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 individual’s 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 adolescence—Popular works. I. Title. RJ506.S44H635 2008 618.92'8582—dc22 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

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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 child’s 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 mother’s 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 didn’t 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. It’s all too easy to get lost ourselves in the emotional storms and breakdowns that overwhelm our kids. Our own understandable worry about our children’s 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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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. That’s what I hope this book will do for you—send 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 Wheelis’s 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.

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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 children’s 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, it’s 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 child’s 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 right—there’s no such thing. No matter how hard we try, we can’t 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 we’re tired or angry. We fail because the world has changed so much from when we were young, or because we didn’t get what we needed from our own parents, so we just don’t 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 don’t try to be perfect and instead focus on staying open to learning from your mistakes. Don’t underestimate your strengths. You may need to

I

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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, I’ve 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 you’re 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 her—at least that’s true for the vast majority. To us, that’s a terrible solution. To your child, it’s one that works. We don’t know why it works—probably because of some combination of biological and psychological factors we don’t fully understand. One of the main purposes of DBT is to help adolescents find other ways to calm and soothe themselves. Rest assured that you’re 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 Sara’s therapist. In the phone call he reported that the therapist wasn’t 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. Sara’s 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 less—and 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, Sara’s 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 Sara’s shoulders. A cloud of sadness swept across Sara’s face, and tears begin to well in her eyes. Right at this moment Sara’s 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 doesn’t want me to do it. We’re trying to understand why I do it—you 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 it’s unhealthy, Sara said, that it worries her parents, and that she doesn’t 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 I’m 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 won’t ever do it again, but I don’t do that anymore. I know when I get into that state I don’t 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?”

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introduction

A faint smile appeared on Sara’s face as she said, “No. In fact, I really don’t want to stop.” Sara’s admission that she was not so sure she wanted to stop cutting clearly surprised her parents. It’s often the case, however, that adolescents who self-injure have come to realize how effectively the behavior helps them to soothe themselves. It’s not at all unusual for them to have mixed feelings about giving it up. Sara’s 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. I’ll 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,”it’s 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, there’s 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 don’t often appear in concert with self-harm. MARIE: “SOMET IM ES I DO N ’T FEEL ANYT HING AT ALL” Knowing that you’re not alone with this issue probably doesn’t make it any less worrisome, frightening, or confusing—especially if you can’t find effective treatment, as happened to Marie’s mother and father.

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5

“It looks like you’re 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. She’d 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 wasn’t ready to engage in therapy. It wasn’t 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 Marie’s father interjected that if Marie doesn’t 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 wit’s end, it also seemed that he’d 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 daughter’s future. Unfortunately, Marie heard it only as a threat and slumped deeper into her chair. I asked Marie’s 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 wouldn’t allow herself to suffer so much. Marie’s 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 what’s going on with her child and burst

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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 didn’t think so,” I responded. “What about when you overdosed? Did you intend to die then?” “Yes,” she mumbled. “I couldn’t 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, that’s 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, you’re 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 can’t name the feeling you still know you feel something very strongly?” “Totally, but sometimes I don’t 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 Sara’s 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

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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 it’s 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 what’s going on with your son or daughter. A teen who goes straight to her room after school may not reveal the roiling emotion that’s 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 she’s experiencing it. So you’re 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. It’s certainly not an acceptable strategy, but understanding how it serves this function is a critically important first step. When you—and your teen’s therapist—understand 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 you’ve sought before may have led nowhere, and your own repeated pleas to your teen for an explanation of why she’s 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 child’s worrisome behavior will help you in two im-

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portant ways. First, it will lessen your own anxiety. When we understand something, our fear and worry usually decrease. Don’t expect to become calm about your kid’s trouble, but odds are, once you understand it, you won’t 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 adolescent’s 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 people’s. 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 balance—it is a solution to the extremely disturbing emotional problem of feeling out of control—and it works. It’s critical that you understand that fact because it explains why your teen, like Sara, may not really want to stop the cutting. Why? It’s 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 don’t 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 don’t 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

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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. I’ll 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, I’ll 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

Caitlin’s parents were at their wit’s end. Whose wouldn’t 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 don’t know what to do at this point,” said Caitlin’s dad. “We’ve 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 don’t think she wants to stop—she must like the attention or something.” Caitlin’s mom chimed in: “She’s such a good kid. I know she’s 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, she’d 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. It’s hard to stay calm when your children seem to be stuck in scary behavior. You experience strong emotions that feel nearly unbearable. And when you’re 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 they’ve been struggling with a problem behavior that has been illuminated by very little scientific research.

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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

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 child’s behavior by doing some things differently yourself. That’s 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 don’t 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 Cynthia’s 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. “I’ve had therapy since I was a kid, and it hasn’t helped with the cutting,” Cynthia told me. “I’ve just become resigned to the fact that this is part of my life. You know, when I cut myself it really doesn’t hurt, but it just seems to help. I’m 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 it’s like an old friend who is a bit troublesome but who is always there when you need her.” Cynthia’s 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 adolescence—and that’s when you’re most likely to be trying to understand and eliminate it from your child’s 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.

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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 it’s the most common reason that parents and some therapists give to account for the behavior—despite 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 adolescent’s 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 Erin’s 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? It’s 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

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cutting”—giving 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 you’re 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 events—relieved 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. There’s 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 it’s a little earlier, from 11 to 15. Hallmarks of this stage of development are the phrases “I don’t want to talk about it” and “Everything is fine”—the second of which often doesn’t 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

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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 don’t want to talk about have in ways that are “over the top,” it” and “Everything’s fine,” they rarely intend to promote tighter teenagers rarely seek parental scrutiny from their parents. Ironically, attention—much 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 Erin’s 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 them—it’s 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 they’re 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 it’s almost always about getting immediate relief from emotional distress. (Those cases where it doesn’t provide emotional relief are discussed in Chapter 3.)

Myth 2: Everyone’s 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 it’s on the rise, but we don’t know for sure. We are uncertain for at least three reasons.

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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. Marie’s 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 can’t 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 wit’s end, are inadvertently generating the confusion.) They tell me that they deliberately self-injure when they just can’t 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 don’t try to make this distinction in your own children. Seek a professional’s 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 won’t be too long before we have more definitive answers to these questions.

Today’s Kids Seem Less Secretive about It
While we don’t 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 child’s 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

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self-injury. We don’t know whether these sites help children to stop selfinjury or induce them to keep it up, but it’s 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 they’re 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. It’s 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, it’s 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, it’s 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. It’s true that cliques are an important part of adolescent life, and I don’t want to downplay the importance of a child’s 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

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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 Melanie’s 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 hadn’t 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 don’t see them much anymore,” she replied. “I know your parents worked very hard to stop you from hanging out Adolescents generally don’t start with them. Is that why?” injuring themselves because of “No way,” she told me. “When the influence of friends. They they wouldn’t let me see them, I just are more likely to choose friends did it behind their backs. I don’t pick who share their behavior. their friends, why should they pick mine? They thought I was being influenced by Dee and Nick, like I don’t have a brain of my own. I don’t know, I just feel like I’m 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 you’re 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

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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 they’re 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. I’m usually very good at math, but I just couldn’t 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 self–hatred. 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 it’s 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 can’t 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? I’m 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

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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 it’s 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 it’s because of its wonderful taste. Clearly, though, the mustard’s 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 it’s true) that they can’t 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 doesn’t accurately or fully explain their self-injury.

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Myth 6: It’s 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 you’re 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 wouldn’t 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. It’s 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 loss—for 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.

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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 it’s only natural to look for an explanation beneath the surface. Surely something else—some hidden, unresolved need—must 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 person’s 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 purpose—both 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 couldn’t remain at college and had to return to live with her mother, although she often spent time at her father’s 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.

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I get really tense when he’s home. I just know that he wishes I would get my act together. He doesn’t understand how much I’m 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 puppy’s 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 didn’t 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 didn’t 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 Tamar’s bingeing a thing of the past. If I had focused exclusively on the meaning of Tamar’s 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 Tamar’s behavior and also work at understanding her beliefs about the behavior. When speaking with your child’s therapist, listen carefully to how the clinician is thinking about your child’s 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 individual’s painful emotional state, providing some sense of relief.

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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 person’s 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 time—time during which the teen’s self-destructive behavior continued. To make matters worse, it wasn’t 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 child’s 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 child’s 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 didn’t 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 I’d been hoping for. DBT has two major strengths (as well as many others, which you’ll 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

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the teen when she does it and gives her other ways to serve the same purpose. As I’ll 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. You’re 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 you’ve 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 DBT’s 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 It’s difficult to bear the uncertainty about what guides the troubled actions of our loved ones. In these moments we’re likely to jump to conclusions. Our thinking tends to become rigid and constricted, so we can’t 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 child’s other parent may not be on the same page. Often one parent’s 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 thinking—neither of which can help the suf-

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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. Aisha’s 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. Aisha’s stepmother was a confident, nononsense kind of person and she reveled in the demands of graduate school. Aisha’s dad, a quiet and thoughtful man, valued peace and harmony in his family life. He told me that often he was puzzled by his daughter’s 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. “It’s not rocket science, Dr. Hollander,” Aisha’s 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 can’t devote the time she usually spends with the kids. It’s not easy juggling full-time family obligations with graduate school. She’s only human; she can’t do everything. Aisha needs to understand that and stop trying to be the center of attention.” Aisha’s stepmom went on to say, “It’s almost like clockwork. Exam time comes around or I have a paper due, and that’s 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.” “That’s not true!” Aisha sobbed. “I don’t 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 can’t do it!” Clearly Aisha felt misunderstood by her parents, but couldn’t 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.

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There had to be more to the story. The parents’ theory made good sense, yet Aisha’s side was equally compelling. What too often occurs in these conversational standoffs is that each person starts to bring more and more energy and insistence—and loudness—to bolster his or her own position, while the capacity to understand the other person’s 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 child’s 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 person’s 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 teen’s self-injury, find point of view later. the kernel of truth in each Of course this is easier said than person’s point of view and then done, especially when your emotions bring all of these kernels together. are running high and your children’s 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. I’ve 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 Aisha’s 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?” Aisha’s stepmom spoke first: “I do what I can for my family—they really are my first priority—but when my schoolwork requires my attention, it becomes a real tug of war about how I’m going to divide my time. I have to admit, I can get pretty irritable and short on patience in those moments.” Aisha’s 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 she’s 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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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 people’s opinions. 3. It’s of little importance to be “right”; the only thing that matters is gathering information to help solve the crisis. 4. Taking pieces of other people’s viewpoints plus pieces of your own, at least temporarily, may yield a fuller picture than any single person’s 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 can’t take it.” “Does your cutting give you some relief from all that stress?” I asked. “Yes!” Aisha answered immediately. Clearly, it was Aisha’s 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 teen’s 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. Janine’s story illustrates. “You just don’t get it! Lizzie is my best friend, and she understands me better than anybody else,” Janine exclaimed through her tears. “She’s no best friend as far as I’m concerned,” countered Janine’s dad. “I don’t think she’s a friend at all! What kind of friend supports you cutting yourself?”

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“She doesn’t 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 Janine’s position and the truths in her father’s as well. What is missing in the dialogue is validation—that is, communicating that you understand and value the wisdom in the other person’s point of view. Validation means communicating that you unValidation is like fertilizer for derstand the other person’s experirelationships—it keeps them ence. This doesn’t mean that you growing. It nurtures and have to share the opinion. enhances the relationship so the For example, Janine’s dad need more arid times are easier to bear. only say that he understands how valuable Lizzie’s 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 Janine’s 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 misunderstandings—between parent and child, between parents, and between child and therapist—that 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 everyone—your teen, you, and the teen’s therapist—understands and validates the teen’s emotional experience, the teen is not likely to be receptive. If you can’t see that she’s 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 didn’t understand that she had broken her leg. Of course emotional pain isn’t visible. Let’s 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.

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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 she’s in a good mood, but accomplish very little when she’s 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 that’s what 80% of kids who selfinjure are doing. But, like many parents, you may notice that your child doesn’t seem to feel any emotions at all. “I just can’t read her anymore,” Ellery’s mom told me with concern. “I know she’s really upset, but she just doesn’t show any emotion. When I ask her how she feels, she just answers ‘Fine,’ but I know she’s hurting.” Some of these children have a sense of dread about directly experiencing their feelings and have developed strategies to avoid them. They’re out of touch with their feelings, unable to apply accurate labels to their emotions. They’re worried that if they were to feel, they would become emotionally overwhelmed—and they may be right. When asked how they feel, they often quickly answer, “I don’t know”—an automatic response that helps them short-circuit any awareness of their emotions.

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Others have developed the ability to “mask” their feelings. They usually have some idea about what they’re feeling, but for a variety of reasons they don’t 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 that’s when they’re 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 child’s 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 she’s 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 I’ll 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-

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ple who are only mildly reactive and on the other end would be the most reactive people. With very few exceptions, one’s degree of emotional reactivity is determined by biological makeup, like eye color or natural athletic ability, not by one’s 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 haven’t 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 wasn’t always this way,” Mrs. Martin explained. “As a child she would certainly have her moments, but since the beginning of adolescence she’s a changed person. The slightest thing seems to send her into an emotional tizzy.” Roberta’s father added: “It’s 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 can’t 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 it’s not obvious that it’s 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 something’s 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 can’t study and he’s going to fail anyway. You suggest that if he does study, then maybe he won’t fail. He says once again that you don’t 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.

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What’s really happening here? Your son can’t 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 me—I know I must have looked crazy, but I couldn’t stop myself. Finally she just walked away. I felt horrible. I couldn’t 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 wasn’t

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really being unreasonable. He was trying to tell me that we couldn’t get together on Friday night because his schedule at work had changed. It was automatic—I didn’t 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 don’t 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. They’re 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. “He’s 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 don’t know. I just felt like I was going to explode if I didn’t get some relief,” Nora replied, her eyes fixed on mine. “When you get emotionally revved up, it seems it’s hard for you to know just what it is that you feel,” I suggested. “I don’t 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 you’ll be to know when to worry

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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 teen’s 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 you’ll 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 don’t know what they’re feeling. All they know is that they can’t stand it. Teens who can’t 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. I’ll talk more about this in the next chapter but, as you can see, emotional dysregulation can affect all aspects of your child’s life. He will have difficulty communicating his needs (how can he get reassurance and comfort from you if he can’t tell you that he’s feeling extreme fear?). He will have a hard time believing his feelings are valid (if he’s totally confused about what he’s feeling, those feelings won’t 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 what’s 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)

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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 components—being “emotionally literate”—is 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 based—while 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” someone’s expression and have a good idea of the corresponding feeling. Emotions are useful tools of communication—in 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 can’t 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 didn’t have any feelings at all. They just make me feel crappy about myself.” Life is confusing enough for adolescents, but for those who don’t know what they feel, it’s exponentially more confusing. Kids who can’t 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

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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 can’t 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 Penelope’s story illustrates. or developing ways to calm “Last night I had a wicked fight down, they’ve learned to do with my father. He can be such an something that will change their idiot. Doesn’t he know by now that powerful inner state immediately. he isn’t helpful when I’m 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 didn’t know what I was feeling and he was just making it worse. He wouldn’t 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 there’s something wrong with us for having the feeling in the first place, or that if I were a better person, I wouldn’t feel this way.

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For example, if your boss tries to blame you for something that wasn’t 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 what’s 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 she’s 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 can’t stand myself and I’m liable to pick a fight with whoever comes my way.” Without the tools to soothe herself or to change her feelings, Nora can’t 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 you’re 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?

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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 wasn’t 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 you’ll 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 don’t 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 don’t or can’t modulate their emotions, they’re 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-dependent—that 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 they’re 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 grandma’s house will be pleasant. If they’re 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 child’s behavior is mood-dependent, you may find it hard to understand that the trou-

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ble he’s having has to do with his inability to modulate his emotions. After all, on the surface there’s not much difference between mood-dependent behavior and sheer lack of motivation or willful disobedience. To make matters worse, he often won’t 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 go”of his or her feelings to get chores done?

While we all find it easier to get our work done when we’re feeling relatively calm, these kids experience a huge difference in their capacity to accomplish anything depending on whether they’re calm or agitated. When they fall behind on life’s requirements, they make their situation worse, increasing the likelihood that the bad mood will be extended.

What’s 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 brain’s 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.

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Assuming we’re in no imminent danger that requires an immediate response to our emotions—say, a ravenous lion is about to attack, in which case our fear would enable us to run for our lives—there 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 can’t or won’t 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. you’re 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.

LISA’S DRESS Lisa and I were discussing the difficulty she’d had at a girlfriend’s 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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“I remember that Gina said something about my dress which, I don’t 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 couldn’t accurately label and identify her emotions, and (2) she couldn’t 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 can’t believe he embarrassed me in front of his family again—he always does this”) or trying to talk yourself out of it (“There’s 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 she’d had at modulate the emotion. her friend’s sleepover, she came in to therapy and related this success: “My friends and I were at Marjorie’s 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 you’ve 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 didn’t 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. Let’s say you’re 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 can’t believe Danielle just ignored me like that. Well, clearly she didn’t have a

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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, I’m surprised and hurt. I wonder why Danielle is so preoccupied that she didn’t even see me. I hope everything is all right. I think I’ll give her a call later and see what’s 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: it’s a wonderful emotion regulation strategy and a handy tool when you don’t 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 them—that 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 you’re 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 can’t get out of bed. I am just too depressed, I have no energy, and I can’t go see my cousins. They are all so perfect,” she told me over the phone. “But if I don’t 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 don’t 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 can’t stay home!” Maureen exclaimed. “Got it! I think it’s time for opposite action to current emotion,” I suggested. “Do you remember how this skill works?” I asked.

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“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, that’s right—and you have to commit 100% to the action. You can’t 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 can’t 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, it’s 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 she’s left for the day and won’t be back in the office until Tuesday. You notice that anger is rising up within you, but you know that you’re 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 it’s 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 she’d 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 wasn’t going. Maybe I shouldn’t have said it, but I re-

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minded her how important this was for her future. I know she has bigger problems right now than getting into college, but I’m so worried she’s going to make decisions now that will ruin her life. Anyway, that’s when all hell broke loose. Celia started screaming that I didn’t 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 couldn’t understand how she didn’t 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 Celia’s emotional state. What went wrong? Let’s look a little more closely to see if we can figure out what Celia’s mom could have done differently that might have prevented a meltdown. Here’s 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 Celia’s relationship with her friend, she’s understandably put off by Celia’s out-of-control behavior, and she’s worried that her daughter will lose sight of her responsibility to go to SAT tutoring. Here’s what happened: Mom’s strategy seems to have ignored her daughter’s emotional distress and focused instead on the issue of getting out of the house on time. Why didn’t that bring the desired results? The central problem was a lack of validation. It’s 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 person’s experience. You don’t 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 don’t valiwhat we’re 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 it’s “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
Celia’s mom didn’t validate Celia’s 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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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.” “I’m not going.” “It’s 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 you’re responsible for your children’s 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 on—it 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 here’s 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 you’re going to manage your feelings. Again, in my example, Mom needed to honor her worry about Celia’s future by acknowledging that this is how she felt, even though it wasn’t 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

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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 life’s hurts and disappointments. It’s natural for you to have been downplaying her emotional response all along, or offering reassurance that things aren’t 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 wouldn’t 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 it’s harder for parents to see their child’s 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 years—hormonal 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 world—often make things especially clearer, and parents really hard for emotionally vulnerable kids. can and do solve many of the child’s difficulties. The new demands of the teen years—the biological changes, the emotional swings, the capacity for abstract thinking, and the broadening of possibilities in the social world—often 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, it’s like the end of the world for her. When I try to reassure her that I understand because I’ve had problems with my own friends, she just blows up. It’s so awful for me when I’m 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 don’t understand,” added Keisha’s dad. “That really frosts my socks, and I won’t speak to her until she apologizes.”

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Keisha’s 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 Keisha’s behavior. Let’s start by making a couple of assumptions about her. First, let’s 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 haven’t 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, let’s 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 person’s 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; it’s 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 it’s a frein which we want to accept the quent aspect of family communicaperson’s 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

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regimented traditional school setting in which academic results are valued over personal growth. Another example of invalidation is bullying by other children when it’s 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 shouldn’t be hurt by your friend; you should be angry that he treated you that way.” 2. “So you didn’t get invited to the party. That’s no big deal—after 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 child’s 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 child’s effectively learning to problem-solve.

Problem Solving Too Early
The first error is to problem-solve before validating. It’s 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 Keisha’s 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 children’s capacity to effectively problem-solve. Celia’s mom provides a good example. In the face of her daughter’s emotional distress, she understandably began to worry about what Celia’s lack of commitment to the SAT tutoring might portend. Introducing her own (perfectly reasonable) worry into the situation invalidates her daughter’s current experi-

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ence. Celia is also the kind of kid who is hypersensitive to other’s emotions, particularly those of her parents—from whom she wants approval, even if she won’t admit it. Her mother’s worry about her overwhelms her and makes her worry about herself at a time when she can’t 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 who’s just trying to be helpful to a distressed child, all the way to child abuse. Human beings just seem to do better when we’re understood and tend to get more emotionally dysregulated when we’re not. When we’re misunderstood we often work hard at getting the understanding that we need. How skillful we are at this will be part of our story. Let’s take a closer look at the ways each of Keisha’s 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 Isn’t 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 don’t 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 can’t possibly appreciate the magnitude of the problem. Consequently, rather than feeling understood and reassured, you’re likely to feel invalidated. Reassurance is a strategy that is often effective with younger children who are more willing to be dependent on an adult’s 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 she’ll be than young children to buy into fine. Not so for the teenager whose an adult’s viewpoint. Therefore parent says the same thing about anthey’re less likely to be reassured other friend’s 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

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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 “I’ve Been There” Isn’t Validating
Keisha’s 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— Keisha’s 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 Mom’s 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. It’s only likely to make your child feel more misunderstood, not less.

Why Putting Things into Perspective Isn’t Validating
Let’s turn our attention now to Keisha’s dad. He enters the fray by trying to help put Keisha’s 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, he’s 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 Isn’t 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 reason—maybe it’s a design flaw—people are more willing to accept advice after they feel they’ve been understood. Very often an adolescent I have been treating will tell me a story

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about a parent’s attempts at problem solving before validating. Later in the therapy I’ll 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 it’s 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 I’ll 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 it’s asked for); and make sure you have validated before moving into problem solving. But wait—there’s more! Both of Keisha’s parents report having very strong emotional responses to their daughter’s seemingly unreasonable behavior. This, of course, is perfectly understandable. They’re 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. Keisha’s 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 child’s behavior in a desperate attempt to be understood. Here is a story that I think brings this concept home.

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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 couldn’t 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 them—the environmental response—will 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 child’s 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 don’t 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 teen’s emotional distress. Do you tend to unwittingly make things worse? It’s 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 we’ll 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.

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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 didn’t 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 shouldn’t do it either, but it’s my body and it really does work when you feel that way.” It’s hard for us to comprehend how hurting yourself can produce a feeling of calmness, but for certain emotionally overwhelmed individuals it does. We just don’t know what differentiates those people for whom deliberate selfharm works as a self-soothing mechanism from those for whom it doesn’t. 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 can’t 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 didn’t 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, what’s up?” asked Kristin in a cheerful voice. “Nothing. I’m just having a crappy day,” Marissa replied “That sucks!” Kristin said. “What are you doing later? I’m going to chill with Sara. Hey, I’m getting another call. I’ll call you back.” Click! The line went silent. When Marissa’s 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, it’s 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 didn’t 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: “It’s like I’m on emotional fire. I can’t 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,’ I’m just a mess. Inside I am overwhelmed with intense feelings, and on the outside I am screaming and crying at the same time.”

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As you’ve learned, these kids often can’t 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, you’re likely to get a reaction that’s a combination of anger and tears. The problem is that these children really Like someone who’s drowning, do experience emotions more deeply people who can’t 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 moment’s 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, you’re 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 children’s bodies seem

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to adapt to the initial levels of The act of self-injury releases chemicals these chemicals. When this into the body—not unlike what using happens, they need to injure opiates would do—to 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 person’s “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 don’t 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. They’re 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

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their children’s deliberate self-harm, it’s 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 couldn’t take it anymore. I felt dead on the inside. You know, numb and empty,” Jill complained. “I stopped feeling part of the world—it was kind of spooky. I felt like I was a zombie.” “How did cutting yourself change that?” I asked, anticipating her answer. “I don’t 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. It’s 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 it’s just the other side of the coin of emotional dysregulation: instead of overflowing with emotion, these kids feel none at all. It’s 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 feet—every step is a everyone else’s 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 it’s 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, we’re prone to making poor and impulsive decisions about how to negotiate life’s many challenges. Under these conditions we’re

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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, it’s 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. It’s almost as if seeing the blood confirms that they’re 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 adolescent’s 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 child’s 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 don’t even know I exist or who I really am. They talk about me as though I wasn’t standing right there. I hate it! Don’t 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?

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“You must feel kind of invisible when that happens,” I said. “Yeah, it’s awful. It’s like I just don’t count for anything. Like I’m not that important even to my parents,” she said between sobs. “I know it’s 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 didn’t even notice our existence. It’s 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 don’t 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 don’t 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 they’re 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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“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 they’re talking about me, it sounds like they’re describing a stranger. I wish I could tell them how I really feel. I’m too afraid they would be disappointed.” It’s not unusual for these adolescents to begin to wonder whether they’ll 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, that’s likely to confirm the child’s 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 child’s 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 couldn’t 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. I’m sure I would have looked like a big loser. I’m 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 don’t think you understand,” Mona said slowly. “Just thinking about a sit-

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uation like that makes me so tense that I just want to die. I was so scared and nervous the night before, I couldn’t sleep—and 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 can’t 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 we’re 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 “It’s 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 there’s nothing to be nervous about, which I think only makes it worse because I still feel anxious. That’s when I start telling myself that I’m such a loser.” While the self-injury probably does calm the child’s 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 OBSESSIVE–COMPULSIVE 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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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 I’ve already discussed, I won’t 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 I’ll 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 child’s 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 you’ve been hurting yourself. I hope that you’ll be willing to talk with me about that for a few minutes,” I said. Nina only nodded her head in reply. “I’ve spoken with many, many kids who have self-injured, and this is what I’ve 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.

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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 child’s 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 child’s 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 E–C 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 couldn’t help but notice the marks on your arms and legs. What is going on for Obsessive–compulsive you?” I asked. disorder can make you feel “It’s kind of crazy, I know, but once I like a slave to the demand start to pick at myself, I can’t 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 I’m doing—I can spend hours in the bathroom looking in the mirror and picking at myself. It frightens me that I have no control over what I’m 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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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, it’s extremely difficult for them to stop. Frequently what drives the child’s ritualistic behavior is some frightening idea that is accompanied by a powerful sense of dread. For example, she may feel that if she doesn’t engage in the behavior, something awful will happen to a loved one. Obsessive–compulsive disorder is more of a biologically based illness than a psychological disturbance caused by the interaction between the child and the environment. If your child’s 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 child’s 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. (I’ll 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 we’ve seen, self-injurious behavior can co-occur with other psychological problems such as auditory hallucinations or obsessive–compulsive 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-

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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 I’ve made so far. Kids who harm themselves in the ways I’ve 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 I’ve 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 don’t 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 child’s capacities to develop the ability to tolerate life’s 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 relief—and 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 doesn’t 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 didn’t even say good-bye. I don’t 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 wasn’t 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 couldn’t 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 Dan’s 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.

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Black-and-White Thinking
You have probably also noticed how often your child is prone to black-andwhite thinking. From your child’s perspective, the world seems to be neatly divided between what she can do and what she absolutely can’t, 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 can’t 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 life’s problems should be easy to solve. The take-home message for them is that most other people don’t 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 life’s 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 hasn’t 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 I’ll introduce you to this treatment.

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DBT
THE RIGHT THERAPY FOR YOUR TEEN

As the parent of a child who self-injures, there’s 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 doesn’t 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 I’ll 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 I’ll discuss, some of these alternatives make for excellent supplementary treatment. Finally, I’ll 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
DBT—a 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 Washington—was 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-

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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 behavior—for example, praising a child after he thanks you for giving him a ride to his friend’s house—may increase the likelihood of the desired behavior happening again. (In addition, that “thank you” may make it more likely that you’ll be willing to give him the ride the next time, so he’s reinforcing you too.) Negative reinforcement occurs when something aversive is applied and then removed after a behavior has occurred, “aversive” being defined by the person’s 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, he’s 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 child’s 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 couldn’t hold out. I don’t 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. It’s not willpower you lack, but the skills necessary to manage that high-powered emotional system of yours.” Melanie’s distorted thinking is based on the faulty assumption that if she had more willpower, she wouldn’t engage in deliberate self-harm. One aspect of a cognitive-behavioral therapist’s 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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injury—specifically, that self-injury is most DBT will teach adolescents often due to lacking the skills to manage new behaviors to finally one’s emotions. help manage their emotions. In DBT the child is taught specific skills—new behaviors—that 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 doesn’t help everyone, but to date it’s the best and fastest treatment there is. Here’s why.

Restores Emotion to Its Proper Status
Emotional dysregulation, as you now know, is likely at the root of your child’s self-injuring behavior. You’ll 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 didn’t feel able to get her laundry done for an upcoming weekend at a friend’s house. “I have no energy. I just want to get into bed,” Chloe complained. “I know you want to see your friend—you’ve really been looking forward

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to this trip for a long time. Maybe if we break the tasks into smaller pieces they won’t seem so overwhelming,” I suggested. “I have no energy. I can’t 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 don’t think you understand. This is not easy,” Chloe said with anger rising in her voice. “I think maybe you’re right. I haven’t 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, I’m just feeling like there’s no way I can make it happen,” she said. “It makes me feel hopeless.” “No wonder you’re 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 dialectics—she put the “D” in DBT. Dialectics is a complicated concept and one that often trips up therapists as well as parents, so I won’t 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. I’ve 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 what’s left out of each person’s 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 can’t 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 can’t do it! I can’t 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 don’t make it sound so easy. I think you misunderstand me. I’m only trying to help you reach your goals.” There isn’t 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 other’s points of view. Here’s an alternate scenario. “I can’t do it! I can’t 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 you’re right. When I talk about using skills, I can give the impression that it’s 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 can’t possibly understand what it’s like to be me.” “I guess I need to pay more attention to that. I do see how hard you’re 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 isn’t that I can’t do this—only that I’m not very good at it yet. I sometimes get angry at you, but mostly I’m 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 Jenna’s experience and moves between acceptance and change so that they can work more collaboratively toward progress.

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As a parent you most likely have had the experience of finding yourself and your partner on opposite sides of an issue. Let’s say your teenager comes home 2 hours past her curfew, but she called 10 minutes before curfew to say that she’d be home in an hour or so. This was something new; often she’d be late and not call. Your partner’s view is that at least she called—he 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 he’s too lenient. He tells you that you’re being too hard on the kid. But if you could both step back, you’d 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 person’s 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, you’ll any one individual’s point of view. find a way both to acknowledge your daughter’s new behavior and to give a consequence for her being late: “We’re glad that you called us to let us know you were safe and what time to expect you. That’s the first time you’ve done that, and we noticed it and appreciated it. But we’re still concerned that you came home 2 hours after your curfew, so you’re 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 it’s your body to manage as you see fit. We can only hope that in time you’ll stop.” The adolescent’s position would go something like this: “I know you don’t 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 democratic—but it’s 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 person’s point of view. It’s 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. There’s no way around this. It’s just not right!” said Jamie’s dad with some tension in his voice. “You can’t stop me, and it’s my body, anyway,” Jamie replied curtly. “Jamie, can you tell your dad about how your cutting helps you?” I interjected. “I could, but I don’t think he cares,” she responded. “Give me a try,” her dad said, somewhat incredulously. “I’m curious about how it could possibly be helpful to you.” “Okay, but you have to listen.” Her dad nodded. “I cut myself when I can’t stand how overwhelmed I feel, and it calms me down. I know that sounds crazy, but it’s 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. “I’m not angry with you,” her father said sympathetically. “I’m really more frightened for you. I want so badly for you to stop hurting yourself. I know I push you. I’m frustrated because nothing has worked and it’s been going on for a long time. You’ve ignored me when I’ve tried to help.” “I haven’t ignored you, Dad. You seem to think it’s all about willpower, and it’s not. Trust me, I don’t really want to do it, and I’ve tried hard to stop, but right now I just can’t. You have no idea how awful I feel right before I cut myself.” “It’s 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,” Jamie’s 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 problem—and real hope for a resolution. Jamie’s dad gains an appreciation for the way his daughter’s 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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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. You’ve 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 teen’s 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 engine—a 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, you’ll probably feel a diminished sense of guilt as you come to see yourself and your child’s’ 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. Regina’s 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 can’t reason with her. It makes us think that we’re not good parents,” Mr. Roberts told me. “It has nothing to do with you,” Regina said. “You just don’t understand! I can’t help it if you guys don’t have feelings. My parents are robots,” she told me. “We have feelings,” Mrs. Roberts said. “We just don’t let them get in the way of being rational.” “Are you telling me that I’m 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 dysregulation—and 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 child’s 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 module—that 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 What’s 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 don’t fit. If you’re 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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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 what’s right for me.” Being unable to self-validate, she’ll 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 dysregulation—that is, finding oneself calls for quiet, reflective time. The DBT therapist actively validates the child’s 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 can’t see the forest for the trees. As you’ve 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. It’s 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, ma’am,” rather than jumping to conclusions. Many of the skills youths learn in DBT—from mindfulness to emotionregulation skills to interpersonal skills—help 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, it’s mindfulness. Mindfulness is the capacity to focus one’s attention and to have a broad enough perspective to take in new information. It’s what we need in order to accurately identify and label our emotions. It’s 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 can’t 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 it’s walking, eating, or listening to music. In the language of DBT, I’m 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 will—that’s how minds work—and 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, it’s extremely difficult for them to work at skillfully analyzing and planning what Mindfulness—the ability to focus to do next. They often seem to one’s attention while having a broad be flailing from one idea to anenough perspective to take in new other, without the capacity to information—can be practiced while slow down and evaluate the most walking, eating, or listening to effective course of action. But music. It can’t 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, they’ll 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. They’re 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 don’t have the skills to go about it. Sadly, the result is often that they’re 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 they’re 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 they’ve 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 wouldn’t 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 mom’s point of view, and I made an apology. It really worked!”

Emotion Regulation
As I’ve discussed at length, these kids don’t 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 can’t 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 you’re giving in or that you like the situation. It only means you’re 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 They’re 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,” Vicki’s 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 couldn’t get my math homework and was starting to lose it. You didn’t 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 didn’t feel like such a jerk for having a hard time understanding my homework.” Vicki’s 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 don’t just go around and around trying to prove we’re right. We understand that Vicki still gets upset and does things that we don’t 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 other’s point of view—we get that we’re 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 can’t 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,” Vicki’s dad replied. “But enough about us. We are really proud of what Vicki has accomplished.” “I want to hear what she has to say.” “It’s 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 I’d 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 didn’t 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 DBT’s 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 adolescent’s 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 child’s individual cents meet as a group 5 days a week for and group therapies. 4 hours a day, during which time they’re 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 child’s 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 2005–2006. 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 didn’t benefit from DBT, either because I wasn’t 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 they’re doing. Over the last 10 years most of them have stopped self-injuring—and 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 teen’s 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 it’s a relatively new treatment, finding a trained therapist isn’t 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 can’t vouch for the kind of training these therapists have received, it’s 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 child’s doctor. 3. Check out your state’s 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 shouldn’t 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 teen’s 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 you’ll 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 don’t 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 you’re talking to someone who’s 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 therapist–patient 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 individual’s 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 you’ve ever participated in family therapy, you know what I mean. If you haven’t, 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 communication—excellent ideas in principle, but open-ended discussions may be beyond what your child (or you) can manage at this moment. If it’s impossible for you to approximate these kinds of discussions at home without psychological meltdown, you’re not going to have much more success in the therapist’s 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 teen’s distress, managing your own worries about the troubles, and working successfully with your adolescent’s 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-limited—lasting, for example, only 12 sessions—or can continue for as long as the group members feel they’re useful. Some groups have a theme—such as what it means to be a boy in modern U.S. culture—or a specific purpose, like teaching social skills. Often, however, they are open–ended, 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, skill–based, 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 won’t do any harm, these kids are not going to get the full benefit of the treatment if they’re not in both individual DBT and the DBT skills group.)

Medication
Psychopharmacology—psychiatric medication—is 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. Don’t be shy: if you aren’t clear about side effects, keep asking questions until you’re 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 child’s 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 can’t 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 they’re 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. It’s 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 don’t begin to work for 4 to 6 weeks, so don’t 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 teen’s 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 that’s 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 patient’s moods by ironing out the extreme fluctuations to which these kids are often prone. “It’s like he’s Dr. Jekyll and Mr. Hyde,” Brian’s mother told me. “One minute all is good in the world, and in the next he’s 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 that’s 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 wasn’t 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 don’t. 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 child’s experience of anxiety, and are often reasonable short-term solutions to overwhelming anxiety. Being overwhelmed with anxiety is a horrible feeling. And often what we’re 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 can’t leave the house is a problem. There’s a good chance that if you’re overwhelmed with worry and take a benzodiazepine, you’ll 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 person’s point of view) is that anxiety is part of life; it’s important to develop the skills to manage it, and cognitive-behavioral therapy can help.

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There’s 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 can’t 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 effect—that 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 child’s 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 aren’t 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 child’s 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 child’s behavior unmanageable in your home, putting other family members at physical or emotional risk? 3. Are you and other members of your kid’s 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.

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It can be upsetting to realize your child needs this level of intervention, but when it’s 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,” Susie’s 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 well—they 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 Susie’s 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. Susie’s 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 weren’t 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. It’s 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 plan’s 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 company’s protocol for services. Your best bet is to work in a collaborative relationship, advocating for your child’s needs while understanding that it’s not the managed care person on the phone who’s 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. Don’t give up! I hope these chapters have given you a clearer understanding of the nature and genesis of your child’s 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, I’ll 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. I’ll 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 child’s world—other family members, friends, teachers—about your child’s difficulties.