for her, we were able to develop a treatment strategy that
would make Tamars bingeing a thing of the past. If I had
focused exclusively on the meaning of Tamars bingeing in
relation to the complicated feelings she had about her father,
her eating disorder would no doubt have continued much longer. I
had to assess the function of Tamars behavior and also work
at understanding her beliefs about the behavior. When speaking
with your childs therapist, listen carefully to how the
clinician is thinking about your childs self-injury so that
you can differentiate the meaning of a behavior from its
function. The accompanying box will help you accomplish this.
1. To find the meaning of the behavior, ask Why?
Answers are generally: I cut myself because I hate
myself, or I deserve to be punished, or
She needs to show people how much she hurts. 2. To
find the function of the behavior, ask What reinforces the
behavior? The most frequent answer to that question is that
it changes the individuals painful emotional state,
providing some sense of relief.
26
U NDE R S T A N D I N G S E L F- I N J U R Y
The Road to a New Therapy
The psychological theories that informed most of my earlier
career were variations on psychoanalytic concepts first proposed
by Freud, then refined and expanded over the years by many of his
followers. As I mentioned, this kind of therapy is very useful
for some kinds of psychological problems, but did not prove
useful for the adolescents I was seeing who were self-harming. My
task as a therapist at that time was to help my patients
understand the reasons and meaning behind their behavior. I saw a
persons troubled behavior as a symptom of some deeper
underlying psychological problem. The idea here was that if I
could help my patients understand the meaning of their behavior,
or develop insight, it would lead them to confront that
underlying issue. They would then be better able to choose a more
adaptive way of managing and resolving what was troubling them.
The problem was that unearthing buried psychological problems so
that the teenager could develop insight took a very long
timetime during which the teens self-destructive
behavior continued. To make matters worse, it wasnt always
possible to find the right insight or combination of insights
that would aid the child in recovery. The adolescent and the
therapist might examine the recurrent patterns in the
childs relationships with friends, for example. The goal
would be for the adolescent to understand what specific needs are
not being met in these relationships and how the child is
contributing to this problem. The idea is that with this insight,
the child can alter his or her friendship patterns, thus reducing
negative emotions that lead to selfharm. A more direct approach
would involve the therapist and the teen monitoring and
addressing the childs self-harming behavior as the problem
that must be solved first. Good therapists, however, have been
taking the more indirect route for years with reasonable results.
My own experience is that the more indirect tactics, while
viable, take longer to resolve self-harm behavior. In addition,
even when some of the kids had that Aha! moment, they
didnt have the emotional skills to overcome their problem.
I needed a way to help these kids stop hurting themselves as
quickly as possible. When I began to read about a treatment
called dialectical behavior therapy, or DBT, I knew it could be
the answer Id been hoping for. DBT has two major strengths
(as well as many others, which youll read about in later
chapters) that address self-injury effectively and efficiently:
1. It targets the problematic behavior directly. It does not
spend time seeking out hidden meanings or ask the teen or anyone
else to attribute the behavior to symbolic motivations. It looks
directly at what self-injury does for
fact versus fiction
27
the teen when she does it and gives her other ways to serve the
same purpose. As Ill explain further in Chapter 2 and
beyond, the purpose self-injury serves is the obvious one, as
counterintuitive as it may seem: At the moment when your teenager
does it, cutting or burning herself makes her feel better, not
physically but emotionally. 2. DBT recognizes that conflict
between the teen, who finds self-injury useful, and the parents
and therapist, who want the behavior to stop, erects a major
obstacle to change. Misconceptions and conflicting viewpoints
about self-injury generate tense and ineffective relationships in
therapy. Youre undoubtedly well aware that they cause
unnecessary distress between you and your child. The
dialectic in DBT is a way of finding a middle ground
where you (and the therapist) can work toward change. On the one
hand, you convey to the teen that you understand her emotional
pain and her need to relieve it, while on the other hand, you
nudge her toward eliminating self-injury by giving her new ways
to alleviate the pain. I hope you can see from this simplified
explanation that DBT is nothing if not practical. The goal for
DBT therapists is the same as it is for you: to help your
teenager stop hurting herself. The element that youve been
lacking so far is the how. DBT supplies that by
offering your teen better ways to ease her emotional pain. This
book will show you how you can adopt DBTs principles and
strategies to contribute to such efforts made in treatment. But
first, let me introduce a couple of teenagers who illustrate the
two points just introduced. AISHA : WEAV ING T OGET H ER M ULT I
PL E POINT S OF V IEW Its difficult to bear the uncertainty
about what guides the troubled actions of our loved ones. In
these moments were likely to jump to conclusions. Our
thinking tends to become rigid and constricted, so we cant
take in additional information that could help us. We can also
lose our ability to logically sort things out, so we become
overwhelmed and helpless. As much as we want to do something,
anything, to help our suffering child, inertia more often than
not wins out. To complicate things even more, you and your
childs other parent may not be on the same page. Often one
parents thinking becomes rigid and constricted while the
other parent feels emotionally overwhelmed, which can lead to an
ineffective parenting approach: Houston, we have a
problem. The single parent faces much the same dilemma,
alternating between hopelessness and a rigid certainty in
thinkingneither of which can help the suf-
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U NDE R S T A N D I N G S E L F- I N J U R Y
fering child. My work with Aisha is a good example of how things
can get derailed and how to get them back on track.
Fifteen-year-old Aisha lived with her dad, stepmother, and
younger brother and sister. She had minimal contact with her
mother, who lived in another state. Aishas stepmom had
worked hard to forge a relationship with her, and in many ways
has been successful in negotiating these very tricky waters. As
every stepparent knows, this is not an easy task. After the
stepmom had been in the house for a while and things seemed to be
settling down, she decided to pursue an advanced degree in
business. This had been a dream of hers for several years, which
she had put on hold while she took on the responsibilities of a
stepmother. Aishas stepmother was a confident, nononsense
kind of person and she reveled in the demands of graduate school.
Aishas dad, a quiet and thoughtful man, valued peace and
harmony in his family life. He told me that often he was puzzled
by his daughters periodic emotional outbursts, and
downright angry about her cutting. I saw Aisha with her father
and stepmother in a one-time consultation. Aisha had just
returned home after a 5-day inpatient stay that was precipitated
by her cutting herself after a family quarrel. So does
anyone have a theory about what this self-injurious behavior is
all about? I asked. Almost simultaneously father and
stepmother began speaking. Its not rocket science,
Dr. Hollander, Aishas father said with a clear tone
of frustration and annoyance in his voice. Aisha picks
those times when her stepmom is overloaded with schoolwork and
just cant devote the time she usually spends with the kids.
Its not easy juggling full-time family obligations with
graduate school. Shes only human; she cant do
everything. Aisha needs to understand that and stop trying to be
the center of attention. Aishas stepmom went on to
say, Its almost like clockwork. Exam time comes
around or I have a paper due, and thats when we can almost
count on Aisha finding a way to cut. She is so predictable. She
just has to have my attention all the time.
Thats not true! Aisha sobbed. I
dont want your attention. Stop saying that. I hate the
attention I get when I cut. I have tried everything to stop
cutting and I just cant do it! Clearly Aisha felt
misunderstood by her parents, but couldnt offer an
alternative explanation for her self-injury. In the absence of
another explanation, the parents held tightly to their point of
view, leaving Aisha with what appeared to be empty denials. The
standoff left everyone feeling frustrated and tense. The more
Aisha denied her cutting as a bid for attention, the more her
parents leveled evidence to support their point of view.
fact versus fiction
29
There had to be more to the story. The parents theory made
good sense, yet Aishas side was equally compelling. What
too often occurs in these conversational standoffs is that each
person starts to bring more and more energy and
insistenceand loudnessto bolster his or her own
position, while the capacity to understand the other
persons point of view goes out the window. I imagine that a
few of you reading this know all too well what I am describing
here. The key to success in moments like these is for you to
stand back and work at gathering more information. I will focus
on how to negotiate these tricky moments in later chapters. For
now, the essential idea is to become unattached from your point
of view and to bring some genuine curiosity and interest to the
situation at hand. Give up on being right. Try
instead to develop an effective collaboration on the issues
facing you and your child. Work at truly taking in your
childs point of view and finding the truth in his or her
position. I refer to this as weaving in multiple points of
view. In doing so we are discovering the kernel of truth in
each persons perspective and working at bringing it all
together to form a more complete view of the situation. To form
the most complete view You can always come back to your of your
teens self-injury, find point of view later. the kernel of
truth in each Of course this is easier said than persons
point of view and then done, especially when your emotions bring
all of these kernels together. are running high and your
childrens welfare is at stake. When you can let go of your
piece of the truth and work at developing a more complete view of
things, however, I promise you that the tension and frustration
will begin to decrease. Ive seen it happen again and again.
It works best when everybody involved is willing to do the same;
but even if just one party makes the shift, it can be beneficial
for everybody. It seems like you guys are stuck, I
said to Aishas family. No two ways about it, things
can get pretty hectic at home with everybody so busy. What is it
like for each of you? Aishas stepmom spoke first:
I do what I can for my familythey really are my first
prioritybut when my schoolwork requires my attention, it
becomes a real tug of war about how Im going to divide my
time. I have to admit, I can get pretty irritable and short on
patience in those moments. Aishas dad chimed in:
I guess we all start walking on eggshells so as not to
disturb my wife during the high-stress periods. You know, one
wrong move and shes liable to bite your head off! he
added, only half-joking. Aisha jumped in: I really get
feeling pretty crazy with all the tension
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U NDE R S T A N D I N G S E L F- I N J U R Y
The key to taking in other points of view to help solve a serious
problem is understanding that 1. You may have developed a rigid
adherence to your own position. 2. You are not betraying yourself
by being curious about other peoples opinions. 3. Its
of little importance to be right; the only thing that
matters is gathering information to help solve the crisis. 4.
Taking pieces of other peoples viewpoints plus pieces of
your own, at least temporarily, may yield a fuller picture than
any single persons viewpoint can. when my stepmom is under
all that pressure. It seems like the whole house and me included
are vibrating with stress. Sometimes I just cant take
it. Does your cutting give you some relief from all
that stress? I asked. Yes! Aisha answered
immediately. Clearly, it was Aishas response to the tension
in the house rather than her wish for attention that generated
her self-injury. Her parents theory, while in many ways
logical, was wrong. In part, their own frustration helped lock
them into a logical but false conclusion. Like the majority of
adolescents who self-injure, Aisha used cutting as a way to bring
relief from the awful emotional tension that she felt inside.
Only when her parents were able to reevaluate their position
could they respond to her with genuine empathy. And when they
understood the function of her cutting, they could begin to come
up with better ways to manage the tension in their household.
JANINE: VALIDAT IN G T H E T EEN S EMOT IONAL EXPERI EN C E
As mentioned above, the other major strength of DBT is that it
tackles the behavior directly because it is based on
understanding that the behavior serves the teens need to
alleviate emotional pain and by giving the teen better ways to
meet that need than harming him or herself. The first and most
important step toward accomplishing that goal is to ensure that
you validate the way your child feels. Janines story
illustrates. You just dont get it! Lizzie is my best
friend, and she understands me better than anybody else,
Janine exclaimed through her tears. Shes no best
friend as far as Im concerned, countered
Janines dad. I dont think shes a friend
at all! What kind of friend supports you cutting yourself?
fact versus fiction
31
She doesnt support my cutting. She just talks with me
about my problems, Janine explained through her sobs. This
is the beginning of a conversation that is guaranteed to go
nowhere. I hope you can recognize the truths in Janines
position and the truths in her fathers as well. What is
missing in the dialogue is validationthat is, communicating
that you understand and value the wisdom in the other
persons point of view. Validation means communicating that
you unValidation is like fertilizer for derstand the other
persons experirelationshipsit keeps them ence. This
doesnt mean that you growing. It nurtures and have to share
the opinion. enhances the relationship so the For example,
Janines dad need more arid times are easier to bear. only
say that he understands how valuable Lizzies friendship is
to her. Validation is like fertilizer for relationships: it keeps
them growing. It nurtures and enhances them, so the more arid
times are easier to bear. Furthermore, after he validates
Janines experience, he will be in a better position to
raise his concerns about Lizzie and have them heard. The concept
of validation may seem simple, but I have found it to be the
single most difficult skill to teach to parents and the most
important one for them to acquire. These brief stories give you a
glimpse into why self-injury can be so difficult to eliminate. By
its paradoxical nature it creates conflicts and
misunderstandingsbetween parent and child, between parents,
and between child and therapistthat can stand in the way of
change. You need a way to bridge the gap between opposing points
of view if you are to work together toward change. And unless
everyoneyour teen, you, and the teens
therapistunderstands and validates the teens
emotional experience, the teen is not likely to be receptive. If
you cant see that shes in a lot of pain and that
self-injury is her attempt to soothe herself, why would she trust
your advice on how to get better? It would be like
telling her to throw away her crutches and cut off her cast
because you didnt understand that she had broken her leg.
Of course emotional pain isnt visible. Lets move on
to a discussion that will bring to light how your child became
vulnerable to the emotional pain that urged her to start injuring
herself.
2
what sets the stage for self-injury?
pend a minute or two thinking about how you would answer these
questions: 1. Do you think your child is more sensitive than
most? 2. Do you think your child has an immediate and often
intense emotional reaction to life events? 3. Does it seem that
it takes your child longer than most to get over emotional
reactions? 4. Can your teen get all her tasks done when
shes in a good mood, but accomplish very little when
shes in a bad mood? My guess is that you would answer
yes to all these questions, thus describing a person
who is emotionally vulnerable and tends to act based on mood.
Your child may be self-injuring as a way to regain some emotional
balance. In fact, some researchers estimate thats what 80%
of kids who selfinjure are doing. But, like many parents, you may
notice that your child doesnt seem to feel any emotions at
all. I just cant read her anymore,
Ellerys mom told me with concern. I know shes
really upset, but she just doesnt show any emotion. When I
ask her how she feels, she just answers Fine, but I
know shes hurting. Some of these children have a
sense of dread about directly experiencing their feelings and
have developed strategies to avoid them. Theyre out of
touch with their feelings, unable to apply accurate labels to
their emotions. Theyre worried that if they were to feel,
they would become emotionally overwhelmedand they may be
right. When asked how they feel, they often quickly answer,
I dont knowan automatic response that
helps them short-circuit any awareness of their emotions.
S
32
what sets the stage for self-injury?
33
Others have developed the ability to mask their
feelings. They usually have some idea about what theyre
feeling, but for a variety of reasons they dont let on
through their facial expressions or words. Avoiding or masking
feelings is a strategy that will not work for long. Eventually
the emotional tension in these kids becomes unbearable, and
thats when theyre prone to self-injury. The recipe
for emotional vulnerability calls for two ingredients: emotional
reactivity and an environment that has somehow made the kids
doubt the validity of their own emotional experiences. When I
talk about emotional reactivity, I am thinking about three
things: first, emotionally reactive people feel things more
deeply than most; second, their reaction to emotional stimuli is
almost immediate; and third, once they are emotionally aroused,
it takes them a longer time than other people to recover. They
are often described as oversensitive, overly
emotional, high-strung,
temperamental, or even dismissively as drama
queens. An environment that fails to help the child learn
how to identify, accurately label, and modulate emotions can
arise from a combination of factors in the childs
surroundings. Let me make clear that this is rarely the result of
inadequate parenting. Rather, the parental strategies of
reassurance and problem solving that work in most cases often
backfire with these children. You The typical parental know this
only too well: these children techniques of reassurance and are
difficult to parent. problem solving often fail with For example,
your daughter may emotionally vulnerable kids. ask you how she
looks in her new dress and you tell her honestly that the color
is beautiful, but you wonder whether it might be too dressy for
the party shes going to. This comment may send her
tearfully sulking to her room and refusing to go out, leaving you
feeling perplexed, angry, and unfairly blamed. In this chapter
Ill help you learn more about the qualities of emotional
reactivity so you can determine whether they are operating in
your teenager, as well as about the environmental factors that
lead to emotional vulnerabilities. Understanding what happens
when these two factors come together puts you in a better
position to help your teenager stop self-injuring.
BIOLOGICAL VULNERABILITIES: THE SENSITIVE CHILD
If we were to measure emotional reactivity on a scale, we would
most likely find that the majority of people fall in the middle.
At one end would be peo-
34
U NDE R S T A N D I N G S E L F- I N J U R Y
ple who are only mildly reactive and on the other end would be
the most reactive people. With very few exceptions, ones
degree of emotional reactivity is determined by biological
makeup, like eye color or natural athletic ability, not by
ones environment. Being emotionally reactive is not
necessarily a psychological problem. We all know people who are
very sensitive and have learned how to manage their high-powered
emotional systems. They tend to be very empathic, to be the kind
of friends you would be likely to let in on a personal
difficulty. Emotionally reactive people live more in the
emotional side of life. But what about those children who
havent acquired the skills to manage their highpowered
emotional systems? These are the ones who become emotionally
vulnerable. They have a truly hard time tolerating negative
emotions like sadness and anger, and they have a hard time
finding ways to increase positive emotions like happiness or
interest. Researchers have coined the term emotional
dysregulation to describe how emotionally vulnerable people
respond to the experience of negative and positive emotions.
Emotional Dysregulation
Roberta wasnt always this way, Mrs. Martin
explained. As a child she would certainly have her moments,
but since the beginning of adolescence shes a changed
person. The slightest thing seems to send her into an emotional
tizzy. Robertas father added: Its like
everything has to be this big drama production, and whatever
suggestions you make, she shoots them right down. I know Roberta
is unhappy, but you would think she has it worse than anybody.
She has no perspective. People who are not emotionally
vulnerable often just cant understand those who are (and
vice versa). Not only is it hard to understand why they seem to
overreact all the time, but their emotional
dysregulation can be manifested in so many ways that its
not obvious that its the central problem behind most
self-injurious behavior. For example, the night before midterm
exams your son comes home from school and begins to play video
games. You have a sense that somethings troubling him, but
when you question him on his way to his room, he tells you
everything is fine. After the second hour you go into
his room and try to talk to him, at which point he tells you that
he cant study and hes going to fail anyway. You
suggest that if he does study, then maybe he wont fail. He
says once again that you dont understand him and tells you
to get out of his room. Naturally the situation deteriorates from
here with you trying to stay reasonable while he becomes more and
more emotionally distraught.
what sets the stage for self-injury?
35
Whats really happening here? Your son cant articulate
how worried and overwhelmed he feels about his schoolwork and the
fact that all his friends seem to be doing better than he is. His
worry and his sense of being a poorer student than his friends
has put him in a dark mood that cripples him and prevents him
from taking the proper action. It is crucial that you begin to
grasp how difficult it is for him to negotiate situations that
evoke anger, sadness, or disappointment. What can seem to you
like You need to understand how hard it is for a small emotional
brushfire your child to negotiate any situation that feels to
your child like a evokes anger, sadness, or disappointment.
full-blown five-alarmer. What seems like a small brushfire to you
Dysregulated people feels like a five-alarm fire to your child.
fall into three patterns of reaction when their emotions are
stimulated. These groupings are relatively distinct, but notice
that in each case the teens resort to self-injury when they find
an emotion intolerable either the initial emotion or a
secondary one triggered by a reaction to the event. Over time a
person may fit into more than one category.
Kids Who Lash Out
Alysa started her session with me by saying: It happened
again. My mother really pissed me off. We were at the mall and
she wanted me to try on this sweater. She knows I hate it when
she picks out clothes for me. I tried to be cool but she just
kept insisting. Finally I just started screaming at her. People
stared at meI know I must have looked crazy, but I
couldnt stop myself. Finally she just walked away. I felt
horrible. I couldnt stand how awful I felt about losing it
in the store with my mother. I went to the ladies room and
cut myself. Alysa belongs to the group of kids who manage
their dysregulation by lashing out at the people around them.
Anybody can be a target when these kids begin to get revved up.
They are quick-tempered and poor at expressing their anger
effectively. Once their anger subsides, however, they often feel
a great deal of shame about how they behaved. When their shame (a
secondary emotion) becomes intolerable, they are likely to engage
in self-injury.
Kids Who Act Impulsively
Mari and I had been working together in therapy for about 2
months when she told me about this phone conversation with her
boyfriend: He wasnt
36
U NDE R S T A N D I N G S E L F- I N J U R Y
really being unreasonable. He was trying to tell me that we
couldnt get together on Friday night because his schedule
at work had changed. It was automaticI didnt even
think about it. I just told him we were done and that I never
wanted to see him again. He tried to apologize. I just dont
know what I was thinking. Right after I hung up the phone on that
idiot of a boyfriend, I was so depressed and pissed off, I just
had to fix the way I was feeling. I marched straight upstairs and
into the bathroom to use the razor on my arm. When
emotionally dysregulated, Mari and others like her are prone to
impulsive actions like self-injury or substance use or making
poor decisions about relationships. These are the people we often
characterize as impulsive: they go from zero to 60 in a
nanosecond, without even a faint notion of the consequence. Even
when their initial impulsive act is not self-injury, after they
have moved into action they may experience unbearable shame or
selfloathing, similar to people who fly into rages. Theyre
not out of the woods yet; these secondary emotions about their
impulsive behavior may then lead them to self-injure.
Kids Who Feel Overwhelmed and Need to Soothe Themselves
Nora and I were speaking about her most recent episode of
cutting, which occurred right after she and her boyfriend had yet
another fight. He knew I was having a hard time and that I
really needed him. How could he do this to me? she
complained. Hes the only person who can calm me down
when I get like that. That must have been awful for
you, I said. Tell me all the feelings you were having
in that moment. I dont know. I just felt like I
was going to explode if I didnt get some relief, Nora
replied, her eyes fixed on mine. When you get emotionally
revved up, it seems its hard for you to know just what it
is that you feel, I suggested. I dont have to
be upset not to know what I feel, Nora admitted. I
can never figure it out exactly. Nora belongs to the third
group, those who hurt themselves as a way of self-soothing. As
with those adolescents in the other groups, the simpler paths to
emotional regulation are not open to her. Nora could find no
other way to release her emotions than to slice into her skin.
Where do you see your child among these descriptions? The better
you understand these patterns, the more likely youll be to
know when to worry
what sets the stage for self-injury?
37
1. Which of the three patterns of reaction (lashing out, acting
impulsively, or needing to soothe) does your child tend to
display? 2. What are the most common triggers that set off your
teens emotional dysregulation? 3. Typically, does your
child have more trouble in the immediate aftermath of the
emotion, or secondarily, as a response to feeling bad about how
he or she behaved in reaction to it? and move into action and
when youll just have to bear your regular level of parental
anxiety.
EMOTIONAL ILLITERACY: WHAT DO I FEEL?
As I mentioned earlier, teens who are emotionally vulnerable
often just dont know what theyre feeling. All they
know is that they cant stand it. Teens who cant
identify or label their emotions are at a distinct disadvantage,
one that has far-reaching implications. This trait can make it
almost impossible for them to keep their behavior under control,
to keep their friendships from becoming strained, to think
clearly when their emotions start to rise, or to achieve a solid
sense of identity. Ill talk more about this in the next
chapter but, as you can see, emotional dysregulation can affect
all aspects of your childs life. He will have difficulty
communicating his needs (how can he get reassurance and comfort
from you if he cant tell you that hes feeling extreme
fear?). He will have a hard time believing his feelings are valid
(if hes totally confused about what hes feeling,
those feelings wont seem very trustworthy). And he will
have trouble developing strategies for soothing himself or
regulating his emotional reactions (how can he talk himself
down The inability to identify, label, and when he has no
idea whats bothmodulate their emotions brings ering him so
much?). enormous difficulty to these children As we all know,
each of our in several key areas of behavior and emotions can be
experienced communication, affecting everything across a broad
range of intensity. from holding on to friendships to We can feel
anger as anything developing a solid sense of identity. from mild
annoyance to murderous rage. Likewise, sadness runs the gamut
from disappointment to deep grieving. In addition, each emotion
can be thought of as having three components: (1) a feeling or
sensation, (2)
38
U NDE R S T A N D I N G S E L F- I N J U R Y
a cognitive element, and (3) a tendency toward certain actions.
When we feel sad, for example, we may (1) have a sinking feeling
or a sensation of a weight on our chest, (2) think about our
troubles, and (3) feel like lying down. Recognizing these
componentsbeing emotionally literateis
essential for us to identify and accurately label our emotions
and to determine what to do about them. While our emotions can be
felt across a range of intensity, there are really only a handful
of fundamental emotions that we feel. In the following list, the
first six emotions are sometimes referred to as the pure
emotions because they are more biologically
basedwhile the last four are most likely learned.
Furthermore, each of these emotions corresponds with a particular
facial expression that cuts across cultures and eras. Wherever
you go on this planet, you can read someones
expression and have a good idea of the corresponding feeling.
Emotions are useful tools of communicationin fact, most of
human communication is accomplished without words. Being
emotionally literate is the key to this process. The pure
emotions are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Anger Sadness Joy
Surprise Fear Disgust Shame Guilt Envy Jealousy
Inability to Ask for Help
Jack is a sensitive 16-year-old boy who has been cutting himself
for about 18 months. He is very sympathetic and understanding
when his friends have troubles, but he cant seem to turn
that quality in on himself. I hate myself for feeling
sad, he told me in one session. It makes me feel like
such a wimp. I wish I didnt have any feelings at all. They
just make me feel crappy about myself. Life is confusing
enough for adolescents, but for those who dont know what
they feel, its exponentially more confusing. Kids who
cant accurately label their feelings are left without an
important blueprint to guide their actions. Instead, they
experience a powerful and confusing inner state that feels
what sets the stage for self-injury?
39
unbearable. Their behavior becomes directed toward changing their
inner state immediately rather than, for example, talking it out
with another person or finding a safe strategy to help themselves
calm down. What this boils down to is that these kids have great
difficulty in asking for help and/or Kids who cant label
their developing ways to help calm themfeelings have no blueprint
for selves down when they are upset, as action. Instead of asking
for help Penelopes story illustrates. or developing ways to
calm Last night I had a wicked fight down, theyve
learned to do with my father. He can be such an something that
will change their idiot. Doesnt he know by now that
powerful inner state immediately. he isnt helpful when
Im upset? Penelope told me. He heard me crying
in my room after instant messaging with my best friend, who was
being a jerk. He started asking me all these questions about how
I was feeling. You know, am I angry or sad or worried? I know he
was trying to be helpful and kind, but I didnt know what I
was feeling and he was just making it worse. He wouldnt
stop pestering me. Giving me all this advice about how I could
solve the problem. I just started screaming at him to shut up!
Finally he got really angry with me and stormed out of the room.
I was so upset I just had to cut myself. If Penelope had
been able to identify her feelings and had some coping strategies
at her fingertips that would lower the intensity of her feelings,
she would have been much less likely to engage in self-harming
behavior. Some simple, immediate solutions would have been to go
jogging or to listen to some upbeat music or to take a bubble
bath. While these strategies would not have solved her
interpersonal problems, they might have helped her to regulate
her feelings and calmed her down enough so that she could think
clearly about what she wanted to do and maybe even tell her
father what she was feeling.
Cooking Negative Feelings
Physiologically our feelings last a very short period of time and
then dissipate on their own. In fact, to make our feelings last
longer we have to keep doing whatever it is that evokes the
feeling or keep thinking in a particular way about what generated
the feeling. The kind of thinking that keeps negative feelings
going is usually spiced with judgments about others or negative
opinions about ourselves: a judgment about how unfair the
situation is, or a feeling that theres something wrong with
us for having the feeling in the first place, or that if I were a
better person, I wouldnt feel this way.
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U NDE R S T A N D I N G S E L F- I N J U R Y
For example, if your boss tries to blame you for something that
wasnt your fault, in all likelihood you will experience
some degree of anger. The feeling of anger will rapidly fade,
however, once you stop thinking about what he did. But if you
dwell on the situation, that anger will cook for a
long time. When we cook our feelings long enough, they turn into
moods. For example, for some kids journaling is a helpful
strategy to help them calm down. For others, it just keeps them
focused on whats troubling them. Consequently the Any
negative feeling, such as anger, more they write about a problem
in will naturally fade after a short a journal, the more they
create a time. But dwelling on the situation negative mood for
themselves. that angered you, usually involving When I asked Nora
if she had judging others or ourselves, will any strategies
besides cutting to cook the anger long enough to help
her calm down when shes turn it into a mood. emotionally
revved up, she said: Not really. Sometimes I try going to
sleep or take some extra medications. But mostly I just stay
feeling crappy, obsessing about what put me in such a bad mood.
After a while I cant stand myself and Im liable to
pick a fight with whoever comes my way. Without the tools
to soothe herself or to change her feelings, Nora cant help
but lash out.
Modulating Emotion to Get Things Done
Being able to lower the intensity of our emotions and to avoid
developing a bad mood as a misstep on the road to
feeling calmer or needing to get tasks done is called emotion
modulation. Anyone can practice enough to acquire the skill. If
youre among those parents whose child has had trouble
calming down after feeling sad or angry ever since she was
little, here are some questions you might want to ask yourself to
determine whether your child has problems with emotion
modulation: 1. Does your child seem to get stuck in a
bad mood that lingers well beyond the event that triggered it? 2.
Does your child demand your help when he or she is
upset, refusing help from any other adult? Yet at other times
does he or she refuse help when you offer it? 3. Has it been
extremely difficult for your child to make a transition to a new
activity when he or she feels sad or angry?
what sets the stage for self-injury?
41
This makes me think of a story from several years ago; when I was
in my forties and I tried my hand at competitive cycling. I had
the opportunity to train with a guy who was a bit older than I
was but had been a former Olympian. I have to tell you that I put
in more hours and miles per week on the bike than he did, and yet
there was no way I could keep up with him. It wasnt a
matter of practice and training; he was innately stronger on the
bike than I was. In other words, he was just naturally better.
Think about those things that have come relatively easily for you
and those things that Think about the skills that have you had to
work hard at mastering come pretty easily to you in life and
youll understand what I am compared to those you had to
work getting at here. hard for, and you can begin to see It may
be that people who are how hard it is for your child to
hard-wired to be emotionally reacregulate his or her emotions.
tive have to work harder at developing the capacity to regulate
their emotions, but we just dont know for sure. Nor do we
know what other innate variables come into play to make this
easier or harder for a given person. What we do know is that most
kids who engage in deliberate self-harm are at the emotionally
reactive end of the emotional continuum. If they dont or
cant modulate their emotions, theyre more likely to
make poor decisions, to fall prey to impulsive actions, and to be
ineffective in their relationships. To modulate his emotions,
your child needs to activate the part of his brain that controls
logical thinking and reasoning, that part of the brain that helps
him reappraise his emotional situation, rather than the part that
leaves him wallowing in the emotion. As you can see, emotion
modulation skills are absolutely critical to our well-being.
Mood Dependency
In addition, being able to modulate our emotions makes it easier
for us to sidestep an angry or depressive mood. Kids who lack
this capacity tend to be mood-dependentthat is, their mood
determines how effective they can be in carrying out their
responsibilities and how they will experience any particular
event. For example, if theyre in a good mood, chances are
they will be able to get their chores done and complete their
school assignments or the long car ride to grandmas house
will be pleasant. If theyre in a bad mood, they may not be
able to get anything done and neutral or even potentially
pleasant events can get tainted by their negative emotions. If
your childs behavior is mood-dependent, you may find it
hard to understand that the trou-
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U NDE R S T A N D I N G S E L F- I N J U R Y
ble hes having has to do with his inability to modulate his
emotions. After all, on the surface theres not much
difference between mood-dependent behavior and sheer lack of
motivation or willful disobedience. To make matters worse, he
often wont be able to explain his behavior, except to say
that at the time it seemed like a good idea. Skipping school to
play video games, for example, may have seemed like a good idea
to him at the time. Ask yourself the questions in the
accompanying box to help determine whether your child is
mood-dependent:
1. Is there a big gap between what your child can do when he or
she is relatively happy compared to what he or she can accomplish
when a blue mood strikes? 2. Can your child harness himself or
herself to choose the effective solution that the situation
requires or does he or she take the easy path? 3. Can your child
let goof his or her feelings to get chores done?
While we all find it easier to get our work done when were
feeling relatively calm, these kids experience a huge difference
in their capacity to accomplish anything depending on whether
theyre calm or agitated. When they fall behind on
lifes requirements, they make their situation worse,
increasing the likelihood that the bad mood will be extended.
Whats Going On in the Brain?
Earlier I mentioned that kids who self-harm have more difficulty
than the rest of us in calling on the part of the brain that
controls logical thinking and reasoning. Researchers are
beginning to study just how the brain operates when we modulate
our emotions. Scientists can use functional MRIs to map the
brains activity as it works to solve particular problems.
Here is a simplified version of what they have discovered about
emotion modulation. For the most part, emotions originate in a
part of the brain called the amygdala. Depending on the
situation, signals are sent from the amygdala to the prefrontal
cortex, that part of the brain involved with reasoning. Here the
brain works at evaluating what to do about the emotion. While
there is nothing we can do to prevent ourselves from having a
particular emotion, we can change how intensely and how long we
experience it. Through the use of thought and logic, humans have
developed several tried-and-true strategies to modulate their
emotions.
what sets the stage for self-injury?
43
Assuming were in no imminent danger that requires an
immediate response to our emotionssay, a ravenous lion is
about to attack, in which case our fear would enable us to run
for our livesthere are any number of strategies and skills
we can use to modulate our emotions. In the following discussion,
every emotion regulation strategy begins with accurately labeling
and identifying our emotion. All the emotion regulation
strategies are based on accepting and acknowledging what we feel.
Emotion regulation is about (1) being willing to have the
emotion, and then (2) working at modulating it. When we
cant or wont accept our feelings, we inevitably make
the situation worse either by cooking them or by impulsively
moving into ineffective behavior.
Using Problem Solving to Modulate Emotions*
When we understand which situations are likely to produce intense
negative reactions, any of us can use problem-solving skills
either to avoid these situations or to craft some strategy that
will lower the intensity of the feelings. For example, if you
know that spending time with your angry and critical sisterin-law
is going to rile you up, you might solve the problem by cutting
your visits short or by meeting her in a public place that will
make her less likely to go into a harangue. This strategy might
be useful in keeping the intensity of your feelings at a lower
level, but not all situations will allow you to do this.
Sometimes events happen that just get under your skin. In these
moments you need Simple problem-solving strategies some
strategies to lower your emothat seem obvious to you may be
tional temperature. One example is beyond the reach of children
who to take an emotional time-out. Say are emotionally
vulnerable. youre at a party and someone makes a comment
that really hurts your feelings. What do you do? The simplest
thing would be to walk away and get absorbed in another
conversation. Such a strategy may seem obvious to you, but would
often be beyond the reach of your emotionally vulnerable child.
LISAS DRESS Lisa and I were discussing the difficulty
shed had at a girlfriends sleepover. We were trying
to understand what had caused her to cut herself.
*The credit for much of what I outline in the following pages
belongs to Marsha M. Linehan and her colleagues who developed
DBT.
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U NDE R S T A N D I N G S E L F- I N J U R Y
I remember that Gina said something about my dress which, I
dont know, upset me I guess, she explained. All
I remember is that I felt kind of spacey and maybe a little sad.
I just stood there for a while and then I went into the bathroom
and cut. Lisa lacked two critical skills that prevented her
from problem solving: (1) she couldnt accurately label and
identify her emotions, and (2) she couldnt think clearly
enough to find a better way to modulate her emotions.
Observing and Describing Emotions
It seems that in some cases simply identifying and accurately
labeling our emotion can lessen its intensity. In essence, we
just accept that how we feel at that moment is simply how it is.
For example, the mere act of acknowledging that you are angry at
your husband without either cooking it (I cant
believe he embarrassed me in front of his family againhe
always does this) or trying to talk yourself out of it
(Theres no reason for me to feel The simple act of
acknowledging angry) may help in the process of your
negative emotion without modulating your emotion.
cooking it or trying to talk Several months after
Lisa and I yourself out of it can help you had discussed the
trouble shed had at modulate the emotion. her friends
sleepover, she came in to therapy and related this success:
My friends and I were at Marjories house yesterday
and we were talking about what we were going to wear to the prom.
I described my dress and Gina just made fun of it. This time I
used some of the skills youve been going over with me and
just observed and described to myself how I was feeling:
insulted, hurt, mad. It really worked. I was still mad at Gina,
but it just didnt seem so overwhelming to me.
Tell Yourself a Different Story
A second problem-solving strategy is to bring a process called
reappraisal to our emotional experience. When we
reappraise, we change our initial interpretation of the event
that led to our emotion arising. Lets say youre at
the grocery store and you notice that a friend whom you recently
had over for dinner is coming down the aisle from the opposite
direction. She passes you without a trace of acknowledgment.
Almost immediately you are feeling hurt and angry. Your mind
begins to weave a story to explain the situation: I
cant believe Danielle just ignored me like that. Well,
clearly she didnt have a
what sets the stage for self-injury?
45
good time at dinner. Still, what kind of friend ignores you? Who
does she think she is? If you follow this path, you are
certainly going to cook those negative feelings into a spicy
emotional stew. Suppose instead that you tell yourself a
different story in response to your emotions: Well,
Im surprised and hurt. I wonder why Danielle is so
preoccupied that she didnt even see me. I hope everything
is all right. I think Ill give her a call later and see
whats going on. In all likelihood this version of
your story is going to decrease the intensity of your hurt and
anger. You have accomplished this by reappraising or
reinterpreting the event that evoked the feelings. Tell yourself
a different story: its a wonderful emotion regulation
strategy and a handy tool when you dont know why something
happened but you find yourself creating a story that makes you
feel worse.
Acting in Opposition to How You Feel
I will have a great deal more to say about this powerful emotion
regulation strategy in Chapter 8, but here is the short version.
All our emotions, as I mentioned earlier, have an action tendency
associated with themthat is, they make us want to take some
kind of action. For example, sadness and depression often push us
to lie down because we feel drained. Fear often makes us want to
run away. Shame makes us want to hide or disappear. You can
change the duration and intensity of these feelings by, first,
acknowledging what you feel; second, deciding that you no longer
want to feel it; and third, doing exactly the opposite of what
the emotion is prompting you to do. If youre feeling blue
and your whole being is saying Get into bed and pull the
covers up, you would instead throw yourself into some kind
of physical activity. Maureen, a 15-year-old DBT patient, paged
me in crisis. I cant get out of bed. I am just too
depressed, I have no energy, and I cant go see my cousins.
They are all so perfect, she told me over the phone.
But if I dont go, my parents will kill me.
Oh, man, you are between a rock and a hard place, I
replied. It seems like the better choice is to find a way
to go, and that is going to take some real effort. I
dont have the energy, she repeated. Yes, that
is exactly what depression makes us feel. It saps us of our
strength, and all we want to do is get into bed, I said.
But I cant stay home! Maureen exclaimed.
Got it! I think its time for opposite action to
current emotion, I suggested. Do you remember how
this skill works? I asked.
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U NDE R S T A N D I N G S E L F- I N J U R Y
Yes. I have to do the opposite action that my depression is
telling me to do. Even though it feels like I have no energy, I
have to get myself up and out of bed. Yes,
thats rightand you have to commit 100% to the action.
You cant do it halfway, I added. I think I just
have to do this, she replied.
Distraction
Finally, we can use distraction as an emotion regulatory
strategy. Like the other strategies, distraction usually starts
by identifying and labeling your emotional experience. But if the
experience is so intense that you cant clearly label the
feeling, you can use distraction to lower the emotional intensity
to try to get a better read on your emotional state. For example,
its late on a Friday afternoon and you open an e-mail from
your boss criticizing your work. As you read it you realize that
she lacks pertinent information that would change her point of
view. Unfortunately shes left for the day and wont be
back in the office until Tuesday. You notice that anger is rising
up within you, but you know that youre going to be unable
to resolve the situation until Tuesday. You decide that it would
be a good idea to make yourself busy with activities and friends
over the weekend. You distract yourself from your anger by
picking up the phone and throwing yourself into making plans for
the next couple of days.
ENVIRONMENTAL FACTORS: WHEN OUR BEST INTENTIONS FAIL
Yesterday Celia came home from school and she was just a
mess, her mother told me. She and her best friend,
Julia, had had a falling out. She has the same fight with this
best friend about 5 times a week, and its
getting a little old. I heard her up in her room slamming things
around and cursing. It really unnerves me when she gets so
emotional and I try not to think that she may hurt herself. I
knew that shed probably forgotten that she had SAT tutoring
that day, and we were going to have to put a move on if we were
going to be on time. I simply went upstairs and in a calm voice
told her we needed to leave in 10 minutes. I should tell you that
although I was calm on the outside, I was trying not to worry
that this would turn into one of those several-hour meltdowns.
Celia told me she wasnt going. Maybe I shouldnt
have said it, but I re-
what sets the stage for self-injury?
47
minded her how important this was for her future. I know she has
bigger problems right now than getting into college, but Im
so worried shes going to make decisions now that will ruin
her life. Anyway, thats when all hell broke loose. Celia
started screaming that I didnt understand and all I was
interested in was college. That did it for me. I told her that
her friend Julia was a loser, and I couldnt understand how
she didnt see that. Does this sound familiar? Clearly
the mom did her best in the beginning to keep the situation low
key, which makes sense, given Celias emotional state. What
went wrong? Lets look a little more closely to see if we
can figure out what Celias mom could have done differently
that might have prevented a meltdown. Heres what we know:
Celia is emotionally dysregulated, and her mom needs to get her
to tutoring on time. We can speculate about a few other factors:
Mom is losing patience with the repeated troubles in Celias
relationship with her friend, shes understandably put off
by Celias out-of-control behavior, and shes worried
that her daughter will lose sight of her responsibility to go to
SAT tutoring. Heres what happened: Moms strategy
seems to have ignored her daughters emotional distress and
focused instead on the issue of getting out of the house on time.
Why didnt that bring the desired results? The central
problem was a lack of validation. Its a common tactical
error that we all make, and it can lead to all sorts of
difficulties. To validate someone is to communicate that you
understand that With the best of intentions, someone
persons experience. You dont may tell you not to let
something bother have to like it or agree with you that is
bothering you. We want the it; you just have to acknowlpeople who
care about us to understand edge it. When you dont valiwhat
were feeling before they move on date, interpersonal
communito how we can get over it. cation is more likely to stall.
Just imagine that a friend has hurt you, and your spouse tells
you not to let it get to you because its no big
deal. How well does that play? Even if ultimately it turns
out not to be a big deal, you want your spouse to understand that
it hurts right now.
Validating Your Child and Yourself
Celias mom didnt validate Celias emotional
distress, and she seemed to invalidate her own worry through
avoidance. (We need to validate ourselves, too. When we
self-validate, we are acknowledging what we feel without
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U NDE R S T A N D I N G S E L F- I N J U R Y
avoidance or judgment.) It may have worked better had the
exchange gone something like this: So Julia did it again. I
know she can really get under your skin. It must be hard to like
someone who also can be so irritating. Anything I can do to help?
No? Okay, then. As angry as you are, you probably forgot about
tutoring. Im not going. Its
really hard to shift gears and think about tutoring when you feel
so hurt and angry. That makes perfect sense. But this is a
commitment and we need to leave in 10 minutes. In my
experience, invalidation generally stems from parents
reasonable and good intentions for their children. The terms
validation and invalidation might sound condemning or critical,
but please understand that I am in no way blaming you or saying
that youre responsible for your childrens troubles.
After 30-plus years of working with children and parents, I have
seen that the overwhelming majority of parents only want to be
helpful to their kids. Kids who are extremely sensitive are a
special parenting challenge. Please read the following sections
as examples of how our best intentions can go south and what we
can do to make things better. My only goal is to help you
understand what might account for your best parenting efforts
falling short. There are different degrees of validation and
invalidation. Kids who are emotionally reactive are probably more
sensitive to even the mildest incidents of invalidation. So what
may be no big deal for one child may be experienced as a very big
deal for another. Hold onit gets even more complicated:
what may be experienced as mildly invalidating on one occasion
could be felt as really invalidating on another if the child is
emotionally charged up. Short of being candidates for sainthood,
how can you validate in the midst of your own worry and your
kids emotional storms? In Chapters 6 and 7 I will have more
to say about this, but for now heres the short course.
Three key factors will optimize your chances for success in those
emotionally perilous moments. First, get very clear about your
goal. In the earlier example, the goal was to get Celia to
tutoring on time. Second, make sure to self-validate, and decide
how youre going to manage your feelings. Again, in my
example, Mom needed to honor her worry about Celias future
by acknowledging that this is how she felt, even though it
wasnt going to be effective to give voice to it in light of
the shorter term goal of getting Celia to tutoring. Finally, work
at validating your child to help defuse the emotional crisis. Mom
validated Celia when she expressed her understanding about her
hurt and anger. For your emotionally sensitive child not to
become emotionally vulnerable, she may need extra help from you
to learn emotion regulation skills. No
what sets the stage for self-injury?
49
one gave you a childrearing manual, and you may not know
intuitively what she requires. Every since she was little, your
child may have been more sensitive than others to lifes
hurts and disappointments. Its natural for you to have been
downplaying her emotional response all along, or offering
reassurance that things arent as bad as she thinks they
are. If your child seems to be having what you perceive to be an
exaggerated response to a minor hurt, what parent wouldnt
want to reassure him or her and try to put the problem into some
more reasonable perspective? This is a situation where
parents well-meaning intentions can backfire. Sometimes
its harder for parents to see their childs
sensitivity during the elementary school years. Some parents tell
me that they thought everything was right on track until
adolescence, when suddenly it Some parents tell me that they
thought seemed like the wheels just everything was right on track
until came off and they were dealadolescence, when suddenly it
seemed like ing with a totally different the wheels just came off
and they were kid. My best guess is that dealing with a totally
different kid. The some emotionally reactive new demands of the
teen yearshormonal kids have less trouble durand emotional
shifts, a new capacity for ing middle childhood. The abstract
thinking, and the beckoning of a rules for behavior are social
worldoften make things especially clearer, and parents
really hard for emotionally vulnerable kids. can and do solve
many of the childs difficulties. The new demands of the
teen yearsthe biological changes, the emotional swings, the
capacity for abstract thinking, and the broadening of
possibilities in the social worldoften present a rocky
terrain for these teens to navigate. KEISHA : VALIDAT ION AN D I
N VAL I DAT I O N Keisha is just too sensitive! her
mom explained to me. When she has a problem with a friend,
its like the end of the world for her. When I try to
reassure her that I understand because Ive had problems
with my own friends, she just blows up. Its so awful for me
when Im trying so hard to help and she just pushes me away.
Then I get hurt and angry and usually go to my room and cry and
it just becomes a big mess. Yeah, and if you try to
let her know that the whole thing is not such a big deal and give
her some advice, she runs out of the room crying and screaming
that you dont understand, added Keishas dad.
That really frosts my socks, and I wont speak to her
until she apologizes.
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U NDE R S T A N D I N G S E L F- I N J U R Y
Keishas parents attempts to help with her troubles
are eminently reasonable and clearly well intentioned. As any of
us might do instinctively, Mom acts reassuringly and Dad tries to
help with problem solving. Clearly, however, their attempts at
being useful to their daughter fall short of the mark. Is Keisha
just an unreasonable person who revels in the drama of
interpersonal conflict? Does she just not want to be comforted or
to get the benefit of parental advice, preferring to make a
scene? Not likely. No one would choose to live in such an
emotionally distressed way and relish constant interpersonal
turmoil. There is another explanation for Keishas behavior.
Lets start by making a couple of assumptions about her.
First, lets assume that she was born with an emotional
system that is on the highly reactive end of the spectrum.
Second, we will assume that she has not developed the skills that
are required to effectively regulate and modulate her emotions.
Her parents description would seem to confirm that
assumption. Consequently, we can consider Keisha to be
emotionally vulnerable. As discussed, people who are emotionally
vulnerable are usually emotionally reactive, and they also lack
emotion regulation skills because they havent had
sufficient modeling or validation about their emotional
experience. In fact, we can get a glimpse into some possible
reasons why Keisha has not learned to regulate her emotions.
Before we do that, however, lets revisit the concept of
validation and introduce its opposite, invalidation. Remember
that when we validate another person, we are simply communicating
that we understand his or her current experience and how, under
the circumstances, it makes sense. We just accept the other
persons experience as it is, without making a judgment and
without offering a solution. Problem solving, which of course is
terribly important, can be thought of as the opposite of
validation. When we are invalidating, our communication to the
other person is that his or her current experience is not
justified; its exaggerated or inaccurate under the
circumstances. We all invalidate one As important as problem
solving another from time to time, so it beis, it runs counter to
validation, comes a problem only when its a frein which we
want to accept the quent aspect of family communicapersons
experience just as it is. tion. Invalidation can also occur
outside the family and be a real problem for a child. A family
may be quite validating of their sensitive child, who then enters
a school environment that may be such a mismatch that the child
feels harshly misunderstood and judged. For example, a very
sensitive child may feel continually invalidated in a
what sets the stage for self-injury?
51
regimented traditional school setting in which academic results
are valued over personal growth. Another example of invalidation
is bullying by other children when its not effectively
addressed by the adults in charge. This is especially true when
the adults expect the child to be more assertive in stopping the
bullying or tell the child to stop letting it bother him so much.
Validation is a key task of parenting. When we validate our
children, we are teaching them how to accurately label their
inner experiences and to trust those experiences and use them to
self-validate and effectively problem solve. When we invalidate
our children, of course, we create just the opposite situation.
We teach them that what they feel is inaccurate or inappropriate
to the situation. Here are two examples of parental invalidation:
1. You shouldnt be hurt by your friend; you should be
angry that he treated you that way. 2. So you
didnt get invited to the party. Thats no big
dealafter all, these kids hardly know you. In both
examples the intention of the parent is to be helpful, but you
can see how the response invalidates the childs experience.
Helping children problem-solve in the moment and helping them
anticipate problems and plan for the future is another important
task of parenting. When it comes to this task there are two
common pitfalls that lead to invalidation and compromise the
childs effectively learning to problem-solve.
Problem Solving Too Early
The first error is to problem-solve before validating. Its
a very easy trap to fall into. After all, you just want to
resolve whatever problem is causing your child so much pain. You
can probably already see that Keishas father succumbed to
it when he told Keisha that her problem with her friend was no
big deal and immediately tried to give her advice.
Letting Your Own Bigger Worries Get in the Way
The second problem occurs when parents are having difficulty
tolerating their own worries about their childrens capacity
to effectively problem-solve. Celias mom provides a good
example. In the face of her daughters emotional distress,
she understandably began to worry about what Celias lack of
commitment to the SAT tutoring might portend. Introducing her own
(perfectly reasonable) worry into the situation invalidates her
daughters current experi-
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U NDE R S T A N D I N G S E L F- I N J U R Y
ence. Celia is also the kind of kid who is hypersensitive to
others emotions, particularly those of her
parentsfrom whom she wants approval, even if she wont
admit it. Her mothers worry about her overwhelms her and
makes her worry about herself at a time when she cant
handle any more emotional input. As you can see, the kicker is
that you can be invalidating even when your intentions are to be
helpful. There are degrees of invalidation that run from the
well-intentioned parent whos just trying to be helpful to a
distressed child, all the way to child abuse. Human beings just
seem to do better when were understood and tend to get more
emotionally dysregulated when were not. When were
misunderstood we often work hard at getting the understanding
that we need. How skillful we are at this will be part of our
story. Lets take a closer look at the ways each of
Keishas parents respond to their daughter. Please keep in
mind that these are reasonable parents struggling to find a way
to be helpful to their child.
Why Reassurance Isnt Validating
The first thing we notice is that Mom seems to rely on two
strategies to be helpful. The first strategy is reassurance; the
second is to bring her own history into the discussion as a way
of letting Keisha know that she understands. Clearly these two
seemingly reasonable strategies dont work. Why not? When
you are emotionally revved up and someone tells you that
everything is going to be okay, your feeling may be that the
person cant possibly appreciate the magnitude of the
problem. Consequently, rather than feeling understood and
reassured, youre likely to feel invalidated. Reassurance is
a strategy that is often effective with younger children who are
more willing to be dependent on an adults point of view.
The preschooler who is nervous about a play date with a new
friend is likely to be calmed down by a parAdolescents are often
less willing ent who reassures her that shell be than young
children to buy into fine. Not so for the teenager whose an
adults viewpoint. Therefore parent says the same thing
about antheyre less likely to be reassured other
friends hurtful comment. just because you tell them
Naturally, we rely on strategies everything is going to be all
right. that have worked for us in the past; therefore parents
sometimes offer up reassurance just because it used to work. Once
your child reaches adolescence, however, she has a strong
instinct to be her own person and rely less
what sets the stage for self-injury?
53
on you. In addition, during adolescence the brain becomes capable
of processing more abstract ideas. Since the world is no longer
so easy to understand, your simple reassurance is experienced by
your teen as unrealistic.
Why Saying Ive Been There Isnt Validating
Keishas mom also tries to let her know that she understands
how Keisha feels by bringing in examples from her own life.
Again, this appears reasonable Keishas mom is looking
for common ground. The hope is that Keisha would feel her mom has
some credibility because she too has struggled with friendships.
Despite all the right intentions, the effect of Moms
behavior is to make Keisha feel misunderstood. What went wrong?
When we try to let someone know that we understand his or her
situation by bringing in examples from our own lives, we run the
risk of shifting the focus toward ourselves and away from the
person in need. Furthermore, it is the exceptional adolescent who
is going to believe that her parents situation back
in the day can have any relevance to her own. Its
only likely to make your child feel more misunderstood, not less.
Why Putting Things into Perspective Isnt Validating
Lets turn our attention now to Keishas dad. He enters
the fray by trying to help put Keishas difficulties into a
more reasonable perspective. While he may be on to something,
this approach is almost guaranteed to be invalidating. Why?
Although it is certainly not his intention, by telling his
daughter that she is making too big a deal of something,
especially when she is dysregulated, hes invalidating her
experience. Please remember that he is dealing with an
emotionally distressed teenager, not someone who is currently
functioning rationally or fully in charge of her reactions.
Why the Best Advice Given Too Soon Isnt Validating
Then Dad compounds his mistake by offering unsolicited advice to
the very person he has just invalidated. What is the chance
Keisha is going to be grateful for his words of wisdom? Zero! The
real shame here is that his advice might be right on the money.
For whatever the reasonmaybe its a design
flawpeople are more willing to accept advice after they
feel theyve been understood. Very often an adolescent I
have been treating will tell me a story
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about a parents attempts at problem solving before
validating. Later in the therapy Ill ask, With the
distance you have now, how would you assess the advice?
Invariably, he or she tells me that the advice was pretty good,
but the timing was terrible.
Master Class: You Need to Model Emotion Regulation Skills
I hope you can begin to see the subtle ways invalidation works.
When its a pervasive part of the interaction between parent
and child, it becomes very difficult for the child to learn to
identify and to trust the accuracy of his or her emotional
experience. When this happens children are prone to being pushed
around by their emotions rather than being competent at managing
them. In later chapters Ill give you some suggestions about
how to get better at validation. For now, be warned about
reassurance; stay away from bringing in your own history (unless
its asked for); and make sure you have validated before
moving into problem solving. But waittheres more!
Both of Keishas parents report having very strong emotional
responses to their daughters seemingly unreasonable
behavior. This, of course, is perfectly understandable.
Theyre trying their best to be helpful and the whole thing
is blowing up right in their faces. How they manage their own
emotional turmoil, however, is another potential problem. To stay
on track, emotionally reactive kids need more validation than
other kids, and they need parents who can model effective emotion
regulation skills. I understand that at times this is certainly
easier said than done! My own kids will tell you that I have lost
my temper with them too. Keishas parents are not helping
the situation either by becoming outwardly dysregulated or by
withdrawing into an icy silence. Their daughter really needs her
parents, most of the time, to show her by their own behavior that
emotions can be regulated to improve interpersonal relationships
and attain a balanced sense of well-being. Please read Chapter 7
to see whether you need to work on this.
The Snowball Effect of Invalidation
When an emotionally reactive child meets an invalidating
environment, the climate is just right for a perfect
storm of trouble. The interaction of the two has a
synergistic effect, like a snowball going downhill that just
keeps picking up speed as it builds upon itself. This snowball
effect generally follows two distinct patterns. The first is
distinguished by an escalation of the childs behavior in a
desperate attempt to be understood. Here is a story that I think
brings this concept home.
what sets the stage for self-injury?
55
Desperate to Be Heard: Floyd and the Farmer
One summer during my college years I hitchhiked through Europe
with my brother and a college friend named Floyd. Floyd spoke a
little French but not enough to get by. Soon after we arrived in
France we were picked up by a farmer, and we attempted to
communicate to him where we were headed. Floyd started using his
French but couldnt make himself understood. The farmer
became increasingly frustrated with him. Floyd responded by
speaking louder, as if he would be better understood at a higher
volume. When it was clear that the farmer still had no idea what
Floyd was saying, Floyd spoke even louder and began to introduce
English words into the mix (albeit with a French accent). It was
chaos. The farmer just dropped us off in the nearest town. I use
this story as a metaphor for the transactional nature between an
emotionally reactive child and an invalidating environment. When
a child feels invalidated, her emotions run high and she
redoubles her efforts to be understood. Unfortunately,
emotionally vulnerable kids are not skilled in this regard and,
like Floyd, usually just raise the decibel level rather than
figuring out a way to express what they need. Naturally, the
reaction from people around themthe environmental
responsewill be aimed at the loud behavior and
not at the emotional need behind it. Consequently the child feels
more invalidated, which intensifies her emotional dysregulation.
Now overwhelmed with intense feelings and lacking regulation
skills, the child is prone to self-injure. This transactional
cycle takes on a life of its own, and over time it becomes a
stable if dysfunctional communication pattern.
The Silent Treatment
In the second pattern, the childs sense of being
misunderstood and the accompanying hurt go underground as she
becomes increasingly silent and withdrawn. Family members may
then increase their efforts to get the child to reveal herself,
which meets with only more silence. The child has given up on
being understood and just retreats into silence and phony
compliance with parental expectations. On the inside, however,
she is still struggling to manage her emotional turmoil.
Frequently these are the children who have learned to mask their
feelings. Often the parents dont even suspect that the
child is in trouble until they discover that he or she has been
self-harming. Each of these patterns represents a different
response to feeling misunderstood and the emotional dysregulation
that follows. As we will see, the self-harm is most often aimed
at regaining emotional balance.
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Does your child fit the pattern of using self-harm to manage
painful emotions?
1. Is your child at the emotionally reactive end of the
continuum? 2. Are you able to determine whether he or she is
emotionally vulnerable and lacking in the skills required to
modulate emotion? 3. Does your child seem to go from one
emotional crisis to another? Or is he or she the kind of child
who masks feelings? 4. Think about your typical responses to your
teens emotional distress. Do you tend to unwittingly make
things worse? Its important to grasp the concept of how the
ingredients of emotional vulnerability and invalidation snowball
into an increased level of emotional dysregulation.
If the answers to most of these questions is yes, then in all
likelihood your child is using deliberate self-harm as a way of
managing emotional distress. In the next chapter well look
more closely at the variety of ways kids use self-harm to manage
their emotions, as well as at some self-harming behavior that is
not in the service of emotional regulation.
3
how does hurting themselves make some kids feel better?
The preceding chapter helped you understand the factors that
predispose
children to hurting themselves. But what does self-injury
actually accomplish? This chapter helps you recognize the
problems your child is trying to solve through deliberate
self-harm, which will make it easier for you to select and assess
the proper therapy.
REGAINING EMOTIONAL BALANCE
I did it again, Lea whispered into the phone.
It really chilled me out. I kind of felt calm, like things
were going to be okay. The feeling didnt last too long, but
at least I stopped feeling crazy on the inside. Yeah,
I know what you mean, replied her friend Jonathan. I
know I shouldnt do it either, but its my body and it
really does work when you feel that way. Its hard for
us to comprehend how hurting yourself can produce a feeling of
calmness, but for certain emotionally overwhelmed individuals it
does. We just dont know what differentiates those people
for whom deliberate selfharm works as a self-soothing mechanism
from those for whom it doesnt. Nor do we know exactly why
and how it works to soothe and calm kids. At this point all we
can say is that the mechanism is probably a combination of
biological and some as yet unspecified psychological factors. It
is important that you understand the degree to which your teen
feels emotionally overwhelmed and out of control. While some of
these kids are
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pretty good at keeping their level of distress hidden, inside
they are a whirlwind of emotional chaos. If parents cant
tell when their kids are emotionally revved, the self-harm may
look like an impulsive act that comes out of the blue. While it
might be impulsive, it certainly didnt come out of the
blue. Marissa was feeling deeply hurt by her friends, whom she
felt did not include her in the discussion at lunch. To make the
day worse, she got a C on an English paper on which she
thought she had done well. On the way home, she phoned her best
friend for some support. Hey, whats up? asked
Kristin in a cheerful voice. Nothing. Im just having
a crappy day, Marissa replied That sucks!
Kristin said. What are you doing later? Im going to
chill with Sara. Hey, Im getting another call. Ill
call you back. Click! The line went silent. When
Marissas mom described that evening to me later, she said:
I kind of knew that something might be wrong when Marissa
came home from school. She was a little quieter than usual, but I
just thought she might be tired. When I asked her how she was,
she just said fine and went upstairs to her room.
When she came down for dinner, she was in a much better mood.
During dinner I noticed the blood on her sleeve. When
children hide their distress, their parents are in an especially
difficult position. There is a natural tendency on the
parents part to become more vigilant, which the child
customarily experiences as intrusive and so he or she may in
response become even more secretive. In addition there is a
natural tendency for adolescents to seek privacy. On the other
hand, its awfully difficult for a parent to stand by and do
nothing. Parents who find themselves in this dilemma have to
negotiate the foggy waters between the shoals of harmful secrecy
and the open channel of age-appropriate privacy. We will examine
how to navigate these waters in Chapter 6. It took us a
long time to figure out when we could trust Candice with some
privacy and when she needed us to be more attentive. We started
to be able to read the subtle signs of trouble and how to gently
offer our help. It didnt always work, but when it did it
was good. For example, we slowly were able to distinguish the
buzzwords that let us know she was having trouble. Like
Candice, most kids describe the sense of going crazy
with intense emotions. They wish they could jump out of
their skins to escape the emotional pain: Its
like Im on emotional fire. I cant think straight and
feel all panicky on the inside. Nothing makes sense and I just
have to end this horrible feeling. Another patient told me:
When I get what you call emotionally
dysregulated, Im just a mess. Inside I am overwhelmed
with intense feelings, and on the outside I am screaming and
crying at the same time.
hurting makes some kids feel better
59
As youve learned, these kids often cant accurately
label their feelings. They experience their emotions as an
intense hodgepodge of inner sensations. If in these moments of
inner turbulence you attempt to get a clear reading of what your
child is experiencing, youre likely to get a reaction
thats a combination of anger and tears. The problem is that
these children really Like someone whos drowning, do
experience emotions more deeply people who cant modulate
their and more quickly than the rest of us, emotions flail about
and reach and they have real trouble bringing for something to
save them. Their themselves back from an emotional self-harming
behavior is the only event. Without the capacity to modlife
preserver they can find. ulate their emotions they, like a person
who is drowning, flail about in an emotional panic, reaching for
something to save them. Deliberate selfharm can become the flimsy
but functional life preserver that resolves their inner turmoil.
Self-Injury as Painkiller
Immediately following self-injury these children experience a
period of calmness and relief. How long this sense of relief
lasts differs for every child and even from episode to episode.
It can last anywhere from a few short minutes to several days.
When people feel as desperate as these kids do, getting even a
moments relief feels like a gulp of cool water on a parched
throat.
Diminishing Returns
Ruth has been cutting herself at least three times a week for the
past 2 years. The following conversation occurred in our first
meeting. So, Ruth, youre pretty clear that cutting
helps you regain some emotional relief when you are really
upset, I said. Have you noticed that you have to cut
more frequently in each episode of self-harm to get relief?
I asked. Yeah, it used to be that I could cut once and I
would feel calm. Now I have to cut 10 or 15 times to get the same
feeling, she replied. Like someone who is addicted to
opiates, Ruth is one of those kids who need to keep upping the
dosage to get the same result. In all likelihood there is a
biological basis for this phenomenon. In moments of self-injury
the body releases certain chemicals (that are, in fact, similar
to opiates) as a way of helping to manage the tissue damage and
pain. Some childrens bodies seem
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U NDE R S T A N D I N G S E L F- I N J U R Y
to adapt to the initial levels of The act of self-injury releases
chemicals these chemicals. When this into the bodynot
unlike what using happens, they need to injure opiates would
doto help manage the more frequently in order to attissue
damage and pain. Some teens tain the same sense of
calmbodies adapt to these chemicals, and ness. How and why
deliberate they need to injure themselves more self-harm works
this way for often to reach the same state of calm. some kids and
not others is not clearly understood. In both situations the
relief most likely comes from the opiate-like substances that are
released at the time of injury. We all have different responses
to drugs; for example, some people have a low tolerance for
alcohol, while others can drink a much larger quantity before
they get intoxicated. While there are several different
influences that contribute to a persons drug of
choice, body chemistry is certainly one important factor.
Is your child self-injuring to relieve emotional pain? 1. Does
she seem to escalate the harm to herself with each successive
incident? 2. Does the self-injury seem addictive? 3. Are there
multiple wounds when she self-injures?
Self-Injury as Suicide Prevention
When I feel so down and hopeless that suicide seems like a
reasonable way out, I turn to cutting, Brad told me.
I dont want to kill myself, and I get really scared
when I start thinking that way. I know cutting will take the edge
off. A small number of kids, like Brad, turn to self-injury
as a kind of suicide prevention strategy. These are a subset of
children who are struggling with both suicidal preoccupations and
emotional vulnerability. Theyre trying to escape from the
intense fear and anxiety that often accompany suicidal ideation.
In a desperate attempt to end the disturbing preoccupation, they
turn to deliberate self-harm. These children are struggling to
manage both emotional dysregulation and thoughts and feelings
about suicide. They may be at higher risk for suicide. While it
is always important for parents to obtain a careful assessment of
hurting makes some kids feel better
61
their childrens deliberate self-harm, its especially
critical for this subgroup of kids to be identified and undergo
an ongoing risk assessment as part of their treatment.
Is your child self-injuring as a way to stave off suicide? (See
also the box on page 23 in Chapter 1.) 1. Does he or she ever
talk of suicide? 2. Has your child experienced a recent loss? 3.
Has there been a recent suicide in the community?
Self-Injuring to Feel Alive
I just couldnt take it anymore. I felt dead on the
inside. You know, numb and empty, Jill complained. I
stopped feeling part of the worldit was kind of spooky. I
felt like I was a zombie. How did cutting yourself
change that? I asked, anticipating her answer. I
dont really know, but as soon as I made the first cut and
saw the blood, I felt alive again. To someone who feels
dead or numb on the inside, life feels devoid of pleasure.
Its as if everyone around him or her is living in a world
of Technicolor and his or her life is in black and white. Each
day is drudgery. In a way its just the other side of the
coin of emotional dysregulation: instead of overflowing with
emotion, these kids feel none at all. Its not a state of
being emotionally cold, but of being empty. To kids in this
state, the world around them has an unreal quality to it; they
feel more like a spectator of When our emotions are unavailable
life than a participant in life. It to us, we feel numb and
alone. Our feels as if they have lead weights lives feel sterile
and bland, as if on their feetevery step is a everyone
elses life were in Technicolor Herculean effort. There is
ofand ours was in black and white. ten an overwhelming sense of
aloneness. When our emotions are not available to us, our
experience has a sterile, bland quality to it. Nothing seems to
have much value, so its difficult to hold on to goals. Our
emotions are an extremely important source of information about
how we are experiencing ourselves and the world around us. When
this mirror is unavailable to us, were prone to making poor
and impulsive decisions about how to negotiate lifes many
challenges. Under these conditions were
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likely to act in ways that are self-defeating and self-limiting
at best, and potentially dangerous at worst. As you can imagine,
its difficult to be in this state for any length of time.
At some point it becomes more than a person can bear, and some
effort becomes directed toward changing this state of affairs.
All too often a child who is contending with this experience
moves quickly into behaviors that are in the service of ending
the numbness in the short run but that often lead to more
problems over the long haul. An indiscriminate sexual encounter
or turning to drugs and alcohol can end the deadness, but even
these poor solutions require some planning and access. Deliberate
self-harm, unfortunately, can be done quickly, privately, and
easily. Like Jill, kids who are struggling to end the deadness
and numbness often report that they need to see blood before they
get relief from this awful state. Its almost as if seeing
the blood confirms that theyre alive. Often these children
vacillate between feeling an inner numbness and feeling a deep
and powerful sense of self-hatred. Many of them have endured the
painful and confusing trauma of sexual abuse. So whenever the
self-injury appears to be in the service of ending an
adolescents inner numbness, the adults in his or her life
must at least consider whether there may have been a history of
abuse. Some research suggests that victims of early sexual trauma
may be prone to more severe self-injurious behavior. This has
Teens who resort to self-injury to end certainly been my clinical
expethe feeling of inner deadness often rience. vacillate between
feeling emotionally This relatively small, but numb and feeling a
profound sense of very worrisome, group of kids also self-hatred.
Many of them have been is at higher risk for attempting victims
of sexual abuse. suicide. One tragic consequence of early trauma
is the childs belief that what happened was his or her
fault. The legacy of this misguided belief is often intense
contempt and self-loathing. For these children, self-injury can
function as a self-soothing strategy and/or as an expression of
deep-rooted selfhatred. When it is the latter, they literally
attack their bodies as a way to punish themselves and to resolve
the guilt and shame they experience for their imagined complicity
in the sexual abuse.
Self-Injuring to Counter Feelings of Invisibility
Sometimes I think they dont even know I exist or who
I really am. They talk about me as though I wasnt standing
right there. I hate it! Dont they know I have feelings
too? Lindsey complained.
hurting makes some kids feel better
Is your child self-injuring to feel alive again? 1. Does your
child seem to be going through most of his or her days in a state
of drudgery and emptiness? 2. Has your child ever claimed to have
felt better as soon as he or she drew blood? 3. Was your child
sexually abused? Do you need to investigate whether this is the
case?
63
You must feel kind of invisible when that happens, I
said. Yeah, its awful. Its like I just
dont count for anything. Like Im not that important
even to my parents, she said between sobs. I know
its the wrong thing to do, but when I cut myself they
notice me and I feel like they see me and I feel real
again. Most of us at one time or another have been in a
situation in which we have felt ignored, as if those around us
didnt even notice our existence. Its an uncomfortable
moment that can bring on intense emotions. Our options are to
flee the situation or to do something that gets us noticed. The
subset of children who self-harm and feel invisible usually
dont want to be the center of attention or to feel jealous
of the attention others are receiving. (Remember that only about
2 in 50 kids self-injures to get noticed.) They just want to stop
the feeling of being invisible, of disappearing into the void.
Rather than being self-centered and taking dramatic steps to hog
the spotlight, these kids feel unnoticed in their own families.
This situation generally comes about when the child has the
feeling of being ignored in her family. In my experience parents
have not deliberately, or in some cases even unwittingly,
overlooked their child. Instead, due to her innate sensitivity,
she may need more affirmation than any parent could reasonably be
expected to perceive. I have found that these children are often
reticent about Children who feel invisible may expressing their
thoughts and feelneed more affirmation than parents ings.
Frequently their parents have could ever realize. They dont
a tough time understanding, and want to be the center of
attention; therefore tolerating, their kids inthey just
need to stop the sense that ability to articulate their thoughts
theyre disappearing into the void. and feelings. What ends
up happening is that the parents fill in the gaps and thereby
create a persona for their child. They then respond to the
persona rather than to the real kid. Of course, the child
complicates things by not correcting the parents
misperceptions.
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U NDE R S T A N D I N G S E L F- I N J U R Y
They say they know me and understand me, but all they know
is how they want me to be, not how I really am, Lindsey
continued. Sometimes when theyre talking about me, it
sounds like theyre describing a stranger. I wish I could
tell them how I really feel. Im too afraid they would be
disappointed. Its not unusual for these adolescents
to begin to wonder whether theyll ever fit in and whether
their parents value them. These kids rarely give voice to their
concern, so their parents usually remain in the dark about these
worries. The parents can find themselves in a no-win situation
when their child resorts to deliberate self-injury: If they
respond to the behavior with a fair amount of attention and
soothing, they run the risk of reinforcing deliberOne approach
may sound odd ate self-harm and at the same time or cold, but can
be very confirming their own view that the effective: Pretend you
are a self-injury is all about being at center loving
anthropologist and adopt stage. If, however, they respond with an
attitude of patient curiosity. anger or even a more neutral
position, thats likely to confirm the childs view of
not being seen or understood. One way out of this
dilemma is for parents to adopt an attitude of patient curiosity.
Rather than push their kids to define themselves, parents can
remain open and curious about their child. I sometimes describe
this to parents as adopting the stance of a loving and caring
anthropologist who is interested in studying a foreign culture.
Is your child self-injuring to counter feelings of invisibility?
1. Does your child have a lot of difficulty stating his or her
thoughts and feelings? 2. Does your childs reticence extend
so far that you often feed him or her the responses you think he
or she should be giving you? 3. Does your child frequently
complain of feeling misunderstood?
Self-Injury as Avoidance
I just couldnt do it, Mona said. There
was no way I could get up in front of that class and make a
speech. I just get so nervous. Im sure I would have looked
like a big loser. Im not like the other kids in my
class. A lot of people get really anxious in those
kinds of situations, I replied. It can be very tough
for some folks to speak in front of people. I
dont think you understand, Mona said slowly.
Just thinking about a sit-
hurting makes some kids feel better
65
uation like that makes me so tense that I just want to die. I was
so scared and nervous the night before, I couldnt
sleepand nobody seemed to understand. I think I
get it. You were feeling really desperate and trapped, I
offered. Exactly. I had to do something, and cutting myself
was the only thing I could think of. When my parents found out,
they called my doctor and she told them to take me to the
hospital. That was a real pain, but it was better than having to
make my class presentation. A small fraction of the kids
who self-injure do so as a way to avoid situations with
expectations they feel they cant manage. For these kids,
certain upcoming events are so fraught with anxiety that
self-injury seems to be the only way out. What differentiates
these children from kids who use a stomachache or other feigned
illness as an avoidance strategy is the degree of guilt and
self-loathing they feel. When we avoid something, we usually
experience mild or moderate guilt; we know were doing the
wrong thing, but we can tolerate our misstep. Kids whose
avoidance takes the form of self-harm are in a different category
altogether: their avoidance confirms their sense of weakness; it
raises their level of selfloathing; and in combination with The
difference between the child their anxiety, it produces an emowho
self-injures and the child tional experience that overwhelms who
fakes a stomachache to avoid them. an event is the extreme guilt
and Its just so hard to explain what self-loathing
the self-injurer feels. happens for me, Mona continued.
I start to get really nervous about what I have to do. Then
I start telling myself that theres nothing to be nervous
about, which I think only makes it worse because I still feel
anxious. Thats when I start telling myself that Im
such a loser. While the self-injury probably does calm the
childs anxiety, its primary function is to help the teen
avoid situations that he or she anticipates with intense dread.
If you think your child falls into this category, it may be
useful to get a consultation around treatment for anxiety in
addition to therapy for self-injury.
MANAGING DISTURBING THOUGHTS: PSYCHOTIC ILLNESS AND
OBSESSIVECOMPULSIVE DISORDER
Two or more psychiatric conditions can exist in the same person
at the same time. So sometimes self-injury is one aspect of other
psychological problems,
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U NDE R S T A N D I N G S E L F- I N J U R Y
Is your child self-injuring as an avoidance strategy? 1. Do you
find that your child self-injures when you know he or she is
anxious about an event in the near future? 2. After the injury,
does your child focus on how it precludes his or her having to
attend, perform, or otherwise be engaged in something he or she
has been dreading? 3. Is your child generally anxious and does he
or she seem to worry excessively about seemingly small matters?
problems that have less to do with managing emotional
dysregulation than with managing disturbing thoughts. (Sometimes
children with posttraumatic stress disorder, or PTSD, self-injure
to avoid the intrusive memories called flashbacks, but since
these flashbacks are almost always accompanied by the
dysregulated emotions or feelings of emptiness Ive already
discussed, I wont address PTSD separately here.) I include
here a brief description of two conditions that can coexist with
self-injury just to complete the picture of deliberate self-harm.
These children generally need a therapy other than the DBT that
Ill discuss in Part II. It is very important that you
obtain a thorough diagnostic assessment to help you understand
the way self-injury fits into your childs current troubles.
NINA : HEARING VO I C ES Nina walked into my office and slipped
quickly into the chair across from me. Her face was nearly
expressionless, giving no clue to what she might be feeling. I
attempted to make some small talk to break the ice, but I only
got oneword responses for my efforts. I understand that
youve been hurting yourself. I hope that youll be
willing to talk with me about that for a few minutes, I
said. Nina only nodded her head in reply. Ive spoken
with many, many kids who have self-injured, and this is what
Ive learned from them. Some kids deliberately hurt
themselves as a way of managing intense and overwhelming
emotions. Other kids have told me that they hurt themselves when
they feel numb and empty and that feeling becomes intolerable for
them. Finally, some kids hurt themselves because the voices in
their head tell them to do so. Do you think you fit into any of
those categories? I asked. The last one, Nina
said softly.
hurting makes some kids feel better
67
Some children who have a major mental illness (bipolar disorder,
schizophrenia, or schizoaffective disorder) experience auditory
hallucinations voices that command them to
self-injure. While all psychological difficulties are due to an
interaction of biological process and environmental influences
(e.g., family, society), these conditions are probably more
biologically than environmentally based. Frequently the
voices are of a harsh and critical nature and demand
that the children injure themselves as punishment. The
childs brain processes these voices the same
way it would process anything else he or she were to hear, and it
can be very frightening. The voices seem very To kids
who hear voices, real to these kids and they may feel comthey are
very real. They pelled to comply with their demands. may feel
compelled to do While psychiatric medications can have what the
voices tell them. some troublesome side effects (such as weight
gain or slowed thinking), they can be very effective in treating
hallucinations of this type. If you suspect that your
childs deliberate self-harm is due to such command
hallucinations, the first order of business is a complete
psychiatric evaluation that includes a psychopharmacological
consultation, neuropsychological testing, and a thorough medical
workup. ROBIN: OBSESSIV EC O M PUL S I V E DI S O RDER When
Robin walked into my office, the first thing I noticed were the
bright red marks on her arms and legs. It was immediately clear
that she had been picking at herself and that she was not
allowing the wounds to heal. After a few minutes of chat we got
down to business. I couldnt help but notice the marks
on your arms and legs. What is going on for
Obsessivecompulsive you? I asked. disorder can make
you feel Its kind of crazy, I know, but once I like a
slave to the demand start to pick at myself, I cant stop. I
get this to get things just right. idea in my head
that I just have to get it perfect. I kind of get lost in what
Im doingI can spend hours in the bathroom looking in
the mirror and picking at myself. It frightens me that I have no
control over what Im doing, Robin said as tears
filled her eyes. Is it like you are a slave to the idea
that you have to get it just right? I wondered.
Exactly!
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U NDE R S T A N D I N G S E L F- I N J U R Y
People with obsessive-compulsive disorder get fixated on an idea
and often have to gratify that idea through compulsive and
repetitive behavior. The very notion of not allowing themselves
to engage in the behavior produces a sense of extreme dread and
worry. For some children the compulsive behavior may take up
hours of their time and compromise their ability to get their
schoolwork done, or it may interfere with having a normal social
life. One kind of compulsive or ritualistic behavior is skin
picking. As Robin explained, once these children begin the
ritual, its extremely difficult for them to stop.
Frequently what drives the childs ritualistic behavior is
some frightening idea that is accompanied by a powerful sense of
dread. For example, she may feel that if she doesnt engage
in the behavior, something awful will happen to a loved one.
Obsessivecompulsive disorder is more of a biologically
based illness than a psychological disturbance caused by the
interaction between the child and the environment. If your
childs self-injury seems to follow this pattern, then a
combination of cognitive-behavioral therapy and medication would
be the best course of treatment. Understanding the functions that
deliberate self-harm serves for your child will help you and your
childs mental health practitioner figure out which problems
to target in treatment and which skills your child lacks for
dealing with painful emotions and solving problems. I listed
those emotion modulation strategies in Chapter 2. A major goal of
therapy should be to help your child acquire those skills so that
self-injury no longer performs a necessary function. (Ill
show you later in the book how you can help your child learn
better ways to handle emotion, particularly by offering the
validation that your child needs to begin to understand and trust
his or her emotions.)
The Importance of a Comprehensive Psychiatric Assessment
If your child is engaging in self-injury, your first step should
be to obtain a thorough psychiatric assessment, for the following
reasons.
Identifying Other Psychological Problems
As weve seen, self-injurious behavior can co-occur with
other psychological problems such as auditory hallucinations or
obsessivecompulsive disorder. Researchers have discovered
that adolescents who engage in deliberate selfharm fall into a
wide spectrum of diagnostic categories, from mood disorders
(e.g., depression) to various forms of conduct disorders and
personality disor-
hurting makes some kids feel better
69
ders. One of the benefits of a thorough assessment is that it
should help you determine whether your child is struggling with
other problems.
Preventing Unaddressed Self-Injury from Leading to Suicidality
Second, there is a clear link between self-injurious behavior and
suicidal behavior. No, I am not contradicting the points about
suicide that Ive made so far. Kids who harm themselves in
the ways Ive been describing are not doing it to try to end
their lives, and they can almost always make a clear distinction
between using self-injury to perform one of the functions
Ive described and trying to end their lives. A thorough
assessment can determine whether your child is engaging in
self-injury to soothe emotional distress or is suicidal. But you
should also know that helping your child stop injuring himself
may prevent him from becoming suicidal in the future. It is not
my intention to be unnecessarily alarming, but I want you to have
the facts as we understand them in this moment. Some current
research on the relation between nonsuicidal self-injury (i.e.,
deliberate self-harm that is used to control emotions) and
suicide attempts indicates the following: 1. The longer someone
engages in deliberate self-harm, the more likely he or she will
be to make a suicide attempt. 2. People who dont feel pain
when they self-injure are more likely than those who do to make a
suicide attempt. 3. Kids who self-injure using multiple methods
are more likely to make a suicide attempt than those who use just
one method. If any of these descriptions sound like your child,
the earlier the intervention, the better the chance for a
speedier recovery.
Freeing Your Child to Develop the Skills to Lead an Effective
Life
Finally, deliberate self-harm undercuts a childs capacities
to develop the ability to tolerate lifes painful moments
and to effectively problem-solve. We all need to know how to
successfully handle the difficulties life throws our way.
Self-injury is like taking aspirin for recurring headaches: the relief is almost immediate, but the pain is guaranteed to surface again.
Deliberate self-harm is a short-term solution to long-term problems, like taking aspirin for recurring headaches.
It produces almost immediate reliefand with the onset
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of relief, the adolescent turns his attention away from the
issues that precipitated the emotional dysregulation and takes
comfort in feeling better. Dan, 15 years old, and I were trying
to get a better idea about what set off his recent cutting. He
and I had been working together for a little over 3 months.
Yeah, so my girlfriend was just being a bitch, he
said. She doesnt like the guys I hang out with. Well,
I went over to her house with these friends and she was just
cold. I said, Screw this. We just left. I was so mad
at her I didnt even say good-bye. I dont know,
somebody had a bottle of Jack Daniels and I just chugged about
two-thirds of it in like one gulp. Man, that is a lot
of alcohol to drink in a short period of time. What were you
thinking? I asked. I wasnt thinking at all.
Anyway, after I got home my parents smelled the alcohol and
busted me. They said we would have to talk about it in the
morning. I knew they were really mad. When I woke up, I felt
horrible. They came into my room and tried to talk about what
happened. They really put me in a lousy mood. I called my
girlfriend to see if she might cheer me up, but she just gave me
grief about the night before. I was really mad. I was so mad I
couldnt even think straight, he said. And maybe
a little sad and guilty? I wondered. Yeah, I guess
so. Anyway, after I hung up I went into the bathroom to look for
a razor. After I cut myself I felt a bit better, but then I began
to think of what a loser I am. As you can see in Dans
story, when kids resort to the short-term strategy of deliberate
self-harm to manage emotional dysregulation, they are keeping
themselves from learning how to solve interpersonal problems and
remaining vulnerable to impulsive behavior and all the difficult
consequences that follow. They have trouble thinking clearly.
Furthermore, they begin to consolidate a view of themselves as
people who are defective, Among the many harmful repercussions
weak, and worthless. Often at of self-injury, a less obvious one
is that this point the adolescents are it keeps children from
developing the struggling more with their inproblem-solving
skills they will need all ternal judgments about having their
lives in relationships. given in to self-injury than with the
patterns that bring on the emotional turmoil. Of course, without
a clear understanding of these patterns there can be no new
learning of how to manage these potentially painful situations.
Consequently these kids become chained to their repetitive
self-injury and stuck in misery.
hurting makes some kids feel better
71
Black-and-White Thinking
You have probably also noticed how often your child is prone to
black-andwhite thinking. From your childs perspective, the
world seems to be neatly divided between what she can do and what
she absolutely cant, between what is good and what is not,
between what is fair and what is unfair. All the different shades
and nuances that are part of living for you are unavailable to
her. While all-or-nothing thinking is a hallmark of adolescents,
it is a more prominent feature in kids who self-injure, and is
especially dominant when they are emotionally dysregulated. How
does this come about? In all likelihood black-and-white thinking,
or what psychologists call dichotomous thinking,
results from an interaction between high emotional reactivity and
an invalidating environment. As I mentioned earlier, when we get
emotionally revved up, our thinking becomes rigid and
constricted. We see things in terms of absolutes: I will
never get better or I cant make friends
or I am stupid. Our emotions drive our thinking to
make rigid categories for our experiences. One consequence of an
invalidating environment is that kids feel that lifes
problems should be easy to solve. The take-home message for them
is that most other people dont seem to be bothered by what
trips them up, and if they were only better, stronger, or
smarter, they would sail through life. Consequently, they are
prone to oversimplifying lifes complex problems. This
effort at simplifying things requires them to disregard
complexities. As you can see, self-injury is a behavior that
needs to be addressed quickly and effectively. Time is of the
essence. Until recently there hasnt been a treatment that
has been shown to be effective in helping these kids turn away
from deliberate self-harm in a relatively short period of time.
But dialectical behavior therapy has become the gold standard for
helping these kids. In the next chapter Ill introduce you
to this treatment.
4
DBT
THE RIGHT THERAPY FOR YOUR TEEN
As the parent of a child who self-injures, theres nothing
you want more
than to see the behavior stop. In Chapter 1 I talked about how
searching for the hidden meaning behind self-harm doesnt
tackle the problem directly. Consequently, forms of treatment
that focus on uncovering such meaning can take a very long time
to produce change. In this chapter Ill describe dialectical
behavior therapy (DBT), the best treatment to help your child
find ways other than self-injury to deal with his or her
emotional vulnerability. DBT is more successful than other forms
of psychotherapy or medication, but, as Ill discuss, some
of these alternatives make for excellent supplementary treatment.
Finally, Ill give you some pointers on finding a good
therapist and determining whether your teen needs more sustained
help than outpatient therapy can offer.
HOW DBT ADDRESSES WHAT YOUR TEEN DOES AND THINKS
DBTa form of cognitive-behavioral treatment that was
developed and tested in the late 1980s and early 1990s by Marsha
Linehan and her colleagues at the University of
Washingtonwas initially used to help suicidal women, but
over time has been applied to a wide variety of psychological
troubles. The cognitive part of cognitive-behavioral therapy
helps people change by examining and challenging their prior
unhelpful, unrealistic beliefs about themselves and their world
(cognitive distortions). The behavioral part helps people change
by teaching and reinforcing new and effective behaviors. The
behavioral component is in all likelihood a more powerful agent
of change than the cognitive piece. After all, the chal-
72
the right therapy for your teen
73
lenge is to get your teenager to stop doing something that, while
it serves a particular purpose, is clearly harming her terribly.
A behavior is reinforced by anything that increases the
likelihood that it will occur again. There are two types of
reinforcement, both of which you may remember from the days your
child was a toddler. Things that positively reinforce
behaviorfor example, praising a child after he thanks you
for giving him a ride to his friends housemay
increase the likelihood of the desired behavior happening again.
(In addition, that thank you may make it more likely
that youll be willing to give him the ride the next time,
so hes reinforcing you too.) Negative reinforcement occurs
when something aversive is applied and then removed after a
behavior has occurred, aversive being defined by the
persons emotional response. For example, sending a child to
her room for a timeout may be aversive for one kid, but for
another it may be a chance to rest, play video games, or talk on
the phone. Consider the child who must stay in the classroom
during recess (the aversive condition) until he apologizes for
his rude behavior to the teacher. Once he does, hes allowed
to join his class at recess. So the teacher has reinforced
apologizing. In most cases the behavior of deliberate self-harm
is under the control of negative reinforcement. Your child is
feeling emotionally overwhelmed (the aversive condition), and
self-harm brings immediate relief. Self-harm is now more likely
to occur again because it resolved the childs painful
emotional experience. One of the few examples of deliberate
self-harm being under the control of positive reinforcement is
for that very small group of children who hurt themselves to get
attention. As you know, teenagers who injure themselves also
operate on a number of false or distorted beliefs that contribute
to their urge to hurt themselves. This is where the cognitive
part of cognitive-behavioral therapies comes in. A sad but common
cognitive distortion held by kids who self-injure is that they
are defective and weak. I did it again last night,
Melanie told me. I tried not to cut myself, but I just
couldnt hold out. I dont think I have the willpower
to stop. Your inability to refrain from cutting is
not a function of willpower, I countered. You have
enormous capacity for willpower and self-discipline just
look at how focused you are on your schoolwork and sports.
Its not willpower you lack, but the skills necessary to
manage that high-powered emotional system of yours.
Melanies distorted thinking is based on the faulty
assumption that if she had more willpower, she wouldnt
engage in deliberate self-harm. One aspect of a
cognitive-behavioral therapists job is to help the
adolescent challenge this belief and to replace it with one that
conforms to the facts about self-
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injuryspecifically, that self-injury is most DBT will teach
adolescents often due to lacking the skills to manage new
behaviors to finally ones emotions. help manage their
emotions. In DBT the child is taught specific skillsnew
behaviorsthat will help modulate and/or change painful
emotions. While it is important to challenge these beliefs, the
most powerful agent of change is helping the child learn a new
behavior to replace the harmful one that serves the same
function.
DBT: THE NATURAL ANTIDOTE
DBT directly targets the specific emotional and behavioral
problems that plague the adolescent who deliberately
self-injures. One of the key components of DBT is to teach these
adolescents the relevant skills to handle their powerful
emotional system. DBT is not a miracle treatment. It doesnt
help everyone, but to date its the best and fastest
treatment there is. Heres why.
Restores Emotion to Its Proper Status
Emotional dysregulation, as you now know, is likely at the root
of your childs self-injuring behavior. Youll also
recall that when a person is emotionally dysregulated and in need
of help, offering a solution to her problem before helping her
see that her emotional state is real and important can be a
recipe for disaster; it skips the critical step of validating her
emotional experience. Without validation, these adolescents come
to believe that their emotions are exaggerated or untrustworthy,
robbing them of the important information their emotions are
sending them. This leaves them not only unsure of what to do in a
specific situation but with a pretty shaky sense of self overall.
Linehan noticed that offering her patients techniques for change
without first accepting and validating their experience kept them
stuck, unable to move forward in treatment. Her Eureka! moment
came when she tried incorporating acceptance strategies and
validation into the treatment. Lo and behold, her patients began
to get better. The following example illustrates the importance
of validation. Notice how stuck we get as I start with problem
solving before validation. Chloe paged me because she felt so
depressed and lethargic that she didnt feel able to get her
laundry done for an upcoming weekend at a friends house.
I have no energy. I just want to get into bed, Chloe
complained. I know you want to see your
friendyouve really been looking forward
the right therapy for your teen
75
to this trip for a long time. Maybe if we break the tasks into
smaller pieces they wont seem so overwhelming, I
suggested. I have no energy. I cant do
anything, Chloe told me with some irritation. Has
your goal of going on this trip changed? I asked.
Because I know you could get your chores done if we came up
with a plan. I dont think you understand. This
is not easy, Chloe said with anger rising in her voice.
I think maybe youre right. I havent let you
know that I do understand that the laundry and the rest of your
chores feel just too hard to do when you feel this way.
It feels impossible for me to do anything when I feel this
way. You are really up against it. You really want to
see your friend, and the things you need to do to make that
happen feel like trying to swim with lead shoes on, I said.
I do want to go, Im just feeling like theres no
way I can make it happen, she said. It makes me feel
hopeless. No wonder youre feeling up against
it, I said. Would you like some help problem
solving? Yeah. What do you think I should do?
Moves between Acceptance and Change
In a DBT treatment we are always moving between accepting and
validating things as they are and looking for solutions to bring
about change. This constant moving back and forth led Linehan to
the concept of dialecticsshe put the D in DBT.
Dialectics is a complicated concept and one that often trips up
therapists as well as parents, so I wont get into a long
explanation of what the word means. Suffice it to say that in DBT
it frees parents and teens, or therapists and teens, from the
polarized points of view that stand in the way of change. When
our positions are polarized, each side has a tendency to dig
their heels in and cling tightly to their view of the truth. The
discussion now is characterized by the issues being black or
white, and all the colorful shades in the middle are lost. When
we are thinking dialectically, we come to understand that truth
is neither absolute nor relative (except in the case of things
like gravity or the temperature at which water boils at sea level
vs. in the mountains). The idea is that in most interpersonal
encounters, no one individual holds the whole truth; rather, each
has a piece of it. Ive already spoken about this in
relation to learning to let go of your own dearly held position
in order
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to work with others toward a solution. In DBT, we take this
notion a step further, learning to build a more complete
understanding that goes beyond the simple sum of our combined
truths. In fact, one helpful device for moving into dialectical
thinking is to begin looking for whats left out of each
persons position. (Can you think of anything more at odds
with the black-and-white thinking that is often a hallmark of
kids who self-injure?) Two versions of a dialogue between Jenna
and a therapist portray a typical impasse. The therapy cant
move forward until the patient and the therapist find a way to
get unstuck. JENNA : BREAKING T H RO UGH T H E I M PAS S E
I cant do it! I cant just tolerate that awful
feeling. Do you think I cut myself for no reason? You make it all
sound so easy. You never really get it, do you? Jenna said
as she began to cry. I dont make it sound so easy. I
think you misunderstand me. Im only trying to help you
reach your goals. There isnt a shred of dialectical
thinking going on here. Jenna and her therapist are at the
opposite ends of the spectrum. They need to search for what is
left out or not being articulated in each others points of
view. Heres an alternate scenario. I cant do
it! I cant just tolerate that awful feeling. Do you think I
cut myself for no reason? You make it all sound so easy. You
never really get it, do you? Jenna said as she began to
cry. You know, I think youre right. When I talk about
using skills, I can give the impression that its simple.
What I want you to know is that simple is not the same as easy.
This is really hard work. It makes sense to me that you would
feel misunderstood. We have to work together to help you stop
cutting. Yeah, I really feel like no one gets how
hard this is. I feel like you cant possibly understand what
its like to be me. I guess I need to pay more
attention to that. I do see how hard youre trying, and I
want to keep encouraging you. That would help. I know
sometimes I back myself into a corner, Jenna replied.
You know, it isnt that I cant do thisonly
that Im not very good at it yet. I sometimes get angry at
you, but mostly Im just frustrated with myself. Here
Jenna and her therapist are both looking for what was left out of
the discussion in the first example. The therapist validates
Jennas experience and moves between acceptance and change
so that they can work more collaboratively toward progress.
the right therapy for your teen
77
As a parent you most likely have had the experience of finding
yourself and your partner on opposite sides of an issue.
Lets say your teenager comes home 2 hours past her curfew,
but she called 10 minutes before curfew to say that shed be
home in an hour or so. This was something new; often shed
be late and not call. Your partners view is that at least
she calledhe wants to support that improvement by not
giving your daughter a consequence. You think she should be given
a consequence because she was late. You both feel strongly about
the correctness of your positions, and neither of you is budging.
Before long things heat up. You tell your partner that hes
too lenient. He tells you that youre being too hard on the
kid. But if you could both step back, youd be able to see
To engage in the dialectical thinking that each of your positions
inat the heart of DBT, we need to see cludes some truth and
excludes that each persons position has some some truth.
Once you realize truth to it. The dialogue can then be a that
each of you holds a legitiseries of building blocks that go
beyond mate piece of the truth, youll any one
individuals point of view. find a way both to acknowledge
your daughters new behavior and to give a consequence for
her being late: Were glad that you called us to let
us know you were safe and what time to expect you. Thats
the first time youve done that, and we noticed it and
appreciated it. But were still concerned that you came home
2 hours after your curfew, so youre grounded next
Friday. JAMIE: T HE T RUT H, T H E DI AL EC T I C AL T RUT
H, AND NOT HING BUT T H E DI AL EC T I C AL T RUT H Why is
dialectical thinking superior to other types of reasoning? If we
held truth to be absolute, we would conclude that deliberate
self-harm is either good or bad. A parent would take one position
and the child who self-injures would take its opposite. With no
common ground, the situation would generate a great deal of noise
and smoke but very little light. Seeing truth as relative would
have the parents taking a position like this one:
Self-injury is not something we would do, but its
your body to manage as you see fit. We can only hope that in time
youll stop. The adolescents position would go
something like this: I know you dont like what I do,
but you respect my decisions to manage my body as I choose, since
my behavior is not hurting anybody else. This position is
very democraticbut its not going to solve anything.
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If we were to think dialectically about self-injury, however, the
dialogue would be a series of building blocks that would go
beyond any one persons point of view. Its exemplified
by Jamie and her father, who came to see me about her cutting.
Their conversation quickly got off track. You just have to
stop hurting yourself, Jamie. Theres no way around this.
Its just not right! said Jamies dad with some
tension in his voice. You cant stop me, and its
my body, anyway, Jamie replied curtly. Jamie, can you
tell your dad about how your cutting helps you? I
interjected. I could, but I dont think he
cares, she responded. Give me a try, her dad
said, somewhat incredulously. Im curious about how it
could possibly be helpful to you. Okay, but you have
to listen. Her dad nodded. I cut myself when I
cant stand how overwhelmed I feel, and it calms me down. I
know that sounds crazy, but its true. I hate myself for
doing it. I hate myself even more when you get angry at me about
it, Jamie said, suddenly in tears. Im not angry
with you, her father said sympathetically. Im
really more frightened for you. I want so badly for you to stop
hurting yourself. I know I push you. Im frustrated because
nothing has worked and its been going on for a long time.
Youve ignored me when Ive tried to help.
I havent ignored you, Dad. You seem to think
its all about willpower, and its not. Trust me, I
dont really want to do it, and Ive tried hard to
stop, but right now I just cant. You have no idea how awful
I feel right before I cut myself. Its hard for
me to believe that hurting yourself really makes you feel better,
but if it does, I guess I can understand why you keep doing it. I
never knew that. I guess I thought you did it mostly to spite me.
We have to help you find another solution for those times when
you get overwhelmed, Jamies dad said as he reached
for her hand. Notice in this conversation how each person adds a
little more information that opens the possibilities for a new
and expanded view of the problemand real hope for a
resolution. Jamies dad gains an appreciation for the way
his daughters self-injury helps her and learns that Jamie
really wants things to be different. Jamie learns that her father
is willing to help her in the process of finding a solution to
her emotional dysregulation while trying to be less judgmental.
Thinking dialectically can open the door for real understanding
and help parents and kids join together to find the path to close
and effective relationships.
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79
Heads Off Guilt and Self-Blame
In DBT your teen and you will be oriented to what is called the
biosocial theory of self-injury. Youve already
been introduced to this theory in Chapter 2, without the
ten-dollar name; it simply means that kids are prone to the kind
of emotional upheaval that can lead to self-injury as a result of
both biology and environment. Understanding this origin of your
teens problems helps both of you understand what went wrong
without feeling like either of you has to take the blame. Your
child is not weak or defective but simply
endowed with a Ferrari of an emotional enginea
characteristic, incidentally, that has its plus sides too as it
can, for example, imbue your teen with the passionate drive to
pursue dreams and right injustices as an adult. The biosocial
theory should also reassure you that your child is not having
problems with emotional regulation because you are a bad parent.
The biosocial theory is just as important a foundation to DBT as
dialectics because it not only explains what has gone wrong but,
even more important, provides a kind of road map about how to get
back on track. Your child needs to learn the skills necessary to
manage her high-powered emotional system, and you need to find
ways to help your teen view her emotions as real and significant.
As you become more familiar with DBT, youll probably feel a
diminished sense of guilt as you come to see yourself and your
childs difficulties from a more compassionate
perspective. Likewise, your teenager will understand that her
troubles are not a function of some inherent character flaw or
deficiency, but the understandable outcome of emotional
dysregulation. Mr. and Mrs. Roberts, two computer engineers, and
their daughter, Regina, a lovely 15-year-old girl who was heavily
into the arts, came to see me for a consultation. Regina had been
self-injuring for the last year, and nothing her parents tried
seemed to help. Her parents described her as being overly
emotional and not able to think clearly. Reginas
parents were confused and worried. We are very rational
people and Regina can be just a bundle of emotions. When she gets
like that, we just cant reason with her. It makes us think
that were not good parents, Mr. Roberts told me.
It has nothing to do with you, Regina said. You
just dont understand! I cant help it if you guys
dont have feelings. My parents are robots, she told
me. We have feelings, Mrs. Roberts said. We
just dont let them get in the way of being rational.
Are you telling me that Im not rational? Regina
asked, getting ready for battle.
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As he or she undergoes DBT, your teenager will understand that
his or her self-injury is not the result of a character flaw but
of emotional dysregulationand that he or she can gain the
skills to stop it.
I think it may be that there are some real differences in
the way each of you experiences emotions. These differences may
be part of the problem you all are having understanding each
other. Understanding these differences can be an important first
step in solving the problem, I suggested.
Directly Attacks Emotional Dysregulation from Multiple Angles
As I discussed in earlier chapters, emotional dysregulation
affects all aspects of a childs life: managing cognitive
processes, working toward goals, and developing a sense of
identity. As your teenager becomes emotionally fluent
over time, he will have enough practice in skillfully managing
his emotions either through change strategies, like
opposite action to current emotion from the emotion
regulation skills module or by learning how to tolerate them
using the crisis survival strategies from the
distress tolerance modulethat he will not have to resort to
deliberate self-harm. I will introduce you to the skills that
make all this possible a little later in the chapter. For now my
point is that DBT directly targets emotional dysregulation in
multiple ways by giving the teen a number of different skills
that serve as direct replacements for self-injury.
Helps Teens Learn Who They Are and Whats Right for Them
The development of a cohesive sense of identity is one of the
core tasks of adolescence. Our sense of identity is a complicated
set of interrelated strands that help give us that feeling of who
we are, no matter what situation we find ourselves in. It has to
be flexible enough so that the person we are when we are at home
with our family can shift into the person we are at work. In
addition, our sense of identity includes our ethical standards,
values, and personal ambitions. Developing a sense of identity is
a complex process in which the child tries on various personas,
tossing those that dont fit. If youre the parents of
a child in early to middle adolescence, you know that this age is
characterized by remarkably rapid changes in clothing styles,
speech patterns, and interests. These kinds of behaviors help
adolescents begin to define themselves. In order for this process
to occur, they must be able to focus their attention on how they
think and feel about themselves in relation to an array of
interpersonal,
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81
ethical, and moral issues. This process of ongoing
self-reflection requires adolescents to integrate clear thinking
and emotional experience. They need to be able to modulate their
emotions, to be mindful (more about this shortly) of their
thoughts and feelings, and to validate the wisdom in their
conclusions. Clearly, an emotionally dysregulated adolescent is
going to have a hard time with these tasks. She will not come
easily to the statement This is who I am, and this is
whats right for me. Being unable to self-validate,
shell struggle to find a stable platform from which to
declare her selfhood. Furthermore, this process occurs best when
kids are not continually disrupted by extreme moments of
emotional dysregulationthat is, finding oneself calls for
quiet, reflective time. The DBT therapist actively validates the
childs growing sense of herself while working on helping
her figure out her own set of values and teaching the skills she
will need for self-validation.
Helps Teens Pay the Right Amount of Attention
When we are emotionally overwhelmed, our thinking either
constricts and we become focused on too narrow a view, or our
thinking becomes diffuse and we cant see the forest for the
trees. As youve undoubtedly seen in your teenager, this
loss of attentional control leads to poor decision making and is
the fertile ground for the distorted thinking that often plagues
these children. The DBT therapist helps the teen identify
distorted thinking that results from a view that is either too
concentrated or too scattered. Then the therapist teaches skills
to keeping the view at just the right perspective.
Helps Teens Control Their Impulses
The terrible feeling of being emotionally overwhelmed often
drives kids who self-injure to rush into impulsive and other
risky, ineffective behaviors geared toward bringing short-term
relief. Its not uncommon for them to take acMany of the
skills your teen tion without knowing what propelled will be
taught in DBT wind up them. In individual DBT, adolescent helping
with impulse control too. and therapist look step-by-step at what
led to a behavior, the behavior itself, and its long- and
short-term consequences. This step-by-step process is called a
behavior chain analysis; each link in the chain
represents a thought or a behavior that led to whatever
problematic event is being investigated. Like the cops in the old
TV series Dragnet, the DBT therapist teaches
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patients to focus on Just the facts, maam,
rather than jumping to conclusions. Many of the skills youths
learn in DBTfrom mindfulness to emotionregulation skills to
interpersonal skillshelp with impulse control too.
GAINING THE SKILLS TO SUCCEED
An important underlying assumption in DBT is that these
teens difficulties arise because they lack the skills to
manage their powerful emotions. This skills deficit leads to
behavioral problems, poor thinking and poor judgment, and an
insecure sense of self. What can they do? Reckless sexual
behavior, disordered eating, and, of course, deliberate self-harm
can all calm down the adolescent who feels emotionally
overwhelmed. Living life in an emotional whirlwind often makes
interpersonal relationships difficult. And with their poor
judgment and general sense of identity confusion, these kids are
often at a distinct disadvantage when it comes to negotiating the
normal tasks involved in becoming a competent adult. DBT directly
addresses these skills deficits, both in individual therapy and
in skills-training groups. In individual treatment the DBT
therapist and the adolescent review recent events and work at
figuring out what would have been a more skillful approach to the
situation. Together they may practice the new skill through role
playing or the therapist may assign homework. In
skills-training groups the child is introduced to the four skills
modules that are essential to DBT: mindfulness, interpersonal
effectiveness, emotion regulation, and distress tolerance. Here I
can only briefly describe what takes many sessions and hours of
outside practice time for my adolescent patients.
Mindfulness
If there is one skill at the heart of DBT, its mindfulness.
Mindfulness is the capacity to focus ones attention and to
have a broad enough perspective to take in new information.
Its what we need in order to accurately identify and label
our emotions. Its the capacity to stay present in our
lives, doing what our circumstances require and accepting things
as they are. Without mindfulness, the other necessary DBT skills
cant be accessed. We can do anything mindfully. For
example, as a mindfulness practice I often suggest that teens
pick an activity and just stay focused and present on what they
are doing, whether its walking, eating, or listening to
music. In the language of DBT, Im asking them to fully
participate and to do this one thing mindfully. I ask them to
notice when their mind wanders off the task, which
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it certainly willthats how minds workand to
gently bring themselves back to the task at hand. This ability is
significantly compromised when we are swept away by our emotions.
When these teens are emotionally revved up, its extremely
difficult for them to work at skillfully analyzing and planning
what Mindfulnessthe ability to focus to do next. They often
seem to ones attention while having a broad be flailing
from one idea to anenough perspective to take in new other,
without the capacity to informationcan be practiced while
slow down and evaluate the most walking, eating, or listening to
effective course of action. But music. It cant take place
when we mindfulness works at undercutare swept away by our
emotions. ting many of the problems associated with emotional
dysregulation. As these kids practice it, they learn to stay
focused on just what is, without either being swept away by their
emotions or judging them as negative. Mindfulness practice helps
kids know how to observe and describe their thoughts and emotions
in a nonjudgmental way. As they become more proficient at this,
theyll be much more competent at modulating and managing
powerful emotions, and their thinking will stay on track.
Interpersonal Effectiveness
Teens who self-harm often have difficulty in interpersonal
relationships. They may work hard at fitting in, but never really
believe that they do. Theyre often very sensitive to
perceived rejections, and so they guard against rejection and the
accompanying sense of abandonment by holding on too tightly in
relationships. Not surprisingly, this backfires and their friends
often find them clingy. Some children are daunted by
the thought of making friends because they just dont have
the skills to go about it. Sadly, the result is often that
theyre left out socially, or at best only marginally
included in the adolescent community. Helping them learn
interpersonal effectiveness skills allows them to figure out what
theyre shooting for in an interpersonal situation. The
first question they are asked to mindfully consider is, What is
your priority for this interaction? Follow-up questions include:
Are you asking for something? Trying to repair a relationship?
Setting a limit that will help you hold on to your selfrespect?
And how do you want to feel about yourself after this
interaction? Once those key questions are answered, the
adolescent is taught to use interpersonal skills, practices them
in therapy, and then applies them in real-life
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situations. Thus armed, these kids are able, often for the first
time, to have successful friendships without the emotional
tension theyve been accustomed to. Brandon, age 16, was
telling me about his most recent argument with his mother. In the
past he and his mom would frequently argue and not find any
closure. He wouldnt apologize and she would just stay
disappointed and resentful. The resulting tension between them
could last for days and DBT teaches your child to practice was
often a contributing factor to interpersonal skills in therapy
and his self-injury. in the real world. With increasing I
had a big fight with my abilities, emotional tension in mom on
Saturday but this time it relationships begins to melt away. was
different, Brandon told me. Instead of walking away I
used my new skills and tried to understand my moms point of
view, and I made an apology. It really worked!
Emotion Regulation
As Ive discussed at length, these kids dont have the
skills to modulate their emotional distress. In DBT, they learn
specific techniques that help them turn down the temperature on
the emotional upheaval and increase the possibility for positive
emotional experiences. The emotion regulation module essenYour
child will learn specific tially targets dysregulation from three
ditechniques to help turn rections. First, kids are taught
the value down the temperature on that emotions play in our
lives as sources emotional upheaval. of communication, as aspects
of selfvalidation, and as precursors to action. Second, they
learn about all the ways we can become vulnerable to negative
emotions and how managing our lives better can help us avoid
being overwhelmed by them. Third, they learn some specific skills
that can help change the way they are feeling. I demonstrate some
of these techniques in the next chapter.
Distress Tolerance
We all know that there are some problems in life that cant
be solved. They can be as mundane as being stuck in traffic or as
heartbreaking as the death of someone dear to us. Some events in
life are going to be painful no matter
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what, and we need a skill to help us through these tough times.
Kids who engage in deliberate self-harm at such moments have a
way of making the situation worse, often through some kind of
impulsive behavior or by doing something that is interpersonally
ineffective. The DBT skill set that helps us gets through these
moments are the distress tolerance skills, which fall into two
categories. First are the skills we need to accept our current
situation. Accepting things as they are does not mean that
youre giving in or that you like the situation. It only
means youre acknowledging that things are happening the way
they are at that moment and not fighting them. This set of skills
is labeled the basic principles of accepting reality.
The second category comprises the crisis survival
strategies, which are aimed at helpThe two parts of
distress tolerance are ing us get through the moment. accepting
the situation and learning Theyre not geared toward
probcrisis survival strategies to get through lem solving; they
just provide the moment by diminishing our pain skills to
temporarily diminish or or distracting us from it. distract us
from our pain. Crisis survival strategies include doing things
that are self-soothing, like taking a bubble bath, or
distracting, like getting totally involved in knitting a sweater.
I think the distress tolerance skills are one of the most
important skill sets for parents to learn too as they go through
worrisome times with kids who self-injure.
DBT: NOT TREATMENT AS USUAL
The following excerpt is from the last family meeting I had with
Vicki and her parents. Vicki, age 15, and I had worked together
in DBT for a little over a year. We met once a week for
individual therapy. She was also in a weekly skills group. Her
folks attended a skills group for parents during the first 6
months of the treatment. Vicki came to therapy to help her stop
cutting and to reduce her emotional outbursts. Her outbursts
generally occurred when someone in her life disappointed her.
Well, here we are, just about a year after we started. So
what has changed for each of you and as a family? I asked.
Really, a lot has changed, Vickis dad began.
I think I am much better at not jumping to problem solving
with Vicki and my wife. It really helps things from becoming
arguments.
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You have gotten better at that, Dad. Like on Sunday when I
couldnt get my math homework and was starting to lose it.
You didnt tell me I was being irrational, that all I needed
to do was to focus better. You just validated how hard it was for
me and asked if there was anything you could do to help. Then I
didnt feel like such a jerk for having a hard time
understanding my homework. Vickis mom spoke up.
He is better at validating, and I think we are both better
at trying to think dialectically. Give me an
example, I said. Well, she said, when we
disagree on things, we dont just go around and around
trying to prove were right. We understand that Vicki still
gets upset and does things that we dont approve of. In the
past I would be the understanding one and her dad would set the
limit. Now we work hard at understanding each others point
of viewwe get that were both right. So
this is great progress. Anything else? I ask. I think
I can speak for my wife here: we are just better at managing our
worries. Sometimes when Vicki is getting worked up, we just
remind ourselves to radically accept that this is her experience,
and we cant talk her out of it or change it in the moment.
We let her work it out herself, but stay close by. Those distress
tolerance skills have helped us keep our anxiety from making the
situation worse, Vickis dad replied. But enough
about us. We are really proud of what Vicki has
accomplished. I want to hear what she has to
say. Its been 9 months and 17 days since I last
cut myself, Vicki said with a clear sense of pride in her
voice. I never thought Id be able to do that. I mean,
I still get urges, but I feel like I know how to handle them now.
I think the biggest thing for me is that I feel more in charge of
my emotions. They can get pretty strong at times, like when I
have a fight with my boyfriend. But if I use my mindfulness
skills to observe and describe what is happening inside of me,
then I can usually figure out what I should do next.
Vicki, that is just tremendous. I can remember when you
didnt have a clue about what you were feeling, I
said. Anything else? Well, she said,
I think my parents would agree, we all get along much
better these days. You would probably say we are more
interpersonally effective, she said with a smile on her
face. The first studies that demonstrated DBTs
effectiveness were published in the early 1990s. The treatment
protocol called for a year of individual psychotherapy and a year
of skills training in a group. These studies examined DBT in
comparison to a treatment as usual group who
underwent longer term talk therapy with private
therapists and in mental health centers. The
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researchers found, among other things, that compared to people
who received treatment as usual, those undergoing DBT showed a
significantly lower rate of deliberate self-harm, lower rates of
suicide attempts, and fewer days spent as inpatients in
psychiatric hospitals. Although it was not designed specifically
to treat adolescents, toward the mid-1990s Alec Miller, Jill
Rathus, and Marsha Linehan developed an adapted version of DBT
for the adolescent who was suicidal, Adolescents in DBT who had
been engaged in deliberate self-harm, self-harming injured
themselves or exhibited various other forms of less often,
attempted suicide less high-risk behavior. The adolescent often,
and dropped out of therapy would be seen once a week in indiless
often compared with those in vidual DBT, and he or she
particimore conventional therapy. pated in a weekly multifamily
skills group with a parent or guardian. The treatment was
shortened from the standard of 1 year to just 12 weeks, and the
skills group always included the adolescents parent or
guardian. In 1998 my colleagues and I started an intensive
outpatient program in our Cambridge, Massachusetts, offices for
adolescents for whom DBT appeared to be the best treatment. Many
of them were engaged in self-harm and/ or struggling with
suicidal ideas, depression, and eating disorders. The program
Parents are actively involved works the same way today. The
adolesin both their childs individual cents meet as a group
5 days a week for and group therapies. 4 hours a day, during
which time theyre taught the full curriculum of DBT skills.
They also meet individually with a DBT therapist once or twice a
week. Parents are actively involved in the program through weekly
contact with the childs therapist and in their attendance
in a DBT skills group. The children who meet with success in our
program are not cured in a few short weeks. They do,
however, make significant progress. See Appendix A for a detailed
assessment of the outcomes for 42 adolescents treated during
20052006. In summary, there was a significant decrease in
adolescents experience of depression, anxiety, anger, and
other forms of psychological distress, back to within normal
range. In addition, symptoms of borderline personality disorder
and self-injurious thoughts and behaviors showed significant
improvement, as did the development of emotion regulation skills
and functioning at home and in social situations. In my
experience DBT can help kids dramatically reduce self-harming
behavior in 3 to 6 months, as well as reduce overall feelings of
psychological
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distress and depression. Often they continue meeting in weekly
individual and skills-group sessions for another 6 months to a
year. The additional treatment helps them hold on to the gains
they have made and sustain a more normalized teenage life for
themselves. Over the years there have certainly been kids who
didnt benefit from DBT, either because I wasnt
skilled enough to help them or because they had life experiences
that stacked the deck too solidly against them. For the most
part, however, the hundreds of kids I have seen in individual
therapy or who have gone through The guarantee I give
my our program who learned the DBT patients is that if they learn
these skills, practiced them in daily life, new skills, practice
them outside and worked at understanding the the office, and work
to understand triggers for their self-injury showed the triggers
for their self-injury, positive results. One of the best they
will see positive results. parts of my professional life is that
patients sometimes return after months or years to tell me how
theyre doing. Over the last 10 years most of them have
stopped self-injuringand in a shorter period of time than
with any other treatment.
DBT can help kids dramatically reduce self-harming behavior in 3
to 6 months. They also experience reduced overall psychological
distress and depression and improve their ability to regulate
their emotions and functioning in all domains of their lives.
WHAT ABOUT OTHER TYPES OF PSYCHOTHERAPY?
Very few studies have examined the effectiveness of other
therapies on treating self-injury. You may encounter therapists
who use psychodynamic therapies (treatments that focus on how the
teens past is being re-enacted in the present and use this
insight to bring about change), CBT, and integrative therapies (a
mixture of different treatment approaches). To ascertain whether
a particular approach may be useful for your teen, I suggest you
ask each potential therapist Is the therapy going to
directly target self-harm, or is the treatment going to resolve
self-injurious behavior by a more indirect route by helping the
child resolve the problems that lead to the behavior?
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HOW TO FIND A DBT THERAPIST
The good news is that DBT has been adapted to bring swift and
lasting help to teens who self-harm. The not-so-good news is that
because its a relatively new treatment, finding a trained
therapist isnt always easy. Each year, though, more and
more therapists are learning DBT. One way to find a therapist is
to consult the online list, arranged by location, at
www.behavioraltech.org. Behavioral Tech is the national
organization that provides training to clinicians and serves as a
resource for consumers interested in DBT. While Behavioral Tech
cant vouch for the kind of training these therapists have
received, its a good start to hunting one down in your
community. Another route is a hunt-and-peck approach, or
networking. Start by asking your managed care providers if they
know of DBT therapists. Sometimes the state association of
psychologists and social workers can be a good resource. Also,
call your local community mental health clinic and any local
hospitals that have child psychiatry outpatient clinics.
Your sources for locating a DBT therapist include: 1. Consult the
list, arranged by location, at behavioraltech.org. 2. Ask around,
starting with your childs doctor. 3. Check out your
states association of psychologists and social workers. 4.
Phone a local mental health clinic or local hospital and find out
whether they have child psychiatry outpatient clinics.
When you do locate a potential DBT therapist, there are certain
key questions you should ask. Has he or she attended the
intensive training course offered by Behavioral Tech, the major
teaching program for DBT? Or did the therapist learn the
treatment in graduate school? Is he or she part of a consultation
team of other DBT therapists? The consultation team is an
essential aspect of DBT. Its role is to help the therapist stay
on track with the DBT. Is there a mechanism for skills coaching
apart from formal sessions? Finally, does the therapist work with
adolescents? While it is very useful for a therapist to have
attended intensive training, it shouldnt be a deal breaker.
In such cases, however, questions 2 and 3 become much more
critical in determining your decision.
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Is this the right therapist for my child? 1. Has the therapist
undergone an intensive training course? 2. Will there be a whole
consultation team? 3. Is there a clear mechanism for skills
coaching outside the therapy hour? 4. Has the therapist worked
extensively with adolescents?
Guidelines for Choosing the Right Therapist
Individual therapy in all likelihood is going to be the central
treatment plan for your teens recovery, so make sure both
your teen and you feel comfortable with the therapist. You should
feel that you can trust and collaborate with this person and that
youll get your questions answered before and during
treatment. That said, having a good relationship with the
therapist is not enough.
Theoretical Orientation
The therapist needs to have a theory to help guide the treatment.
I always find it worrisome when I speak with colleagues who tell
me they dont have a particular theoretical orientation, or
that they just do what works. Psychological theories
aid therapists in putting their patients behavior in
understandable contexts that generate useful and relevant
interventions. If youre talking to someone whos not a
DBT therapist, ask the therapist which theoretical orientation
guides his or her understanding of kids who self-injure. Make
sure you understand as completely as you can how the theory plays
out in the actual implementation of the therapy.
Degrees and Experience
In my experience academic degrees are less important than the
following, in this order: 1. The therapist should have at least
several years of experience working with people who self-injure
and should be able to explain how the particular therapy is going
to address the issue. 2. The therapist should be considered to
have expertise in working with adolescents. 3. The therapist
should be clear about the parents role in the treat-
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ment and about the limits and extent of therapistpatient
confidentiality.
SUPPLEMENTARY THERAPIES
Sometimes the DBT therapist may recommend additional therapy to
support the DBT treatment. Whatever therapy is recommended needs
to be aimed at helping the child become more adept at managing
his or her emotions. What follows is a brief discussion of the
supplementary therapies your practitioner is most likely to
suggest.
Family Therapy
Family therapy, one of the most commonly prescribed additional
treatments, rests on the premise that factors within the family
are contributing to an individuals troubles; if these can
be identified and remedied, the family system can help resolve
them. As useful as family therapy can be, however, it often calls
forth powerful and challenging emotions. If youve ever
participated in family therapy, you know what I mean. If you
havent, just imagine sitting in a session with your child
and other family members and trying to have a discussion about
the cutting and other sensitive family matters. Family therapy
requires kids who self-injure to employ one of the abilities they
most sorely lack: modulating their emotions. Not surprisingly,
this group of kids typically manages family treatment in three
ways: (1) they become mostly mute and seemingly brain-dead, (2)
they are willing to engage in discussions only about the most
mundane topics, and/ or (3) they become emotionally charged and
head for the door at the speed of light. Be prepared: family
therapy If family therapy is recommended, can be emotionally
intense. here are a few suggestions that may help make it more
workable. First, get a clear sense of what both the individual
therapist and the prospective family therapist envision as the
task of the treatment. A red flag should go up if you hear things
like the sessions being an opportunity for family members to
express their feelings or open up channels of
communicationexcellent ideas in principle, but open-ended
discussions may be beyond what your child (or you) can manage at
this moment. If its impossible for you to approximate these
kinds of discussions at home without psychological meltdown,
youre not going to have much more success in the
therapists office. On the other
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hand, if the therapist outlines the task of the treatment as a
highly structured opportunity to learn and practice the skills
required for effective communication and emotional regulation,
sign up on the spot. Second, as the poet said, timing is all.
Think about whether it makes sense to wait on family therapy
until your kid has developed some emotion regulation skills.
There is very little mileage in going to family therapy and
engaging in an important but emotionally charged discussion that
dysregulates your kid, who then goes home and cuts. In lieu of
family therapy, it may be more useful to become involved in
something focused on guiding parents. Generally, mental health
professionals who have been trained to work with children also
learn the skills necessary to be helpful to parents. Such
sessions can help you become more skillful in responding to your
teens distress, managing your own worries about the
troubles, and working successfully with your adolescents
therapist.
Group Psychotherapy
In typical adolescent group psychotherapy, four to eight kids
meet on a regular basis with one or two clinicians. Groups can be
time-limitedlasting, for example, only 12 sessionsor
can continue for as long as the group members feel theyre
useful. Some groups have a themesuch as what it means to be
a boy in modern U.S. cultureor a specific purpose, like
teaching social skills. Often, however, they are openended,
and participants can raise whatever issues feel most relevant to
them. For most kids group therapy is very helpful because they
often accept feedback that comes from a peer more readily than if
it comes from an adult. But receiving any feedback on their
issues is bound to be an emotionally charged experience, and
adolescent group feedback is no exception. Groups that are highly
structured, skillbased, and limited in emotional expression
can be the most useful for adolescents who self-injure. These are
exactly what the DBT skills groups strive to do. (Sometimes kids
are referred to a DBT skills group by their non-DBT therapist.
While this wont do any harm, these kids are not going to
get the full benefit of the treatment if theyre not in both
individual DBT and the DBT skills group.)
Medication
Psychopharmacologypsychiatric medicationis frequently
an element of outpatient treatment for kids who self-injure.
Referrals to a psychopharmacologist will usually be made by the
individual therapist. If you have questions
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about whether medications might be useful for your child, I
encourage you to ask the therapist and arrange for a
consultation. Get a clear understanding of the benefits and the
side effects of any medications that are being recommended. The
best way to do this is to have your child seen by a qualified
child psychiatrist or by an adult psychiatrist who sees a large
number of children in his or her practice. Dont be shy: if
you arent clear about side effects, keep asking questions
until youre satisfied that you know what to look for and
what to expect. Currently there are no medications that directly
target deliberate selfharm. But there are several that offer
indirect treatment to diminish emotional distress, lift mood,
decrease impulsivity, and level out the extreme mood swings that
are characteristic of these adolescents. Though they are rarely
enough on their own, medications can be a great supNo medication
specifically targets selfport of the childs work with the
injuring behavior. But many can help DBT therapist. indirectly by
decreasing the emotional Unfortunately, many of the distress,
impulsivity, and mood psychiatric medications that are swings
that contribute to the problem. prescribed for kids have not been
subjected to rigorous clinical trials with children. We know they
work with adults, but we really cant say what the long-term
effects might be on children. But depression and other
psychiatric conditions in children can be incapacitating. In
clinical practice we believe that not using the medications when
theyre indicated may make the situation worse. The
following brief descriptions of the more commonly used
medications are offered only as a guideline to help you formulate
questions to ask the prescribing physician.
Antidepressants
There are several classes of antidepressants, but the one most
commonly prescribed are the selective serotonin reuptake
inhibitors, or SSRIs. This class includes drugs like Prozac,
Paxil, and Zoloft. Some of the SSRIs are thought to have a
beneficial effect on anxiety, and can be prescribed when both
depression and anxiety are part of the clinical picture.
Its thought that people who suffer from depression lack
sufficient quantities of serotonin in the brain, and the SSRIs
remedy that by keeping more serotonin available for the brain to
use. These medications usually dont begin to work for 4 to
6 weeks, so dont expect immediate results.
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The SSRIs can be a very effective tool in the treatment of
depression and, with the exception of two very important side
effects that I will describe shortly, they are relatively benign.
It is of the utmost importance, however, that you and the team
with which you are working parse out what is true depression from
the severe gardenvariety unhappiness that may be Be sure the
therapist is not mistaking enveloping your teen. your teens
profound unhappiness for Side effects are an issue depression. If
he or she is not with any psychopharmacological clinically
depressed, antidepressants regimen, and the SSRIs are no may not
be of much help. exception. Some side effects of the SSRIs are
insomnia, stomach distress, and minor muscle pain. These symptoms
are generally mild and short-lived. Warning: children with
undiagnosed bipolar disorder who take SSRIs face a more serious
problem. This class of drug may induce manic episodes: racing
thoughts, inability to sleep, increased agitation or
irritability, grandiose ideas, and an abundance of energy that at
first may seem a welcome contrast to the depressed mood, but soon
leads to bigger problems. If your child seems overenergized after
a couple of doses of an antidepressant, call the prescribing
doctor. A second serious side effect of the SSRIs, one
thats been much in the news but that remains somewhat
controversial, is that they may increase suicidal thinking. These
medications even carry a black box warning (a
cautionary note required by the FDA enclosed in a black box on
the package insert). While all classes of antidepressant have
been known to be somewhat energizing and sometimes this newfound
energy is directed toward selfdestructive thinking, the
controversy surrounds some evidence that the SSRIs may bring this
about in children more often than in adults. The side effect
appears to be present in 2 to 4% of the children who are
prescribed this class of medication. If you even suspect that
your child is experiencing suicidal ideas after starting an
antidepressant, let your doctor know immediately.
Mood Stabilizers
The mood stabilizers do just what their name implies: they
stabilize the patients moods by ironing out the extreme
fluctuations to which these kids are often prone. Its
like hes Dr. Jekyll and Mr. Hyde, Brians mother
told me. One minute all is good in the world, and in the
next hes down on himself and everything and everybody
else. There are essentially three classes of medications
used as mood stabilizers.
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The one thats been around the longest is lithium. Doctors
who were treating gout patients with lithium first noted its
mood-stabilizing effect 200 years ago, but the drug wasnt
approved for the treatment of mood disorders until the late
1970s. Patients taking lithium need to have periodic bloodwork
done to assess that the lithium level is not too high, which can
be toxic to the body. In addition, they often experience
considerable weight gain (a side effect that is unfortunately
present in many of the medications used to stabilize kids
moods). The second class of mood stabilizers are anticonvulsant
medications such as Depakote, Lamictal, and Topamax; although it
is not completely clear why these medications succeed in
stabilizing moods, it is clear that they often do. Some require
that blood levels be drawn periodically and some dont. They
have some propensity to cause weight gain, with the exception of
Topamax, which can suppress appetite. A side effect of Topamax
that kids sometimes experience is a kind of slowing down or
sluggishness to their thinking. The third kind of mood stabilizer
is a low dose of antipsychotic medications, especially the class
known as the atypicals. Medications in this group include
Risperdal, Seroquel, and Zyprexa. In addition to their
moodstabilizing effect, these medications can be used to treat
anxiety, sleep issues, and impulsivity. As with the other mood
stabilizers, the atypicals can cause significant weight gain and
have been linked to an increase in diabetes. And even at very low
doses, they sometimes produce a kind of lethargy and a feeling of
deadness in a child.
Anti-anxiety Medications
Sometimes a psychiatrist will prescribe a benzodiazepine to help
a child manage her anxiety. Medications like Ativan, Xanax, and
Klonopin are all examples of anti-anxiety medications. They
usually do a very good job of diminishing the childs
experience of anxiety, and are often reasonable short-term
solutions to overwhelming anxiety. Being overwhelmed with anxiety
is a horrible feeling. And often what were anxious about
are situations in which there is little reason to worry or our
worry is out of proportion to the situation. For example, being
anxious about going to a party where you will only know a few
people may be reasonable, but becoming so overwhelmed with worry
that you cant leave the house is a problem. Theres a
good chance that if youre overwhelmed with worry and take a
benzodiazepine, youll feel better in 20 minutes and can
probably make it to the party. The next time a similar situation
arises, however, you will have to medicate yourself again. My
personal philosophy of treatment (and this is just one
persons point of view) is that anxiety is part of life;
its important to develop the skills to manage it, and
cognitive-behavioral therapy can help.
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Theres no doubt that anti-anxiety medications can be of
tremendous help when acute anxiety strikes. But the down side is
that they can be addictive, so they cant be used regularly
in the long term. If your child is prescribed one of these
medications, make sure a clear exit strategy has These particular
medications can been set up, or that the medications be addictive
and should not be are limited to times of dire need. used
long-term. If your child Furthermore, these medications can needs
to go on one of them, make have a disinhibiting effectthat
is, sure there is a clear exit strategy. they may cause some kids
to become more impulsive, which can lead to increased incidences
of self-harm. This side effect seems more likely to occur in
families with a strong history of alcoholism. If your
childs psychiatrist recommends medications and has answered
all your questions, I suggest that you give them a try and see
how your child tolerates the regimen. Then you and your child
have to carefully weigh the benefits versus the drawbacks. For
example, if your kid has a history of poor judgment that leads to
dangerous behavior, then the benefits from the medications may
outweigh their drawbacks. On the other hand, if your child is
actively involved in school, sports, and friendships and his
self-injury is limited to times of interpersonal conflict, then
the drawbacks of the medications may outweigh their benefits.
When the DBT and possible medications arent enough help for
your child, it may be time to consider more intensive inpatient
or outpatient treatment programs.
Here is a set of guidelines that will help you, in conjunction
with your childs treatment team, decide whether a more
intense intervention is called for: 1. Is your child in imminent
danger of suicide or seriously reckless behavior that compromises
his or her safety? 2. Is your childs behavior unmanageable
in your home, putting other family members at physical or
emotional risk? 3. Are you and other members of your kids
support network so burned out that you need some respite? If the
answer to one or more of these questions is Yes, a
more comprehensive and containing treatment environment may be
required.
the right therapy for your teen
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It can be upsetting to realize your child needs this level of
intervention, but when its called for, the right program
can be of tremendous benefit. A full discussion of these programs
can be found in Appendix B.
YOUR INSURANCE COVERAGE
Last Saturday was a nightmare. Susie had been out with
friends and returned early, way before her curfew. Right there
and then, we knew something was wrong. She came in the house with
barely a hello and went right upstairs to her bathroom. When my
husband and I checked in on her, she had cut herself and was
beginning to put every pill she could find in her mouth,
Susies mom told me. That must have been scary! Did
you call 911? I asked. We sure did, and in some crazy
way that was when the nightmare really began. It was about 11:00
when Susie was rushed to the emergency room. Initially things
went really wellthey attended to her medical condition
immediately and told us a psychiatrist would be down to see us.
Once she was medically clear, though, we sat for hours waiting to
be seen by a psychiatrist. The psychiatrist arrived around 3:15;
she spent 20 minutes with Susie and told us she thought Susie
should be admitted to a child psych ward and that she would begin
that process. An hour and a half later, the psychiatrist returned
to say that she had found a bed at one of the local hospitals and
that Susie would be transported there immediately. That was
early Sunday morning. On Monday Susies social worker from
the hospital called and asked some questions about Susie and our
family. On Wednesday my husband and I were invited to the
discharge meeting. We were told that Susie was stabilized and
that the managed care worker wanted to step Susie down, as she no
longer met criteria for inpatient care. Susies team told us
that this was standard these days and that the hospital team
would work to put an outpatient program in place. My
husband and I were flabbergasted! I told the team that I had
checked my insurance benefits and I knew we had 60 days per
calendar year of inpatient coverage. The social worker let me
know that the benefits were managed and that Susie would have to
be discharged. We werent sure Susie would be safe at
home. Some of you may have been there and done that
and have the pictures on the fridge. When it comes to
private health insurance, there are several important facts for
you, as customer, to know. Negotiating managed care can be
extremely frustrating. Its sometimes
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1. What are the specific benefits that your plan allows for
mental health? Make sure you are clear on the inpatient benefits
as well as benefits for day hospital, and outpatient visits. 2.
Does your plan allow for out-of-network coverage, or are you
limited to the providers on the plans list? If you can go
out of network, what is the cost to you? 3. Is there any way to
flex your benefits? For example, sometimes an insurance plan will
flex, or make a swap, for inpatient benefits for partial hospital
days. 4. If your child is a high user of clinical services, some
managed care outfits have intensive care managers, who can
sometimes go beyond the strict benefits allowed in your policy.
easier to bear the frustration when you keep in mind that the
people who work for the managed care company are in a tough spot
trying to make sure that your child is getting what he or she
needs while at the same time following their companys
protocol for services. Your best bet is to work in a
collaborative relationship, advocating for your childs
needs while understanding that its not the managed care
person on the phone whos the problem but the insurance
coverage. Your role as the customer of a particular health
insurance may give you the best leverage. The criteria for
accessing public insurance (Medicaid and Medicare) and public
programs vary by state. Some states have relatively comprehensive
services for people who depend on public programs, while others
fall woefully short. While it often takes some detective work,
you should find out about all the clinical services available for
children in your state. Then begin to advocate for what your
child needs. Patience and perseverance are the key ingredients.
Dont give up! I hope these chapters have given you a
clearer understanding of the nature and genesis of your
childs problems, and of the good news about the relatively
new therapy that can make a big difference fast. In the next part
of the book, Ill show you how to apply all the strategies
and skills of DBT to your own dealings with your child. This
therapy will give you a whole new way of interacting, installing
validation as a core ingredient. It will also reduce stress in
the family overall, and possibly even between you and your
parenting partner. Ill also share some ways you can
reinforce the positive effects of the DBT at home and some advice
about talking with the people in your childs
worldother family members, friends, teachersabout
your childs difficulties.