PART II
helping your teen in treatment and at home
5
making the most of DBT
n this chapter I want to bring you into my office and let you see
what happens in a DBT psychotherapy. Parents are too often in the
dark about the process of treatment and therefore not in a
position to assess whether the therapy is appropriate for their
child, or even whether its working. Psychotherapy may be a
mixture of art and science, but its not some mysterious
process that cant be explained. By the end of the chapter
you will understand the different components of DBT and how each
treats the specific problems that contribute to deliberate
self-harm. In addition, I want you to have a better understanding
of the times when you might be involved in the therapy, as well
as those times when youre going to have to stay on the
sidelines and let the process unfold. All therapists think a
little differently about parental involvement. Use this chapter
as a guideline for discussing it with the therapist. When you
know what to expect, youll feel less anxious and youll
be much more effective at supporting your childs treatment.
Please keep in mind that the treatment may often feel like two
steps forward and one step back. The best way to assess whether
its working is to think of it as a stock: Is the trend
going in the right direction over time? In Assessing the
treatment is like moments of high emotional turmoil it watching a
stock. What matters wont be easy to tell whether progress
is whether the trend is going in is being made. For this reason I
suggest the right direction over time. that you keep a weekly
chart to monitor your childs progress. I will have more to
say at the end of the chapter about how you can assess whether
progress is being made and what you can do to support your childs
therapy.
I
101
102
HELPING YOUR TEEN
HELPING TEENAGERS CHANGE: A CRITICAL BALANCING ACT
Therapists who work with adolescents have to be able to relate to
them without losing their adult perspective. To be effective, I
need to hold multiple perspectives (i.e., think dialectically)
and continuously move back and forth between direct, honest
communication and genuine curiosity and interest. Adolescents are
notoriously allergic to phoniness and pomposity, and they will
quickly become disenchanted with a therapist who is stiff and
rigid, regardless of how knowledgeable that therapist may be. I
sometimes think that working with adolescents is like walking a
tightrope over a large tank that is divided in two. If I move too
close to trying to be the adolescents buddy in the service
of establishing the relationship, I render myself useless as a
resource and fall into the side of the tank thats full of
sharks. But if I Therapists need to listen to their come across
as a know-it-all adult, adolescent patients as if their story the
kid tunes me out and pushes me were the headline of the day, all
into the other tank, this one filled the while knowing that
tomorrows with piranhas. The key is to strike paper will
have a new headline. a balance between being seen as someone who
has something to offer and someone who has something to learn. I
am most effective with my adolescent patients when I listen to
them as if their story were the headline of the day, knowing that
tomorrows paper will have a new headline. See Chapter 8 for
ideas on how you can do the same.
WHO, WHAT, WHERE, AND WHEN THE NUTS AND BOLTS
As Ive explained, the standard protocol for outpatient DBT
is a weekly individual session that lasts from 50 minutes to an
hour, plus a weekly skills group for an hour and a half. In
addition, kids have access to their DBT therapist after hours in
times of crisis. Its customary for the therapist to ask for
a particular time commitment. In our clinic that commitment is 6
months, after which the involved parties come together to review
progress. In my opinion, with very few exceptions, parents need
to be involved in their childs treatment. I strongly
recommend that you find out at the start of therapy what form
that will take. The parents involvement can be meeting
regularly with the child and the therapist on a regular schedule,
or just meet-
making the most of DBT
103
ing as needed. Some clinics have parents come to a
multiple-family skills group, where several families come
together to learn the DBT skills.
INGREDIENTS OF YOUR CHILDS DBT
Biosocial theory: A powerful tool to help your child see the
self-harm in a new way and let go of the misguided, destructive
idea that he or she is weak or defective. Commitment to therapy:
Your child must make an explicit commitment to the requirements
of the therapy before the therapist can proceed. Consultation
team: The therapist must be involved with a team he or she can
consult as needed during the therapy. Between-session skills
coaching: Your child must have 24/7 phone access to the therapist
to help implement skills when needed. Diary card: Your child
needs to keep a record of any engaging in the target behaviors.
Skills practice: Using the new DBT skills in real life.
In the first phase of therapy the therapist has several important
goals. Many therapies fail because this foundation for the
treatment has not been cemented. Please review the checklist
carefully. If your childs therapist doesnt raise
these issues, make sure you do. Most of the rest of this chapter
will cover these five essential steps.
THE FIVE ESSENTIAL THERAPIST GOALS TO BEGIN DBT
1. Talk with the adolescent enough to get a clear idea about what
theyre going to work on, and get her to commit to the
requirements of DBT treatment. 2. Give the child and her parents
a clear idea of how her problems developed, using the biosocial
theory (more about this later). 3. Figure out whether the patient
and the therapist are a good match, and highlight the importance
of keeping channels of communication open. 4. Have an open
discussion with the adolescent and her parents about what will
remain confidential and what wont. 5. Outline how the
parents are going to be included in the therapy.
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HELPING YOUR TEEN
ESTABLISHING THE GOALS OF TREATMENT AND GETTING A PRELIMINARY
COMMITMENT
All psychotherapies are a collaborative endeavor. With DBT this
is particularly important. The adolescent and the therapist have
to be a team working toward common goals. Without an open and
collaborative relationship, very little therapeutic work can be
accomplished. It is, in part, the work of the therapist to help
the adolescent see the need for change and get him or her to make
a commitment to the therapy. This is delicate work. The key is to
validate the wisdom in the childs behavior while exposing
its ineffectiveness. Often the first step in this process is to
have a discussion with the adolescent about his or her Assessing
your adolescents short-term and long-term goals. commitment
to therapy will be an The trick is to link the goals to the
ongoing process. The therapist and need for change. We know that
the patient will revisit it many DBT does not begin until the
adotimes over the course of the therapy. lescent makes a
commitment to it. We also know that this commitment is going to
wax and wane. Assessing the adolescents commitment to
therapy is an ongoing process that therapist and patient will
revisit many times over the course of therapy. Parents can
support their childs commitment to treatment in a variety
of ways, from helping to finance the treatment and providing
transportation to actively praising the child for the time and
effort shes putting into it. Ultimately the matter of
commitment is between your child and the therapist. Some parents
hold out consequences if the child refuses to participate. Some
clinicians may find this acceptable, but I dont think
patients can work to change if the sole reason theyre in
therapy is because their parents want them to be. T IFFANY:
MAKING A C O M M I T M EN T Tiffany was a 15-year-old sophomore
who was referred when her school counselor learned that she had
been burning herself. She and her parents came to the first
session together. I could tell everybody was a bit anxious and
tense. The following discussion occurred about 20 minutes into
our meeting. Okay, so you have been burning yourself for
about 2 years now as a way to manage those awful feelings that
come when you think youre going to do poorly at school. Do
I have that right? I asked.
making the most of DBT
105
Yes, thats the only time I do it, but sometimes it
happens a lot, she explained. Up until recently
nobody knew, and everything was fine. You know, Im not sure
if I really want to stop. We had no idea she was
doing this! Weve tried to talk with her about it, but we
dont get too far. All that happens is that we get into an
argument, Tiffanys mom reported. Self-injury
can be a very difficult topic for kids and parents to discuss,
I said gently. Hopefully by the end of today you will have
a better idea about what the behavior is all about and how we are
going to address it. Turning to Tiffany, I asked, It
really keeps you calm, does it? Yeah. I think I just
need to do it less, and then it wont be a problem.
Especially if I keep it quiet. Oh come on, Tiffany!
her dad quickly interjected. That is just crazy behavior.
I certainly understand your worry and how strange Tiffanys
behavior appears, I said. In some ways it actually
makes a lot of sense. I turned my attention back to
Tiffany. So, what do you want to do after high school?
I asked her. I want to go to college. I know what youre
going to think of this, but I want to be a child psychologist. I
think I might be good at it, she offered. Thats
terrific. We really need people who want to work with kids . . .
but hold on a minute, what about the burning? Becoming a
psychologist means going to college and then graduate school, and
school seems to be a big-time stressor for you. Besides that, how
would you feel if you were still engaged in burning when you were
treating kids? I asked. Dont you think that
might be a problem? I wasnt really thinking
that far ahead. I guess I kinda assumed I would be able to stop
it by then. If I was still doing it, I could see how that might
be a problem. I would feel kind of phony trying to help kids if I
was still burning myself, Tiffany said. But Ill
stop it when Im older. Actually, without
treatment, self-injury often continues into adulthood. What do
you think is going to change for you to make it possible to stop?
I asked. I dont knowmaybe Ill just get
better at dealing with stress. How do you think you
can do that? I wondered. Other people manage it
without hurting themselves. I assume I can too, she
replied. Youre absolutely right. I said. But
I suspect you might need some help figuring out how to tolerate
some really uncomfortable feelings. Are you interested?
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HELPING YOUR TEEN
Yes, she said. I dont want this thing to
get in the way of going to school and doing what I want to do.
Great, I replied. Its going to be hard
work to change this kind of behavior, but together I know we can
do it.
Getting Everyone on Board
Tiffanys story describes the first step in the process of
assessing which behaviors are going to be targeted in therapy and
beginning to make a commitment. I like to have parents attend the
first session or two so I can meet them and give them a sense of
the person who is going to be meeting with their child. I want
everyone involved to get an idea about how I think about
selfinjury and how we are going to work at resolving it. Not
every therapist or DBT therapist works this way, but I believe it
is critical to get you into the room at the start. The next steps
include determining what other behaviors need targeting and
getting the teen to Commit to coming
to individual and group treatment Fill out a diary card (more
about this shortly) Agree to coaching by phone between sessions
Learn and practice the DBT skills and whatever other new
behaviors are required to live more effectively
This all has to be hammered out before treatment can begin. Some
of you might be thinking that your kid just wouldnt agree
to these conditions, or at least not in a meaningful way. It has
been my personal experience and the experience of my colleagues,
however, that when managed skillfully, adolescents see the value
in changing their behavior and will make the commitment. Getting
a commitment to therapy, which includes a clear agreement about
what behaviors are going to be addressed, as well as specifically
what the adolescent will need to do in the therapy, is especially
important for kids who are emotionally vulnerable. They are at
high risk for dropping out of treatment or for going through the
motions without actually making any changes. The reason has to do
with the nature of therapy itself. In therapy the expectation is
that one speaks about ones problems, including emotionally
difficult ones. Emotionally vulnerable kids tend either to become
dysregulated by the discussion and avoid therapy (i.e., drop out)
or theyre going to speak only about the most bland and
often less relevant issues in their lives
making the most of DBT
107
as a way to avoid becoming emotionally overwhelmed. Getting a
real commitment about what work the DBT therapy is going to
entail helps prepare the child for whats coming down the
pike. The therapists commitWhen the proper initial work isnt
ment to help teens with their done to get an understanding and
emotionally dysregulated behavior a commitment from adolescents,
through skills training and coachthey embark on the voyage with
the ing provides them with the intherapist without a shared map.
valuable feeling that they will not be alone on this journey. All
too often when this work is not initially done, the therapist and
the child embark on a therapeutic voyage without a shared map.
One great way to be sure theyre sharing a map is for the
adolescent to use a special daily log called a diary card.
Diary Cards
Can I see your diary card? What is on your agenda for
today? I asked Shannon. Lets see, I have it in
my bag somewhere. Oh, here it is, Shannon said as she
rummaged through her backpack. I need to tell you about the
fight I had with my boyfriend, Alex. He was just a jerk. I dont
know why I even hang out with him. You will never believe what he
did, she added as she handed me the diary card. Okay,
so we need to talk about the fight with Alex. Hold on a minute
you cut yourself on Thursday, so we absolutely need to have that
on the agenda for today. I dont remember my pager going off
on Thursday, I said in a casual way. So we are also
going to have to talk about why you didnt page me, I
added. The simplest kind of diary card is a grid that has the
identified target behaviors along the top of the card and the
days of the week going down its lefthand side (see pages 108109).
Each box in the grid is cut in half along the diagonal, and the
bottom half has a Y or an N in it representing either Yes or No
in response to whether the teen engaged in that specific target.
In the top half of the grid shes asked to rate the highest
urge to engage in the behavior on that particular day. The back
of the diary card lists all the DBT skills, and she is asked to
circle which ones she practiced on each day. Some DBT therapists
use a more complicated diary card that monitors more emotions and
behaviors (see pages 110111).
DIARY CARD
Target Behaviors 12345 Yes No 12345 Yes No 12345 Yes No 12345
12345 Yes No 12345 Yes No 12345 Yes No 12345 Yes No 12345 Yes No
12345 Yes No 12345 Yes No Yes No 12345 Yes No 12345 Yes No 12345
Yes No 12345 Yes No 12345 Yes No 12345 Yes No 12345 Yes No 12345
Yes No Yes No Yes No Yes No 12345 12345 12345 Yes No Yes No Yes
No 12345 12345 12345 12345 Yes No 12345 Yes No 12345 Yes No 12345
Yes No 12345 Yes No 12345 Yes No Yes No Yes No Yes No Yes No
12345 12345 12345 12345 12345 Yes No 12345 Yes No 12345 Yes No
12345 Yes No 12345 Yes No 12345 Yes No 12345 Yes No
(cont.)
Monday
Tuesday
Wednesday
108
Thursday
Friday
Saturday
Sunday
Rate urges or feelings on a scale of 15. Circle Yes or No
to indicated presence of behavior.
DIARY CARD (cont.)
M Wise Mind: Access wisdom. Know truth. Be centered and calm.
Integrate Emotional Mind and Reasonable Mind. Meditate. Observe:
Just notice the experience. Teflon Mind. Control your
attention. Smell the roses. Experience what is happening.
Describe: Put experiences into words. Describe what is happening.
Put words on the experience, say them in your mind. Participate:
Enter into the experience. Act intuitively from wise mind.
Practice changing the harmful and accepting yourself.
Nonjudgmental Stance: See but dont evaluate. Unglue your
opinions. Accept each moment. One-Mindfully: Be in the moment. Do
one thing at a time. Let go of distractions. Concentrate your
mind on the task at hand. Effectiveness: Focus on what works.
Learn the rules. Play by the rules. Act skillfully. Let go of
vengeances and useless anger. Objective Effectiveness: DEAR MAN.
Describe. Express. Assert. Reinforce. Mindful. Appear confident.
Negotiate. Relationship Effectiveness: GIVE. Gentle. Interested.
Validation. Easy manner. Self-Respect Effectiveness: FAST. Fair.
No Apologies. Stick to values. Be Truthful. Reduce Vulnerability:
PLEASE. Treat PhysicaL illness. Balance Eating. Avoid drugs.
Balance Sleep. Exercise daily. Build Mastery: Try to do one (hard
or challenging) thing a day to make yourself feel competent and
in control. Build Positive Experiences: Do pleasant things. Be
mindful of positive experiences. Be unmindful of worries.
Opposite to Emotion Action: Change emotions by acting opposite to
current emotion. Approach rather than avoid. Distract: Wise Mind
ACCEPTS. Activities. Contributing. Comparisons. Emotions. Pushing
away. Thoughts. Senses. Self-Soothe: With the five senses.
Sights, sounds, smells, tastes, and touch. Be mindful of soothing
sensations. IMPROVE the Moment: Imagery. Meaning. Prayer.
Relaxation. One thing in the moment. Vacation. Encouragement.
Pros and Cons: Think about the +/ aspects of tolerating
distress. Think of the +/ of not tolerating distress.
Radical Acceptance: Choose to recognize and accept reality.
Acceptance does not have to mean approval. Commit to Acceptance =
Turning the Mind.
T
W
Th
F
S
S
109
110
HELPING YOUR TEEN
From Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007).
Dialectical behavior therapy with suicidal adolescents. Copyright
2007 by The Guilford Press. Reprinted by permission.
making the most of DBT
111
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HELPING YOUR TEEN
The Therapist as Juggler
Setting the stage for therapy with an adolescent is like being a
juggler who has to keep his eyes on three crystal ballsone
slipup and youve got glass shards at your feet. The first
ball is the relationship ball. I want to make sure that the child
and I are going to be a good enough match. I know that our
relationship is going to be tested from time to time, and I want
to have some confidence that were going to like and have
sufficient respect for each other when the going gets tough. The
second ball has to do with the goal of therapy: What does the
teen want to change, and what is his or her current level of
commitment to the process? Am I going to have to do a fair amount
of commitment work or is this patient ready to make some changes?
As a DBT therapist I am actively trying to stretch these teens to
get them to commit to stopping self-injury and Im willing
to settle for the best they can do in the moment. So while I
would like to get them to commit taking self-injury off the table
for good, I will settle for less and keep working over time to
firm up the commitment. Finally, the third ball has to do with
the external context in which the child lives. For example, are
the parents supportive of therapy? Is the child in a school
setting that is going to tolerate some behavioral ups and downs?
In the beginning of therapy, especially DBT, all these factors
are discussed with an eye on how they may play out in the future.
MAT T HEW: UNDER S TAN DI N G H O W T HE PROBLEM DEVELO PED As Ive
mentioned before, children who engage in self-harming behaviors
generally see themselves as weak and/or defective. They believe
that if they were stronger or had more willpower, they wouldnt
be so overwhelmed by their emotions. I have also met some
children who dont think theres anything wrong with
self-harming since it helps them feel better and doesnt
hurt anyone else. This rationale usually develops because the
child has given up any hope of stopping the behavior. As weve
discussed, the legacy of your teens inability to
effectively manage his or her emotional life includes poor
self-esteem, depressed mood, a flimsy sense of identity, and a
tendency toward impulsive behavior. Trying to reason a kid out of
the position that he cuts because he has a character flaw is
about as productive as shoveling sand to keep the tide from
coming in. The solution instead is to offer a different
explanation for the behavior,
making the most of DBT
113
one that resonates with his experience. In DBT that alternative
is the biosocial theory. I like to explain this theory to the
teen and the parent in the same session in order to get everybody
engaged in the work, as I did with Matthew. I have really
tried to stop, but nobody believes me. My parents tell me that if
I truly wanted to, I would just stop. I know my father thinks I
am a weakling for doing it, Matthew bemoaned. Maybe
hes right. I obviously havent tried hard enough
because Im still doing it. So, like your dad,
you sometimes think that the problem is a lack of willpower or
self-discipline, I replied. Not only is that theory
probably untrue, but it guarantees that you will continue feeling
lousy about yourself. From what youve told me about how
hard you work in school and manage all those extracurricular
activities, you dont strike me as someone who is short on
willpower or discipline, I added. I think there may
be a more accurate explanation. Are you interested in hearing
about it? Okay, he replied half-heartedly.
Great, but first I have to ask you three questions. When
you think about yourself compared to other people you know, do
you think you are more sensitive? I asked. Absolutely!
was his immediate reply. Okay. As you think about yourself,
do you notice that your emotional reaction time is really quick?
That is, youre not someone who has to ponder your feelingsyour
response is almost immediate. Yeah, I think thats
true for me. Although sometimes I dont know what I feel, Im
just overwhelmed by emotions. All right. Do you think
it takes you longer to calm down than other people when you get
emotionally revved up? I asked. Most definitely. My
dad is always telling me to get over it already. But its
not so easy for me, Matthew said. I think your dad
may have a hard time understanding that you experience your
emotions very differently than he does. So here is my best guess
about you. I think youre someone we would call an
emotionally reactive person. That means youre hard-wired to
feel things in a more powerful way than the average person. In
and of itself this is not a psychological problem. The world is
full of sensitive people. They are often artists or writers or
even shrinks. We need sensitive people. It only becomes a problem
when we havent developed the skills to manage our
high-powered emotional systems. When we dont have those
skills we are emotionally vulnerable. From what you have told me
about your dad, he seems to be the kind of person who oper-
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HELPING YOUR TEEN
ates more on the logical and rational side of things, while youre
more about the emotional side of life. Do I have that right?
I wondered. For sure. My dad is a computer scientist and I
want to be a poet. Sometimes I think we just dont speak the
same language, he replied. I wouldnt be
surprised if your father had a hard time accepting your way of
experiencing your feelings. He may have tried to talk you out of
what you were feeling or suggested that you were overreacting. At
any rate, he probably had a hard time validating your emotional
experience. I dont know how your mom fits into this picture
because we havent spoken about her much, but it would be
useful to also think about her response to you. I bet you and
your parents were doing the best you could, but for a variety of
reasons just missed some things in helping you learn how to
manage that powerful emotional system of yours. As you can
see, the biosocial theory offers adolescents an alternative
explanation for their troubles that resonates with their personal
experience it makes sense according to their view of
themselves. Its also a first step in undercutting their
deeply held and painful notion The biosocial theory is a powerful
way that theyre weak or defecto help adolescents (1) view
their selftive. Furthermore, the theory harming behavior in a new
light, (2) let leads directly into the prigo of the deeply held
and painful notion mary goal of the treatment: that they are weak
or defective, and to help them build a useful (3) build a useful
skill base from which skill base from which to manto manage their
emotions effectively. age their emotions effectively. Davids
story illustrates the third goal in the early phase of therapy:
figuring out whether patient and therapist are a good match and
stressing the importance of open communication. DAV ID: IT S
A MATC H The week before, my conversation with 17-year-old David
had focused on getting him to begin to understand the function of
his cutting and to assess his long- and short-term goals, and
reviewing the biosocial theory. At the end of the session I
suggested that he take some time to think about whether what we
had spoken about made sense and whether he was willing to make
the commitment to tackle the problem. In our second meeting I
began to outline what would be required of him and what would be
required of me. With this solid foundation, the therapy to follow
would have a much greater chance of
making the most of DBT
115
succeeding. My job was to balance the seriousness of this process
with a light touch. Welcome back! Have you thought about
what we talked about last week? I asked David. Yeah,
a little bit. I dont know. It seems like a lot of work, and
Ive been in therapy a whole bunch of times and, no offense,
but I think it is mostly B.S. Just talking about my problems
doesnt seem to help me, David replied. Well, Im
not surprised by that. Just talking about your problems doesnt
usually help someone like you. In fact, some kids tell me it
makes them even worse. As I mentioned last week, were going
to have to get you to do some things differently. So lets
talk about your problems and Ill help you learn new skills
to manage your life more effectively. You and I will agree on the
behaviors you want to changecalled target behaviorsand
well work specifically on those. How does that sound?
I answered. Well, I really have to get myself together, and
soon. I want to go off to school next year, and my parents arent
going to let me go unless I stop cutting. And you know, I dont
think cutting is helping me, except in the short run. So I guess
Ive got nothing to lose. Okay. From what you
can tell so far, do you think you and I are a good match to work
together? I asked. The reason I ask is that we have
to really be able to collaborate, and if Im doing things
that are annoying you, you have to be able to let me know; and if
youre doing something that is interfering with the therapy,
I have to be honest with you about it. DBT requires both
the therapist and the patient to sign off on some clearly
articulated agreements. We know the treatment is most likely
going to have some rocky moments, and we want to do all we can to
guard against kids dropping out. We cant help patients if
they dont show up, or if all they do is show up and not
participate in a meaningful way. I think we can work
together. So far I have felt pretty comfortable with you,
David said. Terrific! I know Im giving you a lot of
information about the therapy, but its important for you to
truly understand what youre getting into. This is going to
be hard work, and I understand you have a kind of deadline to get
this done in time for school next year, I replied. Absolutely!
I cant wait to get done with high school and get off to
college. I need to get on with my life! David replied
enthusiastically. All right, then. Im going to tell
you what you can expect from me and then what I expect from you,
okay? I am going to do my job to the best of my ability. I am
going to meet with you regularly and do everything in my power to
help you meet your goals. Im good at what I do, but I
sometimes need help.
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HELPING YOUR TEEN
You should know that Im part of a team of therapists who
meet weekly to talk about our patients. If I think Im
losing my way, or if you think that Im not being helpful,
then I will get consultation from my team. Have I explained this
clearly? Good. Now Im going to explain what I expect of
you. First, you need to attend both individual therapy and
skills group for 6 months. That seems to be the right amount of
time to get what we need to get done. Second, I expect that you
will learn and practice the DBT skills. This is key. Learning the
skills is important, but practicing them in real life is
essential. Just learning the skills is like learning to play the
piano in music theory class without putting your fingers on the
keys. In agreeing to be in therapy with me, you are committing to
work on stopping your self-injurious behavior. I also expect that
you will fill out your diary card on a daily basis and bring it
with you to our sessions. Finally, if youre feeling bad and
have tried some skills, but youre still thinking of hurting
yourself, you have to page me. Page you? David
asked. You mean anytime, 24/7? Yes, anytime,
day or night, I responded. What do you think would
get in the way of your doing it? I inquired. I dont
know. I wouldnt want to bother you with my problems in the
middle of the night. And anyway, I just have to learn how to
deal. You are absolutely going to have to get better
at dealing with your problems, David. I couldnt agree more.
Thats why you need my help with skills coaching when youre
in the midst of a crisis. Think about it this way: Im like
the orchestra conductor and youre my orLearning the DBT
skills is important, chestra. The conductor and the and
practicing them in real life is orchestra meet regularly for even
more important. Just learning rehearsalsthats our
therapy. the skills is like learning to play the The actual
concert is real life, piano in music theory class without what
happens outside this ofputting your fingers on the keys. fice.
Now, can you imagine a conductor only being available for
practice and not for the performance? I explained. Im
not crazy about being awakened in the middle of the night, but I
much prefer that to being useless as your therapist. Okay.
When you explain it that way, I see your point, David
replied. The telephone skills-coaching sessions are sometimes
hard for kids to understand at first, but they can offer exactly
the right help when the urge to harm overcomes them after theyve
tried the skills Ive been teaching them. Stephanies
story is a good illustration.
making the most of DBT
ST EPHANIE: A T ELEPHONE SKILL S - C OAC H I N G S ES S I O N
117
My pager goes off just after midnight on Saturday. Its
Stephanie, a 16-yearold girl who has been in DBT treatment with
me for about 3 months. I feel terrible, she tells me
through tears. I really want to cut. I know it will make me
feel better. I just cant stand it anymore. I hate my
boyfriend! He is just a real S.O.B. You cant believe what
he did to me. You sound really upset. I know that
boyfriend of yours can be really insensitive. Tell me, before you
paged me, what skills did you try to help you regain your
balance? I asked. I tried some interpersonal
effective skills with him, but he just blew me off. I even wrote
out what I wanted to say, and he just didnt give a damn. I
just want to hurt myself. I hate him so much. She sobbed
into the phone. I dont know what to do. Well,
you did the right thing by paging me before you cut. Good for
you! It seems to me that right now whats most important is
getting you safely through this crisis. Which of the crisis
survival skills has been helpful in the past? I asked.
I dont know! Im so angry. I dont care
what happens to me. Hes the one who Stephanie,
I interrupted, you called me for help. I can give it to
you, but it doesnt involve talking about your boyfriend
right now. Weve talked in session about the self-soothing
skills that work best for you. Which ones might be good to try
right now? Ummm, I guess I could put on my headphones
and listen to my music, especially the upbeat stuff,
Stephanie replied. Okay. What might you try after that?
I could take a shower and put on my flannel pjs. Im
going to turn off my phone because Im not going to talk to
my boyfriend anymore tonight or Id cut for sure, she
said, clearly starting to calm down. Great! Youre
starting to think of ways to help yourself get through these
difficult feelings without making it worse. Terrific job! I would
love to get a voice mail at my office letting me know how the
night worked out for you. Yeah, I can do that.
Thanks, Doc. I will leave you a message, she said. One of
the most effective aspects of DBT is the between-session skills
coaching. Stephanie and countless other patients would have
harmed themselves without it. Later that night she left a voice
mail for me saying how shed listened to some music and
taken a shower before settling down to
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sleepwith her phone turned off. In DBT adolescents are
required to access their individual therapists, day or night, if
they are about to engage in what theyve identified as
target behaviors. First, the teens should try their new skills to
manage the crisis. If that doesnt work, they should page
the therapist. In the very beginning of treatment, before theyve
been exposed to the DBT skills, paging before trying a skill is
reasonable. After a short while, however, its important for
them to try their skills before paging. Paging is not
psychotherapy over the phone; it is limited to a quick assessment
of the situation (including a suicide assessment, if warranted)
and then skills coaching. Whats your role in all this? The
answer will be hard to hear: little or none. Once youre
aware that your child is struggling, you naturally want to
encourage him to call the therapist. Your anxiety level is high,
and in all likelihood your child is becoming emotionally
dysregulated. The scene is set for a discussion that is going to
be emotionally charged and quickly go off track. My advice is to
gently remind the child that the therapist is available to him.
At the next meeting, the issue is probably going to come up. If
the child did not page, he and the therapist will figure out why
not and what they can do next time to make sure he pages when hes
in crisis. Theres more: The therapist cant let you in
on everything that goes on in the weekly sessions and the
between-sessions coaching.
MY POLICY ON CONFIDENTIALITY
The following occurred in the second meeting I had with Manny and
his mother, Isabella. Now that Manny and I have agreed to
work together and we have some clear ideas about what needs to
change, I thought we should discuss issues around
confidentiality, I said. Its important that we
all understand what and how information is going to be shared.
I dont want to know every detail of what you talk
about in therapy, but if he hurts himself I would like to know,
Mannys mom replied. It makes sense that you would
want to know, and my worry is that my telling you is likely to
make it more difficult for Manny to honestly tell me what is
going on. Heres what I propose: if I dont think were
making progress on this issue, then we will all meet to see what
we can figure out. How does that sound? I asked. All
right, but I do worry that hes going to really hurt himself
badly, Isabella said. If I think that Manny is at
risk for seriously hurting himself, then I will
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119
not hesitate to call you and to take whatever measures are
necessary to prevent him from doing that, I said. Are
you clear about that, Manny? Yeah, but Im not
going to do anything stupid, he said. Great! Now I
want your mom to know that she can call me and give me
information anytime she wants. Heres the deal, however:
whenever she calls I will always let you know what she told me.
So, Isabella, I suggest that if youre going to call, you
let Manny know. And that you understand that I will be speaking
with Manny about your concerns, I said. Okay. I like
the idea that I can call you if Im worried, she
replied. Yes, you can. Of course our goal would be for you
and Manny to have that conversation, I said. I routinely
bring up the issue of confidentiality in the first or second
session. This discussion needs to include the teen, the parents,
and any other mental health professionals in the childs
life. I make sure I am clear with everyone involved about what
they can expect me to share and what I am going to keep
confidential. Breaking confidentiality is more complex than just
deciding its warranted if suicide or harm to others seem
possible. It also has to do with the patients age and stage
of development. For example, a 13-yearold found drinking alcohol
is a different story than an 18-year-old doing the same thing. A
certain amount of privacy is crucial in order for the treatment
to proceed effectively. There is a fine line, however, between
age-appropriate privacy and secrecy that undercuts the therapy.
For example, its a problem for a therapist to know that a
kid is smoking marijuana on a daily basis and to keep that from
you for the long termits bound to undercut your
confidence in the therapist and potentially minimize the damaging
aspect of the behavior on your child. Generally, I do not break
confidentiality if my patient engages in selfharm. I certainly
can empathize with parents wish to know. But in my
experience, divulging such behavior is all too often
counterproductive: it can make the adolescent clam up about it in
the therapy.
Therapists may vary in their rules about keeping your childs
harmful behavior from you, but in general: 1. They will let you
know if a suicide attempt appears to be a real threat. 2. They
will not let you know if an act of self-injury is revealed to
them. 3. They will let you know if therapy is not progressing.
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YOUR THERAPIST S POLICY ON CONFIDENTIALITY
Ask the therapist directly and get a clear understanding about
what information he or she will share with you and when. Trying
to determine the balance between how much information you need to
have and how much privacy your child needs to make effective use
of the therapy is extremely difficult for the therapist. One
hard-and-fast rule is that if the therapist thinks the child is
in danger of suicide, then he or she must break confidentiality.
But most deliberate self-harm is not about suicide, and breaking
confidentiality when the patient engages in the behavior may
seriously compromise the therapy. On the other hand, keeping
parents in the dark about the behavior for too long risks
undermining their confidence in the treatment. The good news here
is that this is a resolvable dilemma. One of the biggest
challenges for the therapist, especially in the beginning of a
therapy, is to determine whether the kids wish for
confidentiality is in the service of keeping a secret or whether
it is an expression of the need for a private space to understand
and examine his or her behavior. Most adolescents experience some
degree of shame around self-injury that pushes them in the
direction of hiding it. Furthermore, adolescents worry about how
their parents will respond to deliberate self-harm and whether
their friends will truly understand. In addition, there may be
strong consequences for the child if his or her behavior comes to
the attention of school administrators, including being required
to take a medical leave until the situation is remedied. If the
adolescent is committed to ending self-injury and is actively
engaged in treatment, then from my point of view he is entitled
to a degree of privacy. If, however, he has made only a
half-hearted commitment to the therapy and is frequently not
following through on treatment requirements, then I think it is
time to reexamine the therapy, including issues of
confidentiality. So you need to understand that its not
wise to share with you everything that happens in your childs
therapy. This brings up the topic of the match between you and
the therapist and how you can be of the most help to your child.
THERAPISTS AND PARENTS
Most therapists and parents find ways to work together.
Occasionally, however, the contact between parents and therapist
is problematic, even though
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121
the parents and the therapist feel that this is the right match.
These problems do not have to stand in the way of effective
therapy if you keep the following ideas in mind. First, each
party might be coming to the table with a fair amount of
emotional freight. The very idea that they have a child in need
of treatment makes some parents feel that theyve failed in
some way. The guilt and shame around this misguided idea can be a
fertile ground for defensive and aloof behavior. As for the
therapist, he or she may feel inadequate when parents raise
concerns for which there are no clear answers. We just dont
know enough to respond definitively to questions about the
outcome of the treatment. Furthermore, individuals vary a lot in
their response to treatment. Some therapists can be defensive. We
can sometimes be distracted by the intensity of your fear and
anxiety, forgetting that this is a perfectly understandable
response to a childs dysfunction. Instead of allaying your
fears with clear answers, we often have to ask you to be patient.
Therapy is not an exact science. Therapists are only human, and
we can be influenced by how we are treated. What makes me as a
therapist eager to respond to parents questions has a lot
to do with their attitude. I tend to respond more positively to
parents who appear genuinely curious about the process of therapy
and who, even if they feel it, do not openly express skepticism.
Parents who are actively interested in collaboration are always
going to get my best. Heres an example of an ineffective
comment from a parent: So what makes you think you can be
helpful to our daughter? And an effective one: Help
me understand how youre going to be helpful to our
daughter. Both comments occur after an explanation of how
therapy works, but the first is adversarial. The second is more
of an invitation. Think of yourself as being on the same team
with the therapist, a coaching team that is going to help your
child learn and practice being in the world in a different way.
All the elements Im discussing in this chapter form a piece
of the puzzle that, when completed, will yield some workable
solutions to your childs troubles. One step leads to
another in a chain, which we refer to as a chain analysis.
As I continued to talk with Shannon, a chain analysis of her
target behavior began to emerge. In other words, together we
began to see what triggered her to cut and what specific tools
would give her the capacity to stop.
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SHANNON: IM RE ADY T O T RY S O M ET H I N G EL S E
Lets see, Shannon, on Thursday you cut yourself. When
did that happen? I asked. I dont know, sometime
late Thursday night, I guess. Yeah, it must have been, because I
was in my pajamas washing up for bed, she told me. Do
you remember when the idea first came into your head to cut?
I wondered. No. I dont really think I ever thought
about it. It just happened. I cant believe what my
boyfriend did. First, he calls me and tells me that
You know, I really am interested in what happened between
you and your boyfriend, but first we have to figure out the
cutting, I interrupted. What did you do after you
hung up the phone? I asked. I went into my room and
got into my pajamas to get ready for bed. Then I went into the
bathroom to wash up. I was still feeling really mad and hurt. You
know, I saw my razor and without really thinking I just started
to cut, Shannon said. I just needed to get some
relief. When you were getting into your Pjs,
were you thinking about hurting yourself? I inquired.
Well, now that you mention it, I was just crazy on the
inside and just hating my boyfriend and I thought maybe if I cut
myself, like I used to, I would feel better. I kind of didnt
care about anything. I just wanted some peace, she
reported. So you first had the thought while you were
getting into your pajamas, and it sounds like you were in the
kind of mood that you needed just to get some short-term relief
from that crazy feeling, I suggested. Thats
right, and there was the razor and I just did it, she told
me. Okay. Then it seems when you get into that mood, we
need to help you find some solutions other than self-injury. We
need to find a way to slow you down and help you change your mood
so you can think more clearly. I have some ideas about some
skills that might be really useful in those moments. What do you
think? I asked. Im ready to try something else.
To be honest with you, cutting really only made me feel crappier
about myself, she said. After several chain analyses the
patient and I develop a behavioral analysisa relatively
comprehensive understanding of the patterns and events that lead
to a target behavior. Throughout the various chain analyses the
child and I are generating possible solutions that would have
avoided the necessity
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of engaging in a target behavior. In the solution analysis we
look at all the places in the chain of events where the patient
could have made more effective behavioral choices, and
specifically what those more effective behaviors might have been.
Following that analysis we decide which new skillful behaviors
need to be learned and practiced.
FOCUSING ON TARGET BEHAVIORS
You might be asking yourself, How do you know which target
behaviors to address in a chain analysis? In DBT there is a
hierarchy of target behaviors that guide the therapist. The
number one priority is any suicidal or self-harming behaviors. If
the adolescent has contemplated suicide, made an attempt, or
engaged in deliberate self-harm, or if their urges were high,
then a chain analysis of the behavior is a must in the session.
Notice in the story with Shannon how she wanted to speak about
the fight with her boyfriend, but I was not willing to have that
discussion until we had a better understanding of the selfinjury.
If Shannon had been so emotionally distraught that she had too
difficult a time turning her attention to the issue of self-harm,
I would have spent more time listening and validating her
feelings as a way to get back to looking at the higher target
behavior.
BEHAVIOR THAT INTERFERES WITH THERAPY OR QUALITY OF LIFE
The second highest priority is any behavior that interferes with
the therapy, such as not filling in the diary card, showing up
late for therapy, or refusing to speak about a relevant topic.
Therapy-interfering behaviors are not limited to the patient. As
a DBT therapist I am always on the alert for anything that I
might be doing that is getting in the way of the treatment moving
forward. I also have an agreement with patients that if they
think I am engaging in therapy-interfering behaviors, they have
to let me know, and they usually do. The third priority deals
with behaviors that interfere with quality of life. These are
things like skipping school, excessive use of drugs or alcohol,
and non-life-threatening eating disorders. When parents are
concerned about anything that fits into the category of
therapy-interfering behavior, I urge them to give me a call.
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SKILLS TRAINING IN ACTION: LEARNING TO SELF-SOOTHE
Okay, Shannon, now that we see the pattern about how that
awful mood state leads to self-injury, lets go to work on
helping you use skills to change your mood, I said. All
right, but when I get like that, I feel pretty stuck and
hopeless, she replied. I believe that is all too
true, and I know that with some work you will know how to get
yourself unstuck from that terrible mood, I replied. We
need to think about a chain of skills. Here is what I am
thinking, and I need you to tell me whether this makes sense to
you. First let me ask you this: Do you know pretty quickly when
youre falling into that black mood? I asked. Not
always. Sometimes I realize I am in that mood and that I have
been feeling this way for some time. All right, then.
Heres what I think. You and I figured out earlier that
interpersonal conflicta fight with the boyfriend, troubles
with parentsis likely to move you into that mood. What we
need to work on is helping you to use some mindfulness skills so
that you are able to observe and describe the situation and cue
yourself to prepare for the black mood. I know this sounds
simple, but at first its not going to be an easy thing to
do. It will take some practice. I think the next step is to move
right into some emotion regulation skills and the
distress-tolerance crisis survival skills. Do you know which of
those skills work for you? I wondered. Yes, believe
it or not, I like opposite action to emotion and some of the
self-soothing skills, she replied. You are the
greatest! Which self-soothe works for you? And what action would
you use when youre starting to get into that mood? I
asked. When Im in that mood, all I want to do is go
to bed and try and forget everything. So opposite action would be
doing something active, like going for a walk or even dancing in
my room. For self-soothe I have this really great book of
impressionist paintingsI could look at that, Shannon
told me. Shannon was making real progress here.
TROUBLESHOOTING
The next step is for Shannon and me to do some trouble shooting
about any barriers that would preclude her from using new skills.
For example, we might have to anticipate what she should do if
her boyfriend calls her, or her father
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asks her to set the table when she needs some space and is trying
to selfsoothe. We would also address what to do if something she
tries doesnt seem to be working. As you know, DBT is all
about learning the four skill modules. Skills are pushed in
during the group therapy and pulled out in the individual
therapy: the child learns the skills in the group setting and
then the therapist and the patient figure out what skills are
called for to help the child manage whatever issues are of
concern. DBT skills groups are more like educational seminars
than like traditional group psychotherapy. In multifamily skills
groups, both the child and the parents learn the skill sets. In
addition these groups undercut the participants sense of
isolation as they work at resolving their own and their familys
difficulties. The next section offers ideas on how you can help
your child during the therapy.
WHAT CAN YOU DO?: SUPPORTING THE THERAPY
You are already supporting the treatment with the sacrifices youre
making in terms of time and money, so give yourself some credit.
The following suggestions are a few other ways in which you can
be helpful. 1. Naturally you want to know whats being
worked on in your childs therapybut youre
reluctant to intrude. Its important for you to find a
balance between these two positions. The typical teenager is
usually able to express consternation when she feels a parent is
being intrusive, but has more difficulty addressing the problem
of not being noticed. Communicate to your child that you have
confidence in the process and are interested in a general way
about what is being worked onbut that you dont expect
to hear all the details. Let her know that youre interested
in anything she feels comfortable sharing. 2. If your kid has
complaints about the therapy or the therapist, listen, validate,
and help her bring the concerns in to the therapist. 3. When you
feel the need to contact the therapist yourself, always let your
child know. This helps ward off discussions about intrusiveness
and parental control that may miss the point. 4. Let your kid
know that you understand change can be hard. Praise her when you
see progress. 5. Familiarize yourself with the four skill modules
discussed in
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Chapter 4 so youll be better able to help your child use
them. Do not however, offer this help until youre clear
that the child wants it. I will have more to say about the ways
you can be helpful to your child in Chapter 6.
ASSESSING YOUR CHILDS PROGRESS
Its important for you to be able to assess your childs
progress in therapy. Unfortunately, you probably wont
always know when your child is engaging in self-injury, so your
assessment will have to be made on indirect factors: 1. Set up
periodic reviews of the therapy with the therapist. 2. Discreetly
chart the incidence of behaviors that indicate whether the child
is making progress or not. (E.g., if your child has had a history
of emotional outbursts, you could chart how often these occur and
see if over 3 or 4 months the trend is in the downward direction.
If it is, then you can assume that your child is making progress
toward modulating his emotionsa good sign that self-injury
may also be on the decline.) 3. Look for signs of other kinds of
skillful behavior. Is your kid asking for things in a more
effective way? Does she seem better able to accept
disappointments? Is she more interested in sharing her
experiences with you? Does she seem less mood-dependent? The best
way to make the assessment about progress is to look at several
of these elements over time. The idea is to collect information
on several be-
TREATMENT REALITIES
1. Its critical that you find a therapist who is not only a
good fit for your kid but also someone you think you can work
with. 2. Therapy takes time. Plan on your child attending
treatment for at least a year. 3. Progress is often uneven. Be
thankful for the successes and dont panic if things
temporarily slip backward. 4. Therapy is likely to cost you in
time and money. 5. These kids often have a high therapy dropout
rateit may take several tries to get the right fit.
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haviors because that will give you a better picture of what
progress is being made. Progress is going to be an up-and-down
process, so look for trends. It takes time. You should expect to
see some signs of progress within 4 or 5 months of an outpatient
DBT. Now lets turn to a discussion of what you can do to
help your child with emotion regulation.
6
resetting the stage
HOW TO HELP YOUR TEEN RESTORE EMOTION TO ITS PROPER PLACE
Jennys mom met her husband at the door. Jennys
been in the bathroom for
over half an hour. She went out with Mikela again, and when she
came home she had that look in her eye. I think shes in
there cutting herself again. Damn it! This always
happens when she goes out with that Mikela kid. Im going up
there and if I have to, Ill bust the door in! shouted
Jennys dad. She has to stop that crazy behavior right
now! As parents, we are hard-wired as well as socially
engineered to be of use to children. When our children accept our
help, it usually gives us a sense of competence and a degree of
happiness. Theres no doubt about it: successful children
help us feel we are great parents, and children who are having
trouble leave us wondering about our abilities. One of the ways
we feel competent and have a tangible sense that were doing
a good job is when our children do well in school or in music,
art, or sports. While we know that this was truly our kids
accomplishment, we also know that we had something to do with it,
even if it was just to be encouraging. Its not always the
case, but often we feel we were more successful when our children
were younger. When adolescence arrives, its harder to know
how to be helpful; if your child has emotional troubles, the
situation becomes even murkier. Parenting strategies that were
helpful in the past, such as reassurance or direct problem
solving, often now lead to an angry or tearful rejection. The
difference between a fictional patient named Mary at age 7 and 14
makes my point. Little Mary, age 7, comes home from school with a
frown on her face, tears welling in her eyes, and lips quivering.
Mary, you say. Whats the matter?
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restoring emotion to its proper place
129
My friend Jamie doesnt want to be my friend anymore
because I wouldnt share my cupcake with her, Mary
tells you as her tears cascade down her cheeks. Oh, not to
worry. You and Jamie have been friends for so long, Im sure
youll make up [reassurance]. I have an idea: Why dont
we make some more cupcakes and bring some over to Jamie this
afternoon? you suggest [problem solving]. Mary begins to
smile. You are the best mommy in the world! she tells
you. Big Mary, age 14, comes home from school with a frown on her
face, tears welling in her eyes, and lips quivering. Mary,
you say. Whats the matter? Nothing!
she shoots back at you with anger. Hey, Im just
trying to help, and I know somethings wrong, you
reply as your emotional temperature begins to climb. The
problem is that Jamie is a bitch, okay? Now leave me alone,
she shouts back at you. Mary, you and Jamie have been such
good friends, Im sure youll be able to patch things
up [reassurance], you reply gingerly. Im sure
if you and she talk about it, you can work it out [problem
solving]. Screw Jamie! Youre an idiot! Mary
screams as she races to her room. Similar problem, same strategybut
very different results at different ages. When faced with
emotional turmoil, parents, like the rest of humankind, usually
fall back on a set of behavioral skills that worked for them in
the past. It takes some time, a different perspective, and
practice to develop a new set of parenting skills. And skill
acquisition occurs best in relatively calm situations, not in
moments of crisis and high emotional distress. So its not
surprising that you often cant figure out what to do when
faced with your emotionally dysregulated kid. Try as you might,
youre likely to repeat formerly successful behavioral
strategies that just dont work anymore.
WHAT TO DO AND WHY
Having a child who engages in deliberate self-harm is especially
challenging. Youre keenly aware that your child is
struggling emotionally and you can see that her behavior attacks
her own body, a body that you have been trying to safeguard since
she was an infant. Like Marys mother, you often find
yourself frustrated, annoyed, and plagued by helpless rage. Or
else you become ineffectual by pushing too hard to be helpful.
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Sometimes as parents the best you can shoot for is not to make
the situation worse and hope that youll find a way to do
better the next time around. When you are parenting a child who
is emotionally vulnerable and involved with self-harming
behavior, the standard set of parenting skills needs to be
refined and new ones learned. For example, validation takes on an
importance with these children that goes beyond what other kids
need. The good news here is that you can learn some new skills
that will optimize the chances that you will be helpful to your
child. The skills discussed in this chapter are going to overlap
with the skill sets that I am going to teach you about in the
next chapters. So my advice is to read Chapters 7 and 8 before
you start implementing some of the skills and youll be
surprised at how your childs reaction to you will change.
In addition to teaching you some new skills, or at the very least
helping you refine the skills you already have, I will outline
some things that parents have found useful in helping their
children through these rough waters: how to balance giving your
kid reasonable emotional space with low-keyed
vigilance, for example, or when to actively intervene in your
childs life versus when to let natural
consequences play out. Finally, for the sake of covering
the waterfront, Ill review a few things that people
often try that I just dont think are effective. One
important thing to keep in mind as you work on acquiring new
parenting skills is that learning new behavior is like turning
around an ocean linerit takes practice, patience, and
perseverance. Theres just no way it can be done quickly.
Psychologists refer to this process as shaping behaviorgetting
the desired behavior or skill down Learning new behavior is like
turning pat through successive approxiaround an ocean linerit
takes mations or trials. This means practice, patience, and
perseverance. deliberately acknowledging your childs
efforts and/or your own when your behavior may not be dead-on but
is going in the right direction. Praise yourself and your kid
when either of you improve. This will reinforce the behaviorthat
is, it will make it more likely that the new skillful behavior
will occur again. Heres an example of what I mean by
shaping. Big Mary, age 14, comes home from school with a frown on
her face, tears welling in her eyes, and lips quivering. Mary,
you say, Whats the matter? Nothing! Just
leave me alone, she shoots back at you. Okay, but
something has definitely gotten under your skin and is troubling
you, you reply, maintaining a degree of equanimity
[validation].
restoring emotion to its proper place
131
Jamie is a bitch! I hate her! Mary tells you as her
voice begins to rise. Whoa, she really annoyed you and hurt
your feelings, you reply [validation]. Yes! Now I
just want to be alone, Mary shouts as she heads upstairs to
her room. Im sure I could help, you say
[unsolicited problem solving]. Nobody can help. Just leave
me alone, Mary tells you from halfway up the stairs. Here
Marys mom does a more effective job of managing the
situation than she did in the first example, but she still falls
short of helping Mary through her distress. If Mom had told me
about these two incidents in consultation about 14-year-old Mary,
I would have pointed out a few things for her to consider. First,
in the second incident she was able to maintain a relatively calm
manner in the face of her childs emotional distress, thus
decreasing the likelihood that the situation would escalate.
Second, her use of validation seemed to help Mary continue the
conversation. Both of these new skillful behaviors demonstrate
that Marys mom is moving in the right direction. Third, she
probably goofed a bit by offering problem solving without asking
Mary if she wanted some help. Fourth, I would remind Mom that
sometimes no matter what you do you may not get the results you
want, but that her behavior the second time around was more on
target. She is shaping her behavior to be more helpful when her
daughter is in emotional distress. When youre learning new
skills, I encourage you to keep the three Ps in mind: practice,
patience, and perseverance. They hold the key to helping your
child.
Practice
Practice is just working at a new behavior or skill through
repetition. Here are a few suggestions. 1. Dont try to
learn a million skills at once. Pick out a few that seem
particularly relevant and really commit to learning them. 2. Keep
the concept of shaping in mindyou just want to keep getting
more proficient at the skill youre practicing. It takes
time, and some days will be better than others. 3. Remember to
acknowledge and reward your successes. Doing so will help
reinforce your new skillful behavior. 4. Finally, practice your
new skillful behaviors in relatively neutral and calm situations.
Youre not likely to pick up new skills when youre in
the
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midst of a crisis. While it may be true that throwing someone out
of a boat may force him to learn how to swim, I can almost
guarantee that he wont become an Olympic champ.
Patience
I can hear you now: You want me to be patient while my
child is selfinjuring? You cant be serious! Doctor, slip
into your pajamas because you must be dreaming. Well, you
do have a choice: you can either be impatient with your child and
yourself, suffer, and make the situation worse, or you can find a
way to be patient and, in all probability, more helpful. Being
patient is not synonymous with doing nothing. In fact, being
patient in stressful times takes enormous effort.
Self-validation, acceptance strategies, and distress tolerance
are the skill sets required to be actively patient. Ill
discuss these in detail in Chapter 8.
Perseverance
Sometimes I think perseverance is best captured by the old adage
that it doesnt matter how many times you get knocked down;
it only matters how many times you get up. You just need to get
up one more time than the number of times you have been knocked
down. It sounds simple To persevere you need to cultivate an but
its not. There are two main attitude of willingnessaccepting
ingredients in being able to perthe situation as it is and doing
what severe. The first is cultivating is requiredand you
need to be an attitude of willingness and mindful in setting
achievable goals. the second is being mindful to set achievable
goals.
Willingness
Willingness is about directing our energies to doing what our
present circumstances require. By contrast, willfulness is
spending energy on things like complaining that our situation is
unfair or that things just shouldnt be the way they are.
Dont confuse willingness as resignation or as some trick to
get you to like your current situation. Willingness is just part
of accepting the situation as it is and then turning your mind
toward doing what is required. For example, my family is
fortunate to have a swimming pool in our
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133
backyard. With the unpredictable summer weather in New England,
though, the water is often freezing. My wife and kids always used
to get a kick out of watching me get in the pool. I would
complain, go halfway down the steps, get in, then whine some more
about how cold the water was. They would all just jump in and
tell me to do the same, and I would tell them they were crazy. I
was the epitome of a willful person. I wanted to swim, but I
wanted the water to be warmer. Then about four summers ago, I
decided to try a more willing approach to getting in the pool.
That is, I accepted that no matter how much I hated cold water,
if I wanted to swim, the water I had to swim in would not be
warm. On those days when the pool was cold, I just accepted
things as they were and waded in without complaint or delay: I
became willing to do what was required to get in the pool. Im
sure my family misses the old days when they could tease me about
my inability to come to terms with an unpleasant reality, butwhile
I cant say I like cold waterI certainly enjoy the
pool much more than I used to.
Setting Achievable Goals
The second ingredient in perseverance has to do with setting
realistic goals. Nothing reinforces success like success, and
setting achievable goals is one way to help you stay the course.
Lets face it: its hard to keep going when we
experience defeat and failure at every turn. Think about taking
small steps toward your goals. For example, if youre
working on validation, decide in advance how many times per day
or per week youre going to deliberately practice it. This
is a small step and a realistic goal. The idea is to build on
your small steps and avoid overwhelming defeats. Practice,
patience, and perseverance are the mind-set you need to keep on
moving down the rocky path that will enable you to bring help to
your child. It dont come easy, as the song
says, so acknowledge your successes and learn from your missteps.
WHAT NOT TO DO AND WHY
Before launching into what you can do to be helpful to your
child, Id like to tell you about some things that I dont
think work. Some clinicians are still advocating some of these
strategies. If what Im telling you goes against the advice
youre currently being given, then Ive put you in a
tough spot. It could be that these techniques work in your
specific situation. If thats the case, I
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know youll have the good sense to ignore what I have to say
in this instance. If, on the other hand, youre doing some
of these things and not getting results, then by all means take
it up with the treatment team.
Removing the Tools Your Child Could Use to Self-Injure
It might seem to make sense to hide or rid your house of all the
sharp objects your child might use to self-injure. But I think its
a bad idea for at least three reasons. First, there are an
infinite number of things she could use, so its virtually
impossible to make the house safe and keep it that
way for any reasonable period of time. Second, it forces you into
the role of constantly policing the house and potentially into an
adversarial role with your child. I can see no real advantage in
becoming the sharps police. Finally, its far
more important for your child to learn how to accommodate to the
world as it iswith razors, scissors, knives, pop-tops, and
safety pins, to name just a few dangersthan for you to
create (even if you could) an artificially safe
environment. This is a strategy that more often than not lulls
parents into a false sense that theyre in control of their
childs selfinjurious behavior. I have heard of more than
one situation where wellintended parents have locked up all the
sharp objects and the child either found a way to get them or
brought new ones into the house. Dont get me wrongIm
not suggesting that you leave sharp objects like X-Acto knives or
box cutters lying around. Therapists working with kids who engage
in self-harming behavior also need to make sure their charges dont
have a stash of sharp objects in their rooms or backpacks. I
believe that a top priority in treatment is to help teens see the
wisdom in not holding on to objects they have used for self-harm
and to enlist their help in removing objects of temptation.
Please ask your childs therapist how he or she thinks about
this issue.
Body Checks
Parents, therapists, and school administrators sometimes request
that a kid known to have self-harmed be seen by a medical
professional on a regular basis to be examined for fresh
evidence. The goal is to know if the kid is still self-injuring,
as well as to use the knowledge of upcoming examinations as a
deterrent. I have never understood the reasoning behind this
strategy. For one thing, asking teenagers to undress and be
examined for cuts is going to bring shame and humiliation on
them. In the language of behavioral psychology, its much
closer to a punishment than to a reinforcement strategy (as
encouraging more skillful behavior would be).
restoring emotion to its proper place
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I have no doubt that for some kids the threat of a shameful body
check is enough to stop their self-injury. But once the body
checks stop, there is a high probability that these kids will go
right back to self-injuring. Furthermore, its not a
foolproof procedure, since a body check is usually done with the
kid in undergarments, making it possible to hide some injuries. I
cant imagine any therapeutic gain from a strategy that is
potentially humiliating, nor do I think forcing a child to be
more secretive about self-harm is working in the right direction.
So much for the strategies that I think dont work. Now lets
talk about the ones that do.
WHAT WORKS AND WHY Validation
Ive talked about validation before. Its probably the
single most important skill I can teach you. Validating your
childs emotional experience, whether or not you think he or
she should be having that experience, provides the bridge you
need to connect with your child in all kinds of stormy
situations. Kids who are emotionally vulnerable probably need
more validation than other kids do. They need to learn that their
emotional reactions make sense, even when their current
strategies for managing these reactions are ineffective.
Validation often sets the table for an effective
collaboration between you and your child. You will recall that
validating your childs experience or point of view is not
the same as approving or agreeing; it only acknowledges that you
have heard and understood what hes saying with words or
body language. Remembering to stay curious and open about how
your child is thinking and feeling, even when you believe you
have a quick or easy solution, is a challenge for most parents.
We want to help and we believe, sometimes correctly, that we have
the answers. Or were frightened for our child and we want
him to stop something dangerous, but teens must come to their own
wisdomfinding their own way is one of the primary tasks of
adolescence. Validation is kind of quirky. One of the things I
have learned is that when parents begin to practice validation,
it often sounds artificial and stiltedkind of phony. This
is to be expected. Think back to when you first started learning
a foreign language or trying to ride a bicycle. When youre
learning any new skill, your attempts are going to be anything
but smooth. Furthermore, what you say in an effort to be
validating is only validating if the person feels it is. If your
daughter is revved up after an embarrassing scene at school and
you try to validate her, your comments could be spot-on but she
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could still reject what you say because she just cant take
it in. When that happens (and I can almost guarantee it will),
dont give up! Just try to understand that the moment wasnt
right for your kid to feel validated. There are several different
ways to validate your childs experience, from what we call
attentive listening to those rare but lovely moments
when some action of yours is experienced simultaneously as
communicating your understanding of your childs predicament
and as comforting. Youve had these moments in the past, and
as you learn the new skills you need, youll find them
occurring more often. In this chapter Im going to
concentrate on three different types of validation that I have
found to be the easiest for parents to learn and that really
work. But before I get into the details of these validation
strategies, I want to bring up some pitfalls.
Dont Validate the Invalid
It is ineffective to validate what is patently not valid, as
Roberts mother tries to do. I cant believe how
stupid I am! I stayed up all night studying for my advance
placement history test and I still got a C. I am just the
dumbest kid in my school, Robert said as he choked back
tears. You may be the dumbest kid in your school, but your
father and I still love you, Roberts mother replied
in her most gentle voice. Here are some other ways that Roberts
mother could have responded, rather than validate Roberts
feeling that hes stupid: After all that hard work, it
is really disheartening to get a low grade, or I can
see how you might doubt your abilities when you get a grade like
that, or even I can understand how you might think
youre dumb when you get a C on a test for which you
had prepared.
Avoid Personal References
I cant believe Jane would treat me this way! I
thought we were best friends and then she goes and betrays me
like this. Im going to make her pay, Elizabeth said
through clenched teeth. I know exactly how you feel,
her mother replied. When I was your age, the same thing
happened to me with my best friend. Who cares? I dont
want to hear about it. Just leave me alone, Elizabeth
angrily replied. You may very well have had experiences that are
similar to what your child is facing, and you may very well have
managed them in ways that could
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137
be helpful to your child. The problem is that when you introduce
your own experience into the discussion, the scale tips toward
you and away from your kid. Validation is all about communicating
an understanding of the other persons experience. Your past
experiences can be useful, however, so heres one way you
can both validate your child and speak about your own
experiences. I cant believe Jane would treat me this
way! I thought we were best friends and then she goes and betrays
me like this. Im going to make her pay, Elizabeth
said through clenched teeth. Youre really mad! What
did Elizabeth do that got you so angry and hurt? Elizabeths
mom asked. I dont want to talk about it,
Elizabeth shot back. Okay. Are you just too mad right now?
Elizabeths mom inquired. Yeah. I dont know how
she could just disregard me like she did. I told her not to tell
anybody about being in the hospital, and then she goes and tells
Cheryl. Whats up with that? Elizabeth said. Thats
awful! No wonder youre mad, Mom replied. If at
some point you want to talk about it, I can tell you about what I
did when a good friend betrayed me. Sure, Mom, but
not right now, Elizabeth replied. In this case Elizabeths
mom does a fair amount of validating before offering help. The
validation is in the service of understanding and being
supportive of Elizabeth. Validation often seems to invite the
other person to talk more about the problem. Elizabeth tells her
mother more in spite of just having said that she doesnt
want to talk about the situation. Please notice that before
offering her daughter help, the mom asks whether Elizabeth wants
it. This is important! In general, but especially with
adolescents, unsolicited advice is experienced as intrusive and
unwelcome. Kids will often experience it as a sign that you dont
believe they can manage their own problems, so it feels like
being kicked when theyre down. When you ask your kid
whether she wants your advice, you are maximizing the probability
that she will listen to what you have to say. Dont waste
the wisdom you have earned over the years by offering it too
early! Like so many things in life, timing is everything.
The Problem with But
Saying but just doesnt work when youre
trying to be validating. Imagine youre sitting down with
your supervisor for your annual performance review. I just
want you to know how much we all appreciate your hard work, your
capacity to work independently, and your general good humor,
she tells
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you. You are liked by the people who report to you and
valued by management, but there are a few things we need to look
at. Did you notice that everything before the but went out
the window? Doesnt it seem like the really important stuff
is going to come after the but? Somehow the earlier information,
as important and accurate as it may be, is diminished just by the
word but. Take a look at some more examples: I know you
really loved him, but you will get over him. I can
see how sad you are, but you will feel happy again. It
makes sense that youre mad, but you cant carry on
that way. Both parts of these sentences can be true, and
these statements probably wouldnt be experienced as
validating. Thats rightthe magic word is and! If youre
going to offer reassurance or problem solving in the same
sentence and I suggest that you avoid that as much as
possibleplease use and as the connector rather than but.
Try substituting and for but in the examples above. Do you notice
how the word and seems to make both ideas in the sentence of
equal importance? Let the validation do its job before moving on
to the next step.
Three Ways to Validate
Attentive listening, active listening, and giving voice to the
unspoken are the three levels of validation that I want to teach
you. Each of these skills builds on the previous one. I have no
doubt that as you become more skillful with validation, you will
be more helpful to your child. I would encourage you to start
your validation practice at work or with friends. Get the hang of
it in nonstressful situations outside the family, and then move
to noncrisis situations within the family. If you practice
developing the skill this way, you will be ready to use it when
the emotional temperature is running high. Sometimes its
difficult to determine whether you are being validating, so heres
a clue. The easiest way to know is when the person tells you she
feels understood. If she doesnt tell you directly, then
notice whether shes telling you in more detail about the
situation, especially if shes giving you more information
about how she thinks or feels, rather than just details or facts.
Does the person seem more relaxed and open compared to the
beginning of the conversation? If so, then she probably felt
validated.
Attentive Listening
Attentive listening is about posture, eye contact, and focus.
With attentive listening, your entire attention is focused on the
other person. Its as if
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139
nothing else in the universe is of any consequencethe only
thing that matters is what the other person is saying. As youre
listening, youre working at seeing the situation from his
perspective. You need to pay attention to any judgments youre
making. For example, are you telling yourself that hes
wrong to feel the way he does, or that hes making too big a
deal about his hurt or angry feelings? Judgments tend to distract
us from truly being able to take another persons
perspective. Notice these judgments and then let them go. Easier
said than done, right? Especially when our emotionally vulnerable
children seem poised on the precipice of a crisis that we think
could be avoided if they could only gain some emotional
perspective. In these moments our judgments often lead to
comments that are invalidating. Here is an example of what I
mean. Monas mother has been using her attentive listening
skill for the last 10 minutes, but Mona is becoming increasingly
distressed. Mom knows from past experiences that when Mona gets
like this, shes liable to engage in self-harm. Judgments
about Mona making too big a fuss over the matter enter Moms
mind. I hate myself! I wish I could disappear! Mona
complained. Oh, Mona! Dont you think thats a
little over the top? After all, it wasnt that big a deal,
Mother interjected. I cant believe you just said
that. I thought you understood. I am done with this conversation!
Mona yelled as she fled to her bedroom. So how do we let go of
our judgments? The first step is to notice when judgments are
arising in your mind. The second step is to accept that these
judgments are likely to be counterproductive to your goal of
validation. Then imagine that they are like clouds in the sky and
let them pass. The key is not to let yourself get too attached to
the rightness of your judgments. In fact, there may
be a fair amount of truth in Moms opinion that
Monas problem wasnt so important that she should hate
herself, and for sure it wasnt worth dying over. Had Monas
mom been a bit better at managing her understandable worry and
avoided her judgments, the interchange may have gone this way.
I hate myself! I wish I could disappear! Mona
complained. Oh, Mona, you are really troubled by this. Thats
a terrible way to feel. Can I help? Monas mom asked.
Not really. Ill get over it, Mona replied. Of
course, validation does not always work as smoothly as it did in
this example, but it will give you a fighting chance to help your
child lower her current emotional temperature. Lowered emotional
temperature will help your child decide how to be more skillful
to get through the crisis.
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HELPING YOUR TEEN
Attentive listening becomes active listening when we add the
element of reflection or, as its sometimes referred to,mirroring.
Reflection is simply restating the other persons feelings
in the service of letting her know you follow her, or as a way to
make sure you understand how she feels or thinks in the moment.
I am feeling really down about Melissa moving to Dallas. We
were just getting to be friends and now shes leaving,
Joan said. I can see how down you are, Joans
dad replied. When we are actively listening, we are not adding
anything new to the discussion; we are simply trying to stay on
point with the feelings being expressed. Some of the time it
might not be altogether clear what emotion is being expressed,
and active listening can help us both to clarify the emotion and
to be validating at the same time. I am feeling really down
about Melissa moving to Dallas. We were just getting to be
friends and now shes leaving, Joan said. It
sounds like youre sad about Melissa moving to Dallas,
Joans dad replied. Yeah, I am so bummed out. In
this example Joans father uses active listening to get
clear about what Joan means when she says shes down.
Staying open and curious about your childs experience are
key factors in being successful at active listening. For some of
us, when our worries or emotions begin to rise, we get locked
into a sense of certainty about whats happening. Our
thinking loses any flexibility; we cant be budged from our
own point of view. We typically refer to such people as stubborn.
Mary did it again. I dont believe her. She is having
a sleepover and she didnt invite me. I had to hear about it
from Sheila. I could have died, Kate complained. It
sounds like you are really mad at Mary, said Kates
dad. No, Im not mad, Im humiliated, Kate
responded. I dont knowit seems like youre
mad about it, Dad went on. Stop telling me what I
feel! I hate when you do that, Kate said, the tension in
her voice rising. Kates father gets stuck on what he thinks
his daughter feels and will not give up his point of view. It
would not be irrational for someone in Kates position to
feel mad at Marybut that doesnt seem to be her
experience. Kates fathers refusal to amend his
position is most likely going to make the situation worse. When
youre engaged in active listening as a
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141
validation strategy, its all about acknowledging the other
persons experience as he or she is describing it. Think
mirror and not mind reader. Another
common problem with reflection is that it can come across as
stilted or phony. This is very often the case when people are
first learning the skill, so again my advice would be to practice
the skill outside on neutral ground first. Finally, dont
feel obligated to reflect every feeling as it arises in a
conversation. Use your reflections just to let the other person
know youre following him or her or as a way to help you get
more clarity about his or her experience.
When youre engaged in active listening as a validation
strategy, its all about acknowledging the other persons
experience as he or she is describing it. Think mirror,
not mind reader.
Giving Voice to the Unspoken
Giving voice to the unspoken is the most advanced category of
validation that Im going to teach you. I suggest waiting on
this one until you feel confident that you have the hang of
attentive listening and active listening. Giving voice to the
unspoken requires you to be open, curious, and extremely focused
on what the other person is expressing. Being open and curious
requires that you let go of any judgments about how the other
person should be feeling in the situation and just accept what
she says. Being focused includes paying attention to her words as
well as her facial expressions and body language. Paying
attention to the nonverbal cues (body language and facial
expressions) will lead you to giving voice to the unspoken.
Sometimes as you are listening to your child, you will notice
that there is something shes telling you that goes beyond
the words shes using. It could be that as shes
telling you about how angry she is, you notice a look of sadness
in her eyes; or as she tells you about something that embarrassed
her, her posture takes on an angry quality. When you notice these
unspoken feelings, you can give voice to them. Here is an example
of what I mean. Im furious with Lena. We were
supposed to meet for lunch at the cafeteria and she just blew me
off. I told her how important it was to me that we talk today.
She just didnt show. Finally I tracked her down and she
said Molly needed to talk with her about the trouble she was
having with her boyfriend, Crystal said with a quiver in
her voice. She can be such an idiot. Crystals
mother noticed the quiver in her daughters voice and the
cloud of sadness that seemed to move across her face.
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I certainly can understand how mad you are with Lena. But
tell me, did her not showing up also hurt your feelings?
Crystals mom inquired. Yeah, it hurt my feelings! I
think Im both mad and sad about the whole thing,
Crystal replied. See how Crystals mom gave voice to
feelings that her daughter had not yet articulated? Notice how
she gently inquired, not from a position of certainty but from
one of curiosityunlike Kates dad insisting that she
seemed angry. It is very important that when using this
validation skill, you dont become attached to the correctness
of your point of view. If the other person doesnt confirm
what you think she might have been feeling, let it go. If you dont,
you are very likely to make the situation worse. Often the wish
to understand our children and to help them solve a problem makes
us unwittingly committed to the belief that we understand a
situation when we dont. Parents lose their curiosity, and
misguided certainty takes its place. When we are using giving
voice to the unspoken, we are quite vulnerable to committing this
error. The trick is to stay aware of your mind shutting down.
When you notice this occurring, reach for curiosity. Remain
interested in understanding your childs experience without
assuming that you already understand it. Heres another
example. Izzie had just returned from school and went directly to
the kitchen. Today was the day she was going to hear if she made
the varsity lacrosse team. Izzie is a sophomore and played J.V.
last year with all her friends. She was the only sophomore who
was being considered for varsity. All week she has worried about
whether she was good enough and whether she wanted to leave her
friends behind. Mom, she said. I didnt
make it. Well, I guess your worries are over. Now youll
be playing with your friends, her mom gently replied.
Yeah, I guess youre right, Izzie said without
much conviction. Gee, Izzie, all week long this has been
such a worry for you, and now its settled, her mom
continued. I dont know why I am unhappy, but I am,
Izzie said. I wonder if you arent a little sad that
you didnt make the team? her mom asked. Yeah,
thats it. Im glad Ill be playing with my
friends, but I also would have liked to have been chosen,
she replied with relief in her voice. Once again, notice that Mom
remains curious and open to her daughter and that she offers
another possibility with a light touch. Using a light touch with
real curiosity is the key to this skill.
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Getting more practiced at validation will, over time, help to
avoid emotional turmoil at home. It will give you a better
understanding of your childs emotional stresses and open up
better lines of communication. I encourage you to practice
validation every chance you have at work, with friends, and with
family members. And dont forget to validate yourself for
working hard at learning a new skill! In this chapter Ive
given you some practical skills to help you help your child reset
the stage to identify and work through her emotions. In the next
chapter youll learn a number of additional skills to help
support your teens acquisition of the emotion modulation
skills that will make self-injury an unnecessary stopgap solution
to emotional pain.
7
writing a better script
NEW WAYS TO DISCOURAGE SELF-INJURY
As valuable as validation is in helping your emotionally
sensitive child, its
not a problem-solving strategy. This chapter focuses on skills
you can learn or polishto help your teen develop
emotion regulation skills and leave selfinjury behind. After
practicing and mastering these skills, you will, in a way, be
rewriting the script of your childs emotional vulnerability
to bring about a better outcome.
INTERPERSONAL EFFECTIVENESS SKILLS
In my experience parents and children often develop patterns or
styles of relating that dont work well. When a parent is
struggling to be helpful to a child who self-injures, these
patterns often push the child into emotional dysregulation. In
other cases parents can become so tentative in their requests or
in setting limits that they seriously compromise their ability to
parent. Watch what happens when Bonnies mother hears some
upsetting news. Im going to see Kerri this Saturday
night, Bonnie told her mom matter-of-factly. What! I
cant believe Im hearing this. Every time you and
Kerri see each other you get into trouble. What are you thinking?
Bonnies mom anxiously replied. Thats not true!
Besides, you cant tell me who I can see and who I cant,
exclaimed Bonnie. This is a bad idea and youre not
doing it, Mom firmly replied. F
you! Bonnie screamed as the front door slammed behind her.
I imagine that quite a few of you have been in a situation
similar to this one. When tempers flare, theres no chance
for either party to explain her
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new ways to discourage self-injury
145
thinking. The situation has been made much worse between Bonnie
and her mother overall, and the issue about Saturday night
remains unresolved. Lets take a look at another version of
the conversation that doesnt work for a different reason.
Im going to see Kerri this Saturday night,
Bonnie told her mom matter-of-factly. Oh, thats nice,
I think. Umm, wasnt she the girl you had some trouble with?
I dont know, do you think its a good idea to see her?
Mom asked cautiously. What are you saying? When are you
going to trust my judgment? I dont believe you!
Bonnie replied. Its not that I dont trust you,
uh, its just that Im concerned, Bonnies
mom went on. This conversation is over! Maybe you ought to
see a shrink about your crazy anxiety, Bonnie shouted as
the door slammed behind her. This time Bonnies mom is
walking on eggshells about her very real concerns. Her tentative
approach backfires, and the conversation comes to a screeching
halt. The interpersonal effectiveness skills Ill review
with you in this chapter are designed to help you avoid such
tense and nonproductive interchanges. The skills are drawn
directly from the interpersonal effectiveness module that your
child learns in DBT and are divided into three groups: The
skills required to ask for what you want or to say no to a
request The skills required to repair or enhance a
relationship The skills for setting a limit while holding
on to your self-respect In order to be interpersonally effective,
the first thing you need to do is assess your goals or priorities
for the conversation. A handy way to think about your goals is to
ask yourself these questions: Am I making a request?
Am I trying to set things right? Am I attempting to
set a firm limit? First, if you have more than one goal in a
conversation, choose the most important one. Second, think of
these skills as
Think of interpersonal effectiveness skills as dance steps. You
may need to move fluidly between steps to get the dance right.
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HELPING YOUR TEEN
dance steps, and of interpersonal effectiveness as a finely
choreographed dance. You may need to move fluidly between steps
(skill sets) to get the dance right.
Relationship Objective 1: Asking for What You Want or Saying No
When your top priority is to make a request or to say no, the
mnemonic to remember is DEAR MAN: Describe Express Assert
Reinforce (Stay) Mindful Appear Confident Negotiate Heres
how this skill breaks down. Describe is used to orient the other
person to the situation you want to talk about. Its all
about the facts. For example, Last Saturday night you came
in after curfew or On TuesStarting statements with
You day you said you would clean your instead of
I tends to put people room. Its more
useful to limit the on the defensive, which wont get
discussion to one particular situation you what you want from
them. rather than speaking in generalities like You always
miss your curfew or Ive asked you a thousand
times to clean up your room. These kinds of statements
usually put the other person on the defensive, which is not going
to get you what you want. Next, express your feelings about the
situation: When youre late for curfew, I both worry
about you and I get angry or When you say youre
going to clean your room and dont, I get really annoyed
with you. Again, avoid general statements such as You
make me worry when you are late or You make me angry
when you dont do what you say youre going to do.
When youre expressing your feelings, its important to
remember to use statements that begin with I instead
of You. When you take responsibility for your
feelings, your position in the conversation remains strong; when
you attribute your feelings to the other person, you come across
as simply reactive or as a victim. Next in the sequence is to
assert your request: I want you to be home at
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the time we agreed upon or When you say youre
going to clean your room at a certain time, I want you to do it.
Your assertion needs to be clear and firmno ifs, ands, or
buts. One of the best ways to reach your goal is to spell out
whats in it for the person if she complies. This will
reinforce your request. For example: When you come in on
time for your curfew, it makes it more likely that in the future
Id be willing to extend your time out or When
you clean your room as you agreed you would, I wont have to
nag you so much. When we find a way to reinforce behavior,
we are increasing the probability of getting what we want.
Whenever possible, the reinforcer should be a natural consequence
of doing what you ask. For example, stay away from things like
If you come in on time, Ill get you the sweater youve
been asking for or If you clean your room, you can
have whatever you want for dinner. These certainly may get
you what you want, but theyre bribes that will work just
for the moment, leaving you having to offer more and more in the
future (and inviting rejoinders such as Sure Ill come
in on time, but what are you going to get me if I do?).
Stick to reinforcers that are a logical (natural)
outcome of meeting your request, like When you come in on
time that builds trust, and then Ill be more likely to
extend your curfew in the future. We all know how we can
become distracted in these kinds of discussions. Yeah, I
know I was late for curfew, but what about all the times youre
late picking me up from school? Do I make a fuss? or My
room is a mess? Have you seen my sisters? Why dont
you ever nag her about her room? In the face of these often
emotionally charged distractions, stay mindful of your objective.
(Ill give you more help with developing mindfulness skills
in Chapter 8, and youll find sources of detailed
information on mindfulness practices in the Resources at the back
of the book.) Remember, you are on a mission to reach your goaldont
get sidetracked. This means at times you are going to have to
just plain ignore the distractions and repeat your request, and
at other times you may have to defuse the situation. For example,
I would be happy to speak with you You are on a mission to
reach about arriving late to pick you your goaldont
get sidetracked. up from school right after we finish the
discussion about your curfew or You might have a
point about your sisters room. Ill listen to your
opinion right after we get the issue about your room squared
away. Mindfully giving your objective top priority will
optimize the chances of realizing it. Its also important
that you appear confident when making your request. Notice I said
appearyou can feel like Jell-O on the inside;
you just have to
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look the part. Lets face it: sometimes its really
hard to make a request of your kid if you know it might lead to
an emotionally charged scene. It makes sense that in the face of
an anticipated fight, you may not feel as confident as youd
like to be. So play the part on the outside. How, you ask? Your
posture should be upright but not rigid. Make good eye contact
and keep your tone of voice even, almost matter-of-fact. I know
this may seem a little hokey. If you think its going to be
difficult for you to look confident, try working at it in front
of a mirror. If it seems that youre not going to get
exactly what you want and youre willing to be flexible,
thenand only thentry to negotiate. Parents sometimes
move to negotiation too quickly, depriving themselves of a
greater chance of getting what they want. Be patient. But if you
think the discussion is at a dead end, then you can move to
negotiate. Dont move to negotiation too DEAR MAN is a very
useful quicklyyou may be giving up a and powerful skill. I
suggest that better shot at getting what you want. you try
writing it out and practicing it a few times before you actually
use it. When youre ready, try it out in relatively neutral
situations with friends or at work before bringing it home. Lets
see how Bonnies mother rewrites her daughters
emotional script after shes practiced this skill for a
while. Im going to see Kerri this Saturday night,
Bonnie told her mom matter-of-factly. When you announce
what youre going to do, especially given the trouble you
had last time you went out with Kerri, it raises my worry, and I
am almost automatically going to say no. It would be better for
me if you raised it as a question for us to discuss [describe and
express, beginning of assert], Bonnies mom said
calmly. Okay, what are you going to say if I raise it as a
question? Bonnie asked warily. I dont know. My
decision would be based on the conversation we have. I can tell
you that Im much more likely to agree if I have a sense
that youve taken my concerns seriously [reinforce].
What does this have to do with you? Shes my friend,
and I should decide who I spend my time with, not you,
Bonnie said with some irritation. In part thats true.
But right now we need to settle the issue of Saturday night
[staying mindful of the objective and appearing confident].
Well, what do you want me to do? I want to see Kerri.
Id like Kerri to come here this time and see how it
goes. No! We want to go to the mall.
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She can come here first, and if things go okay, Ill
drop you off at the mall for an hour or so [negotiate].
I dont really like it, but Ill do it, I guess.
Thank you. Bonnies mom ends the conversation
with a smile.
Relationship Objective 2: Repairing or Enhancing the Relationship
It is inevitable that we are going to do or say things that will
hurt other peoples feelings. Its just a fact of being
in a relationship. Frequently the hurt occurs in the context of a
heated interchange when both parties are under the sway of their
emotions. In order for you to use this new skill effectively, you
need to be calm and relatively sure that youll be able to
stay focused on your goal: repairing the relationship. Finding
your way back to a calm state can be accomplished with the
mindfulness practices and distress tolerance skills that will be
outlined in Chapter 8. So wait on practicing this skill until you
have read that chapter. After youve read and practiced it,
you can use the GIVE skill to make a repair. This skill can be
very helpful to your child in ways that go beyond keeping your
relationship on an even keel. After a blowup between parent and
kid in a family where the emotional climate can run hot, often
neither party mentions the fight. Things just settle back down to
normal and everybody goes on as if nothing happened.
Families get into this pattern as a way to avoid another
troubling scene. While the avoidance is understandable, there are
at least four problems that are potentially generated by this
pattern. First, there is little or no resolution about the issue
that started the problem. Second, hurt feelings are not
addressed, which, when left to linger, are going to start
affecting the relationship over the long haul. Third, the kid has
no effective model about how relationships are maintained.
Parents who can model effective ways to repair relationships are
teaching their kids an important life tool. All relationships, to
one degree or another, require work, and one aspect of that work
is knowing how to make a repair when things go sour. Fourth, one
of the tasks of adolescence, one that is especially difficult for
emotionally vulnerable children, is the construction of a sense
of time. I will address this issue in more detail at the end of
the chapter, but here is the short version. Emotionally
vulnerable adolescents sometimes seem to have a snapshot view of
time. Often the emotional fight you and she had in the morning,
which practically ruined your day, appears to be disconnected
from whatever she is asking from you in the afternoonas if
the fight no longer has any relevance. These kids have an
exaggerated sense of That was then and this is
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now syndrome. They dont experience life so much as an
ongoing series of events that are connected, like in a movie, as
like a scrapbook full of still pictures. This snapshot view of
the world is only confirmed when conflicts dont get
addressed in an ongoing way. Its important that parents
Emotionally vulnerable kids often work at modeling the movie have
a snapshot rather than a version of life, and one way
to movie view of events. Do your best do that is
through relationship to give them more of a continuous repair.
And one way to do that is movie view of their lives.
with the GIVE skill: (Be) Gentle (Act) Interested Validate Easy
manner It almost goes without saying that if your objective is to
repair a relationship, your demeanor needs to be gentle. Being
gentle includes a soft tone of voice, being nondefensive, and
being open to examining your contribution to the problem. This is
why my advice to you was not to initiate the give skill until youre
sure youll be able to be gentle. Take whatever time you
need, and do some mindfulness exercises or use some of the crisis
survival strategies from the distress tolerance module (Chapter
8) to get ready. Once youre able to be gentle, the next
step is to bring a degree of interest in hearing the other persons
point of view. You want to convey your interest in whatever point
of view your kid was articulating before the conversation went
south. Notice how, in the following exchange, Jackie seems to
compartmentalize what happened in the morning as somewhat
disconnected from the present. It doesnt have the same
relevance for her as it does for her father. The simple act of
tying the morning to the present helps to undercut her snapshot
view of time. Jackie, Im sorry that we had words this
morning. I know you felt hurt and angry by my remarks. Do you
think we could try again? Jackies dad gently
inquired. I dont want to talk about it! Its
over, donethat was this morning, this is now. Leave me
alone. Anyway if we talk youll just get mad at me again,
Jackie said. Hey, give me a second chance. I know I was
unreasonable this morning. I have a hard time thinking clearly
when your music is so loud, and I didnt do such a good job
of trying to talk to you about it, Dad replied.
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Okay. But remember, the music I listen to is important to
me. When you tell me its crap, I really get
upset, said Jackie. Jackies father doesnt have
to be interested in his daughters music one iota. He does,
however, have to act interested to make sure the repair is
effective. If you cant act interested in the thing that
tipped over the conversation, then get interested in why the
issue is so important to your child. Acting interested is
accomplished by making good eye contact, carefully following the
thread of the conversation, being curious, and asking relevant
questions. Acting interested will help you be more effective at
the third component of the skill, validation. By now you are all
experts at validation, so Im not going to repeat the
how-tos of this skill. Lets move on to the last component
of GIVE, using an easy manner. Back to Jackie and her dad. Okay.
But remember, the music I listen to is important to me. When you
tell me its crap, I really get upset,
Jackie said. I can see how that would make you angry and
hurt your feelings. Hey, but maybe you could cut me some slackI
never grew out of the Beatles, Jackies dad replied.
Using an easy manner requires that we find a way to bring a light
touch to the discussion. We want to ramp down the intensity and
stay matter of fact. A little bit of humor can go a long way to
helping create an easy manner. If youre going to use humor,
I would suggest that it be more self-deprecating than teasing of
the other person. Remember: your goal is repair, and you dont
want to risk offending the other person.
Relationship Objective 3: Setting a Limit and Holding on to Your
Self-Respect
Its a tough job, but someones got to do it. Part of
parenting is being able to set limits. Parents of an emotionally
vulnerable child who engages in selfinjury have an even tougher
job because setting effective limits increases the likelihood of
making the child emotionally dysregulated. If they dont set
limits, theyre dodging one set of problems for a whole host
of others. The bottom line is that all kids need limits, and
emotionally vulnerable kids particularly benefit from them. Often
an emotionally vulnerable child is triggered by too much
discussion about an issue that is not negotiable. The endless
discussion just serves to increase the childs emotional
volatility. Some parents know they should be setting a limit, but
avoid it and then feel guilty that they have abdicated a re-
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sponsibility. Over time the guilt begins to erode a parents
sense of selfrespect. Other parents go in the opposite direction
and set limits like gangbusters, overreacting and being too
harsh. Coming on too strong is sometimes born from frustration,
or it can be a way to make sure they dont avoid the
responsibility. In either case, feelings are hurt on all sides
and parental self-respect is a casualty. Effective limit setting
is a skill you can learn, but of all the interpersonal
effectiveness strategies, it may be the hardest to implement. If
youve been the kind of parent who has avoided setting
limits, things are probably going to have to get worse before
they get better, as they did for Ruth. I understand that its
important for you to see your boyfriend on Saturday night, but I
will not allow you to be at his house alone, Ruth firmly
told her daughter Sarah. What? Come on. Have you gone
crazy? It never mattered to you before, Sarah shot back.
It did matter to me, but I was afraid I would upset you if
I said no, Ruth confessed. Well, thats not my
problem. It just isnt fairyou just cant change
the rules like that! Sarah complained. I can see how
it might seem unfair, but the answer is still no, Ruth
replied. Im not going to follow your stupid rules!
Sarah wailed as she slammed the door. Ruth may be in for several
more go-rounds before Sarah begins to settle in to the new way of
doing things. If, however, Ruth is unable to hold her course and
gives in to Sarah, she will reinforce her daughters
argumentativeness. Im not suggesting that you be rigid and
inflexible with your limits; just dont change them in the
face of your kids dysfunctional behavior. Renegotiate
limits when your child is in emotional control and has made a
convincing case for change. The skill for effective limit setting
is FAST: (Be) Fair (No) Apologies Stick to your values (Be)
Truthful You want to be fair to yourself and the other person.
Notice how Ruth validates both her daughters wish to see
her boyfriend and the fact that changing the rules has an element
of unfairness to it. When youre being fair, you are
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153
undercutting any tendency to blame the other personand when
blame is out of the equation, limit setting goes more smoothly.
No apologies really means no excessive apologizing. When youre
setting a limit, it works best if youre direct and somewhat
matter of fact. Avoid statements like Im really sorry
to have to ground you. I wish I didnt have to do this.
These kinds of apologies undercut your goal and open the door to
fruitless discussion. Any teenager worth her salt is either going
to tell you that you dont have to be burdened by guilt,
just dont set the limit, or shes going to accuse you
angrily of not being sorry at all. Just dont go down that
path. We often set limits when a particular value of ours has
been crossed or is about to be. Ruths value is that its
not okay. to be at a boys house without adult supervision.
Sticking to your values requires you to be clear about whats
important and nonnegotiable versus those issues where you may
have some flexibility to negotiate. Sometimes parents or
caretakers have different values from each other, and sometimes
those differing values become apparent only when one parent is
either setting a limit or expecting the partner to do so. When
this occurs its important that the adults involved discuss
their differing points of view and decide on a course of action.
Often parents feel the need to have these discussions privately,
which is a perfectly reasonable way to go. But theres often
some benefit for parents in clarifying their differing sets of
values and deciding on a course of action in front of the child.
Having the discussion in private deprives our kids of seeing how
conflict is reasonably resolved. Of course, if you think the
discussion If you and your partner disagree on is going to get
heated and contenvalues or limit setting, its sometimes
tious, then taking it behind closed useful to hash it out in
front of your doors is the way to go. child. This will teach him
or her When we set limits, its imhow conflicts can be
resolved portant to remain truthful. Noreasonably. But dont
stage a heated tice how open Sarahs mom is confrontation in
front of your child. about her past behavior of letting her
daughter be at the boyfriends house alone. Im
sometimes amazed at the creativity that parents harness in the
service of preventing their child from doing something while
avoiding the truth. (No Sarah, it is not that we dont trust
you to be alone, its just that we want you to spend the
night with old Aunt Jennie.) If youre avoiding the truth as
a way of dodging an argument, youre settling for a
short-term solution to a longer term problem. Setting limits
helps children learn how to manage disappointment, and wouldnt
you agree that learning how to make it through disappointing
times is an important life skill?
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Being truthful is not the same as being brutally honest, so by
all means deliver a truthful message in a sensitive manner. Your
goal is to set a limit, and the degree to which you can do that
without being hurtful will aid you in accomplishing that goal.
INDIRECT INTERPERSONAL SKILLS
Validation and interpersonal effectiveness are skills that you
can actively and directly use to be helpful to your child. There
are other changes you can make in the way you parent that are
less direct but will also be helpful in steering your teenager
away from self-harming behaviors. Demonstrating your capacity to
manage distressing events and the ways you cope with the
difficult emotions that accompany these events is important
modeling for your kid. This kind of modeling has the potential to
help your child get better at effectively managing these painful
moments in his own life. In addition, all kids need the sense of
security that comes with having parents who pay attention to them
but who also know when to give them some privacy. Effectively and
flexibly responding to these two issues helps the child feel
understood while giving him a sense that you will extend trust to
him when he is managing his emotions more effectively. Often when
we try to protect our children from the natural consequences of
their behavior, we unwittingly communicate our sense that they
are handicapped or damaged in some way. So knowing when to allow
natural consequences to unfold will help your child develop a
more resilient sense of himself. The changes that I will outline
are about creating an environment that will support and enhance
validation, interpersonal effectiveness, and your childs
individual therapy. Probably the single most effective action
that you can take to help your kid is to make sure hes in
effective treatment. Once thats accomplished, here are some
other strategies that will be of help.
Modeling Distress Tolerance
One of the most powerful ways that kids learn skills is by
watching the adults around them. When we employ skillful behavior
we are not only helping ourselves; we are modeling effective
behavior for our children to learn. As you know, one of the
central difficulties for the vast majority of children who engage
in self-harming behavior is not being able to modulate and
tolerate painful emotions. When under the sway of these powerful
and uncomfortable emotions, these children are in a rush to
change the way they feel. They lack
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155
the capacity to sit with their internal discomfort and are prone
to move quickly into action. When parents sense that their child
is in distress, they often unwittingly join them in the rush to
change the situaUnder the sway of powerful and tion. This is what
happens to uncomfortable emotions, these children Tameka and her
mom. are in a rush to change the way they feel. I need to
speak to Jimmie right now! Hes not picking up his cell
phone. I have to know whats going on with us. I cant
take not knowing, Tameka complained. Have you tried
his land line? Tamekas mom asked, sensing her
daughters distress. Of course! Im not stupid,
Tameka angrily replied. Try his cousinyou know he
hangs out there all the time, Mom said as her anxiety began
to rise. It worries me to see you so upset. I
hate his cousin. You know that! Leave me alone, Tameka
shouted. Tamekas mom moves right to problem solving. In her
own hurry to help her child, she joins her in her frantic need to
get things resolved immediately. Tamekas mother skips
validation and begins to offer unsolicited adviceand gets
the predictable negative result. In the second example, Tamekas
mom takes a longer view, modeling the capacity to tolerate
distress. I need to speak to Jimmie right now! Hes
not picking up his cell phone. I have to know whats going
on with us. I cant take not knowing, Tameka
complained. Its so hard to wait, especially about
your relationship with Jimmie, Tamekas mom replied.
Im going to jump out of my skin. Why doesnt he
answer my calls? Tameka responded with sadness in her
voice. Im sorry that he hasnt returned your
calls. Waiting is really hard. I tell you what, why dont we
bake some cookies while you wait? Maybe that will make the time
pass by faster, offered Tamekas mother. Thats
not going to help! I cant stand this! Tameka shouted.
Youre rightits not going to get Jimmie to
call you any sooner, but it just may make waiting easier,
said her mother. I guess youre right about that. Do
we have any chocolate chips? asked Tameka. This time Tamekas
mom does several things differently. First, she takes the time to
validate her daughters experience by acknowledging how
difficult waiting can be. Second, she does not offer any
problem-solving strategies, but models distress tolerance. She
does this when she acknowledges that making
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HELPING YOUR TEEN
cookies is not going to solve the problem but may ease some of
the distress caused by the waiting. And third, she does not seem
to be getting caught up in her daughters increasing
emotional temperature. This is a hard-won parental skill. Mom
seems to have accepted the situation as it is, and is now just
offering a way to manage a problem that cant be solved
right now. By exhibiting these distress tolerance skills, shes
showing Tameka how to do the same. Obviously, its not easy
to model distress tolerance if you, like your teenager, are
relatively sensitive emotionally and you havent fully
developed emotion modulation skills. Chapter 8 will help you
build your own skills further so you can help yourself and your
teen.
Privacy Versus Increased Vigilance
One of the most challenging problems for parents with kids who
engage in self-harm is knowing when to allow them privacy and
when to become more vigilant. Unfortunately, there arent
any hard-and-fast rules about this. There are only some
guidelines or principles to help you think this through. Whatever
course of action you take, however, make sure your child
understands what to expect and knows that her therapist has been
informed of your decisions. The first thing to hold in your mind
is that there are few if any interventions that anyone can make
to prevent someone from self-injuring. Your more modest goal is
to make your child feel noticed and understood when shes in
crisis through the use of validation, and to give her more
privacy when you see that shes more skillfully managing her
emotions. Ask her how shes feeling, gently inquire about
whats on her mind and how shes doingI will
refer to this as checking in. Here are some examples
of how this principle gets transLearn to check in with your lated
into everyday life. child lightly: just gently ask First, let
your child know, in moher how shes doing. ments of relative
calm, that when shes in emotional turmoil, you expect her
to let you in on it. Let her know very clearly that if she wants
your help, its there for the asking; if she doesnt,
you expect her to use some technique or skill to help herself.
Second, when shes having trouble she should expect you to
be checking in with her more frequently than usual. What you want
your child to know is that the objective in checking in is to see
how shes doing and whether she wants any help from you.
Your intention is not to bug her but only to be supportive. Dont
expect your child to welcome your increased vigilance. She may
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even tell you that it wont prevent her from self-injuring
or that it will only make the situation worse. My advice is to
gently stick to your guns and let her know that shes
correctit wont prevent her from self-harming.
Furthermore, if checking in really becomes a problem, you need to
be willing to review the strategy down the line. If, over time,
you feel its doing more harm than good, then discard this
strategy and concentrate on the others outlined in this chapter.
When you are checking in, use a light touch, practice validation,
and stay away from problem solving unless invited to do so. If
your kid says everything is fine and you clearly see that it isnt,
let it go and just keep checking in. How often should you check
in with your child? Thats something youll have to
figure out by trial and error. It will also depend on how
troubled your kid is in the moment and, to some degree, how
smoothly the check-ins are going. If you think your child is in
better emotional control, then decrease the frequency of checking
in. Youll just have to feel your way through this process.
Allowing Natural Consequences
As parents we have an instinctual inclination to protect our
children from hardships. There are times, however, when this
inclination can have a detrimental effect. In these moments we
may be reinforcing the kids sense that she is so weak or
damaged that she has to be protected from the natural
consequences of her behavior. We may be inadvertently sending the
message that she cant emotionally handle the problem,
rather then helping her tolerate the distress that accompanies
the problem. Watch what happens with Jodys parents. Jodys
school called today, Jodys mom told Jodys
father. One of the kids in her class noticed the cuts on
her arm and told the guidance counselor. The guidance counselor
called the nurse, who called me and left a message on the
answering machine. She wants to know if we think theres a
problem. What should we do? Theres no way I
want the school to know that she cut herself again! If they find
out, Jody wont be able to play lacrosse this spring. You
know they get rigid about this kind of stuff. Jodys been
miserable enoughshe doesnt need more stress,
Jodys dad replied. What are we going to do? I dont
feel comfortable lying about whats going on. After all, the
school has been pretty supportive so far. I dont want to
screw things up with them, Jodys mom responded.
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What would you do if you had to wrestle with this dilemma? Jodys
dads position seems entirely reasonable; he wants to
protect his daughter and minimize the stress in her life. On the
other hand, his wifes worry that lying to the school could
potentially backfire is also reasonable. The central question is
how to make the best guess about whats in Jodys best
interest. One way to tackle this problem is to make a Pros and
Cons Chart about the various options. Actually, you need two Pros
and Cons Charts, the first one assessing the short-term
consequences of the decision and the second the longer term
consequences. Doing pros and cons is a pretty standard method for
thinking through complex decisions. Its especially useful
in situations where rational thinking is paramount, but emotions
are liable to run high and compromise the process. The structured
nature of doing pros and cons can guard against emotions taking
the day. At times you may want to have your child be part of this
exercise. If hes been in a DBT treatment, he has most
likely learned this skill already. For the situation with Jody,
the Pros and Cons Chart that will yield the most thorough
information would look like this: Short-Term Consequences Pros
Telling the school: maintain good relations with the school Not
telling the school: maintain Jodys privacy No lacrosse
Deprive Jody of school support Cons
Spend some time with your own ideas about Jodys parents
dilemma. Add to this chart, and create one for the long-term
consequences. Here are some ideas for starting points. One
long-term consequence under the pros category about telling the
school is that Jody will experience the natural consequences of
her actions. The school may decide that from its perspective, she
needs a limited schedule that would eliminate lacrosse. Feeling
the pinch of this loss may help Jody become more committed to
using her therapy to end self-injurious behavior. A con of Jodys
parents withholding information from the school is that it
might move Jodys thinking in the direction that selfinjury
is not so much of a problem if she can keep it secret. As you can
see, there are any number of legitimate ways to think about
whether to intervene in your childs life or to allow
natural consequences to occur. There is no one right answer, just
some effective routes to help you make your decisions.
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I know there may be a lot of new information in this chapter, so
take your time, become familiar with the strategies, and pay
attention to the small successes. You cant help your child
if you put too much pressure on yourself or your child to change
quickly. When youre taking care of yourself, you will have
the energy and the resilience to parent your child. The next
chapter focuses more specifically on how you can take care of the
pain and distress that comes with having a child who is
struggling.
8
taking care of yourself to take care of your teen
I dont have to tell you that parenting a child who engages
in self-injury is
extremely hard work. The stress and anxiety take a toll, and you
may feel exhausted, defeated, and hopeless. Parental burnout is a
debilitating experience. Some common indicators of burnout
include sleep problems, changes in appetite, general
irritability, depressed mood, and increased alcohol consumption.
Your self-esteem can take a nosedive, leading you to question
every parenting move you ever made. You can lose perspective on
your parenting abilities. Guilt and remorse can become your
constant companions. Some parents withdraw from their childrens
problems and become over involved in work or other kinds of
activities in an effort to avoid their feelings of helplessness
and pain. Others become overly focused on their childs
difficulties at the expense of a life outside the home.
SIGNS AND SYMPTOMS OF PARENTAL BURNOUT
1. 2. 3. 4. 5. 6. 7. 8. Increased difficulties in significant
relationships. Increased irritability and/or lack of patience.
Significant decrease in pleasurable activities. Increased alcohol
use. Changes in appetite. Sleep difficulties. Increased sense of
loneliness and isolation. Persistent anxiety and rumination.
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SIBLINGS
In some families the child who is self-harming becomes too much
of the focus; brothers or sisters can feel neglected. Often they
dont protest or talk about how the lack of attention is
affecting them because theyre sensitive to their parents
worry. Their silence often misleads parents into thinking theyre
just fine. Its not unusual for some siblings to become
anxious or withdrawn. Others make their protest known by their
own behavior problems or academic difficulties. Its
extremely challenging and at times draining for parents to stay
focused on the other children in the family, helping them
understand whats going on while taking care of the sibling
who self-injures: negotiating the mental health system, dealing
with the school, and managing extended family. I will address
these complex and difficult issues in the next chapter. This
chapter is all about strategies to keep yourself on an even keel
in the midst of a gale.
PARTNERS
A second casualty of burnout can be you and your partner. Whether
youre married, living with your partner, or living
separately, your capacity to be effective in relationships goes
out the window when youre suffering from burnout.
Relationships take care and attention. When were fatigued
in mind, body, and spirit, that can seem to take more energy than
we have in the tank. If you notice that you have significantly
less patience and understanding for the other person, or feel
that the other person is being intentionally mean, or have the
feeling that your side of the story is not being heard and
valued, then you probably need to examine the relationship. As
difficult as it sometimes is to maintain a relationship, it will
pay off in helping you avoid parental burnout.
DIVORCED PARENTS
Divorced parents who have worked well together in the past often
find that the new challenges presented by a child who is
self-injuring require adjustments. Furthermore, the need for
increased communication between di-
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vorced couples can put a strain on whatever new love interests
the parents may be developing. If, however, what I have described
has gone on between you and your parenting partner for years but
just gets worse in stressful situations, then its probably
not burnout. It may be that you and your partner have a conflict
that youve been unable to resolve. Often problems in
parenting, when you follow them back to the core, are really
problems in the relationship between the parents. Solutions can
be as simple as learning to communicate better or as complicated
as addressing a past betrayal. Whatever its source, it is most
definitely a problem that needs to be addressed. Chronic
parenting problems are always a challenge, but when a child is
having serious emotional trouble, it is imperative that couples
find a way to work at making improvements in their relationship.
Couple therapy, therapy focused on guiding parents, and/or
individual counseling may help you resolve these issues. If,
however, youve tried to work things out and where you are
with your partner is as good as it gets, then its
especially important that you use other strategies to take care
of yourself.
SINGLE PARENTS
Single parents have a unique set of challenges. Often the support
network of family and friends you may have relied on in the past
is not a viable resource anymore. That may be due to your
reluctance to reach out to them because of feelings of shame and
guilt, or because you dont feel your network of people
would be supportive of your child who self-harms. If thats
the case, you can feel extremely lonely and isolated, even
trapped or resentful of your parenting role. All parents are
susceptible to doubt, self-blame, and remorse, but the single
parent is particularly vulnerable to these draining experiences.
For all kinds of parents of children who self-injure, learning
how to take care of yourself and the parenting relationship may
take the edge off the difficult times ahead. What can you do to
keep burnout at bay, or at least diminish its effects? In the
following sections I will teach you some skills to helping you
avoid feeling overwhelmed by negative emotions. These skills are
all part of the emotion regulation and distress tolerance modules
from the DBT skills curriculum. You will recognize them from my
review of teens work in DBT from Part I. Once you start
taking better care of yourself, youll have more energy and
resilience to hang in there through the rough times with your
child.
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ACCEPTANCE VERSUS PROTEST, RESIGNATION, AND DESPAIR
Sometimes I cant believe this is happening!
Kriss mother said with a tinge of anger in her voice.
Kris never had any problems before. I thought she was doing
so wellthen she made these new friends, and the next thing
we know, shes cutting herself. It seems that nothing her
dad and I do makes a difference. Some days I dont even want
to get out of bed. Im sure many of you can identify
with Kriss mother. At times it may seem that feeling
resigned, angry, and hopeless is all you can expect. While its
natural to experience these emotions, they neednt take over
your life. In fact, remaining in such a state will only lead to
more exhaustion and a more depressed moodincreasing the
probability of burnout. Fortunately there is a way out. Here are
some practical steps that are most likely to lead you to a better
emotional place. Remember that learning new skills takes
patience, practice, and perseverance.
Step 1: Becoming Mindfully Aware of the Way Things Are
Slow yourself down by paying attention to your breathing. You dont
have to breathe any special way; just focus your attention on
your breath. When you are a bit more centered, turn your
attention to your current emotions, thoughts, and sensations.
Take a moment and just notice what you are thinking and feeling
and the accompanying bodily sensations. You may find that you
have some judgments about your thoughts and feelingsjust
notice them and let them pass. For example, you may notice your
thought that a stronger or more resilient person wouldnt
feel the way you do or that it isnt fair that this is
happening to you. Let it go. I guarantee you these judgments are
not useful to you. If you find that you have some trouble letting
the judgments pass, here are some techniques to try. Imagine that
your judgments are like clouds in the sky and just watch them
float away. Or picture yourself putting the judgments on a
conveyor belt and watching them disappear from view. The first
step is just about noticing how things areperiod.
Step 2: Letting Go
Once you have noticed what youre feeling, thinking, or
sensing, the next order of business is about accepting the
situation as it is. Nonacceptance reflects itself through tension
in our bodies, repetitive thoughts about not believing the
situation we are in is occurring, and feeling angry and/or sad.
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Heres what you need to do. Slow your breathing down and
notice where in your body you are holding the tension. Often we
hold tension in the face or upper back, but learn where you
yourself typically hold on to tension. Then deliberately relax
that area of your body. Think about softening the muscles, or
imagine the area getting warm and relaxed. Gently and kindly
begin to tell yourself that things are as they are. Remind
yourself that everything changes, and the current situation will
pass. Stick with this process until you feel some relief.
Acceptance can be hard to come by, as we tend to use our
imaginations to construct alternative scenarios. We can say to
ourselves, If only such-andsuch hadnt happened, then
I wouldnt be in the unfortunate place I find myself.
Using our imaginations this way is bound to compound our misery.
It makes us focus on what could or should have been. When that
occurs were likely to distract ourselves with an internal
narrative that, while it could have been true, just doesnt
match whats happening in real life. Or we can become
immersed in creating a story about the future that leads us
astray from effectively managing what is on our plates right now.
Acceptance is about acknowledging whats happening in the
moment whether its planning your childs
treatment, having a terrible argument with your spouse, or
enjoying your dinner. Acceptance does not mean that you like what
is happening or that youre in agreement with it, only that
the facts are what the facts are. Remember when Kriss mom
said she couldnt believe what was happening? That statement
indicates that she has not yet fully accepted her situation (see
box). When you accept things as they are, youll often feel
a sense of relief or calmness. Not accepting your situation is a
direct route to increased suffering.
EXAMPLES OF PHRASES THAT INDICATE LACK OF ACCEPTANCE
1. 2. 3. 4. This cant be happening. This just isnt
fair. Why does this always happen to me/us/her? I just will not
deal with this.
Not long ago during a session in which we were teaching
acceptance skills to parents of kids in our program, a mother
reported the following experience. She told the group that while
she knew that her kid was having troubles, shed never
really accepted this fact. She went on to say that she realized
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that she spent inordinate amounts of time thinking that this
couldnt be really happening to her, that it was just a
phase her child was going through. She even had the idea that she
would wake up one morning to find that it had all been a dream.
She told us she was in a constant state of worry and fear. During
the week after this session, she practiced acceptance and noticed
the following: her anxiety decreased, she felt more able to
harness her energies to help her child, she was sleeping better,
and she was more effective at work. You have no doubt used
acceptance skills in other parts of your lives without realizing
it. Think about a time when you were stuck in traffic, or when
you got some bad news at work, or you heard that your favorite
sports team lost. You found a way to accept these situations and
felt that you had a little more inner peace. The idea is to bring
that same skill set to the current situation you are facing with
your child. Pain, as we know all too well, is an inevitable part
of life. Theres no way to avoid all of lifes painful
situations: people die, people get sick, and decisions we make
turn out badly. Suffering, however, is another matter. Often we
suffer because we wont accept the pain in our lives; we
rail against the injustice of it all. The Buddhist tradition has
an equation that says Pain + Nonacceptance = Suffering Acceptance
occurs when were no longer fighting reality but
acknowledging our situation as it is in this moment. Acceptance
helps to ease the inner emotional turmoil that is produced when
we fight reality. That inner fight is one of the chief
contributors to a sense of despair, impotent anger, and mental
exhaustion that only leads to increased suffering.
Step 3: Repeating Steps 1 and 2
It turns out that acceptance can evaporate faster than dew on a
summer morning. All too frequently our minds make a U-turn and we
head right back toward rumination and suffering. The trick is to
hold in your mind that acceptance doesnt often keep for
long and you are very willing to start the process all over
again. Acceptance can bring relief as long as we remain committed
to working at it. I first encountered the idea of acceptance as a
strategy to help manage distress in my first formal DBT training.
Soon after returning to Boston from the training, I found myself
stuck in traffic that was going to make me very late for an
important meeting. Naturally Id left my cell phone at home.
I began to do what I frequently did in such moments: I castigated
myself for being
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so dumb as to leave the cell phone at home, I thought about how
unjust it was that traffic was snarled when I was in a hurry, and
I lathered myself into a near rage. Then I had the idea that
maybe this was a time to practice acceptance. Okay, I
said to myself. First focus on your breath, then notice
where the tension is in your body. I relaxed the muscles in
my face and back. Okay, now accept the situation as it is.
You are stuck in traffic and you are going to be late. This is
just how it is in this moment. Whatever is going to happen is
going to happen, and there is currently nothing you can do to
change the situation. Relief! Then, approximately 3 seconds
later, Crap! Im stuck in traffic! This acceptance
stuff is nonsense! I shouted out loud. Thats when I
remembered to repeat steps 1 and 2. Acceptance is not a
problem-solving strategy, although its often the first step
in effective problem solving. If you think about it, you really
cant find solutions to problems until you have accepted
your circumstances as they are. Here is an example that I think
will illuminate this point. One day you go to your garage to
start your car. You get in and turn on the ignition and you hear
that whiny no way is it going to start sound. What do
you do? If youre like most people, you turn the key several
more times, as if that will make a difference. You now have a
choice: you You cant find solutions to can complain about
how this should problems until you have accepted not be happening
and worry that you your circumstances as they are. might have to
buy a new car, all the while turning the key again and again, or
you can accept things as they are and call AAA. Remember:
acceptance does not require you to find your situation a good
one; it just means acknowledging whats happening in this
moment.
EMOTIONAL MINDFULNESS
Youre going to do what? Theres no way your mom
and I are going to let you spend the night at Julias house,
Morgans father shouted. Why not? Morgan asked,
her voice beginning to rise in anger. The very fact that
you have to ask blows my mind, her father replied angrily.
Dont you remember what happened last time? You and
she drank in her basement, had boys over late at night, and got
involved in things that triggered your cutting. That
wont happen again. I dont have any money for beer.
Remember, you stopped my allowance! Morgan shouted.
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Thats not the point! You really cant be that
dumb. When are you going to grow up? Morgans father
screamed. Most parents I knowwhether theyre part of
my clinical practice, friends, or relativeshave had the
experience of becoming emotionally overwhelmed with anger and
frustration in the face of some seemingly outlandish aspect of
their teenagers behavior. They often report that in spite
of their best intentions or efforts, they lose their emotional
balance and fan the flames of the heated discussion. Often in the
midst of the emotional storm the parents have the idea that their
own reactions are making the situation worse, yet feel helpless
in the moment to stop. That inner voice says, Slow downyoure
losing it, but they just cant harness sufficient
restraint. Soon afterward, they feel guilt and remorse. Sound
familiar? Its a lousy feeling. Parents who have an
emotionally vulnerable adolescent and one who is engaged in
deliberate self-harm frequently worry whether their loss of
emotional balance is going to trigger an act of self-injury. Some
parents tell me that the most painful and crazy aspect of this
moment is that sometimes, alongside the worry about causing their
child to self-injure, is the goading thought, Okay, kid, if
youre going to hurt yourself, go ahead and do it,
followed immediately by shame, guilt, and remorse. The
overwhelming majority of parents I have met are extremely
troubled by these kinds of experiences and struggle with the very
painful feelings that linger for some time after the event.
Knowing how to sidestep these situations will help you feel
better about yourself, guaranteed. So here is a technique that
can keep you from being swept away by your own emotional tidal
wave: become mindfully aware of your feelings before they
escalate to a troublesome point. Here is an example of what I
mean. Your daughter has been on the phone fighting with her
boyfriend for the last half hour. Suddenly you hear the door to
the bathroom slam shut. Without even thinking, you rush upstairs
and pound on the door, telling her to open up right now. She
shouts back, telling you to leave her alone, that shes
fine. You persist, which only leads to a heated exchange. If youd
been able to be mindful of your emotions, the situation might
have played out differently. You would have noticed that you were
frightened of what your daughter was going to do, and for good
reason, but noticing your fear might have slowed you down and
enabled you to be more effective. Instead of pounding on the
door, you might have knocked, asked your daughter if she was
okay, and communicated your worry. This might have avoided the
fight. When we can identify and accurately label our emotions, we
are building a kind of mental box that helps keep them safely
contained, and we are
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avoiding that awful sense of being ambushed by our own emotions.
Of When we can identify and course, the situation is made more
accurately label our emotions, we complex when were
experiencing are building a kind of mental box more than one
emotion at a time, to contain them safelyplus we but our
task is the same. avoid that awful sense of being Say your child
has been in ambushed by our own emotions. DBT therapy for about 6
weeks and has been doing really well. After she gets a bad grade
on a math test, however, you notice some new scratches on her
arm. Almost without thinking, with annoyance in your voice, you
confront her. The situation quickly deteriorates into an
argument. If youd been able to be more mindful of your
emotions, you might have noticed that while you were angry, your
stronger emotions were fear and sadness. Being more attuned to
all the emotions would most likely have helped you avoid the
argument. When were successful in this process, were
less likely to be pulled into the undertow of an emotional high
tide. When our emotions just take us over, in the language of
DBT, we are in emotion mind. In this state our
thoughts and actions are governed primarily by our powerful
emotional experience; we have the feeling of being pushed around
by our emotions. To the degree that were even thinking
rationally, it seems to have no effect on our actions. From a
neurobiological perspective, the parts of the brain that fire our
emotions are going full blast, while the parts of the brain that
have to do with rational thinking and problem solving have shut
down. The trick is to get the brain systems of the prefrontal
cortex, which are responsible for rational thought and action,
back on line. One way to do this is use the DBT skill called
mindfulness of your current emotion. As with any new
skill, practice this one in situations of relative calm before
employing it in the heat of an emotional firestorm. Practice it
when you miss the bus, when your favorite sports team loses, or
when that new recipe you spent all afternoon on makes an inedible
mess. The two hypothetical examples I just described with your
child are typical situations where this skill can really make a
difference.
Step 1: Turning Your Attention to the Experience of the Emotion
Once again, the first step is to focus on the sensations that
accompany the emotion. Try to locate where in your body you feel
the emotion. Your job is to become a kind of anthropologist who
is gently interested and curious to un-
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derstand all aspects of a particular behavior. For example, most
people when they are sad feel heaviness in their chest; they may
also experience a tightening in their face as a way to prevent
the tears from flowing and a trembling in their lips. When were
angry, we feel a tightening of our fists as our jaws move
forward. Notice how the intensity of the feeling waxes and wanes.
The trick is to begin observing and describing these sensations
as soon as you become aware that youre getting emotionally
charged up. Your task is to simply notice what youre
feeling; thats it. Doing this simple exercise will decrease
the chances of things escalating into an altercation. Notice
whether youre making any judgments about your emotions (I
am wrong to feel angry or Its dumb to feel sad)
and, if you are, work at letting the judgments go. In a
nonjudgmental fashion, just accept this moment as it is. By
deliberately observing and describing your experience, you will
bring your prefrontal cortex into play. When that happens, youll
find that youre more likely to become more rational and
balanced. For example, Ariels mom noticed new cuts on her
daughters legs. Her first impulse was to ask her daughter
what the heck was going on. Instead she noticed that she felt
anger rising in her chest and some sadness alongside it. As she
did this, she was able to put things in perspective and think
about how she was going to address her observations with her
daughter. What was surely headed toward a heated exchange now had
a chance to become a controlled discussion.
Step 2: Doing What the Situation Requires
It may be that as you feel in more control youll want to
continue the discussion, or it may be that you need a break and
will come back to the issue at a later time. Sometimes after
regaining emotional control, what you need is to do something
kind and soothing for yourself. Karen realized in the middle of
confronting her daughter about her selfinjury that she no longer
felt tongue-tied by After regaining emotional frustration and
could calmly talk about it control, do something kind with her
daughter. Sidney felt such an overand soothing for yourself.
whelmingly heavy sadness when his son explained for the sixth
time that month that I just had to do it, Dad, that
he needed to be alone for a little while before he could talk to
his son without making them both feel more overwhelmed. Whatever
you decide to do, it will be done under your balanced emotional
control rather than under the sway of negative emotions, and that
will undoubtedly feel better to you. As I have stressed before,
it is very important that you practice these skills in noncrisis
situations first. Practice emotional
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mindfulness when youre annoyed at a waiter, or when you see
a sad story in the newspaper or on TV. Use the ordinary moments
in life to practice these skills.
CHANGING WHAT YOU FEEL IN THE MOMENT: OPPOSITE ACTION TO CURRENT
EMOTION
Imagine that you just noticed that your child has a new cut on
her wrist. You thought she was in distress an hour or so ago, but
when you asked her if she was okay and if she needed any help,
she said everything was fine. In this situation you
would most likely feel a combination of worry, sadness, and
anger: worry that your child is still resorting to self-injury,
sad that shes unhappy, and anger that when you offered
help, she denied there was a problem. As the day wears on, you
find that these painful feelings keep circulating through your
mind, making it difficult to stay focused at work and impossible
to take pleasure in the good things that happen during the day.
You are stuck in the feelings generated hours ago. Clearly you
need a way to change your current emotional state. The skill set
that will help you in these situations is opposite action to
current emotion. It means you are deciding to change the way you
feel. If what youre feeling seems appropriate to the
situation, though, you may not want to change it. For example, if
you have experienced the loss of a loved one, you want to stay
with the sad feelings as part of the grieving process. Simply
put, opposite action to current emotion requires you to choose an
activity opposite to what your current emotion is pushing you
toward. For example, if youre like most people, when youre
feeling depressed and leYour goal is to change the way thargic
your body tells you get in bed youre feeling. Want to crawl
and pull the covers up over your head. into bed? Take a brisk
walk You have the impulse to get out of life instead. Feel like
screaming and and just lie still. The opposite action pounding
the wall? How about would be to deliberately and with consome
soothing music instead? viction get involved in an activity.
While this is certainly easier said than done, with some effort
you can achieve great results. Staying with this example, you
might decide to take a brisk walk or go to the gym. All emotions
have a corresponding action potential. Anger tends to make us
move toward attack, for example, while fear makes us withdraw,
and shame
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makes us want to hide. Once you recognize an emotions
action potential, the trick is to pick an activity that is its
direct opposite. For example, you come home and find
blood-stained tissues in the bathroom again, and your child has
left a note saying hes gone to a friends house and
wont be back for several hours. After calling him and
checking in, it wouldnt be too surprising if one of the
emotions you felt was anger. You think about calling him back and
insisting that he come home, or you think about how youre
really going to let him have it when he gets back. But wait! You
notice (mindfully) that you are just cooking your anger, and in
fact you want to change the way you feel. You decide to do
something nice either for yourself or for someone else. So
instead of giving in to the action of the angry emotion, you
prepare your favorite dinner for the family. Opposite action to
current emotion is a very effective skill but one that is
difficult to master. In order to optimize your chances, I believe
there are three critical things to keep in mind. First,
understand that this skill is about acknowledging what you feel
in the moment. Its not about denying what youre
feeling or judging what youre experiencingits
only about accepting how things are in this moment. Second, be
sure to accurately label the emotion you want to change and its
corresponding action potential. You can do this by using your
emotional mindfulness skill. You must know what youre
feeling in order to take the opposite behavioral action. Third,
you have to totally commit to doing this skill. You will not reap
the benefits if you participate in a half-hearted fashion.
Opposite action to current emotion requires that you throw
yourself into the activity 100%. The following are some
guidelines for opposite action to the particular emotions of
sadness, anger, fear, shame, and guilt. Feeling Sadness Anger
Fear Shame Guilt Opposite action Physical movement Do something
nice for yourself or someone else Face it Face it Either repair
it or tolerate it
Opposite Action to Sadness: Physical Movement
As I suggested earlier, sadness and depression seem to drain us
of our energy. Often it feels as if we just dont have what
it takes to do the simplest of tasks.
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All we want to do is lie down and rest. We are preoccupied with
dark thoughts, and it feels as if our lives will never get
better. The action potential for depression is to stay still. If,
however, you decide that you want to shake the blues, then choose
an activity that requires physical movement. You dont have
to run a marathon. Try a quick-paced walk, turn up the music and
dance, or go to the gym. I think you will find that your mood
will change as you get involved in the activity. Samantha felt
that she could hardly get out of bed when she awoke, and
instantly remembered the new scabs shed seen on her
daughters arms the evening before. As she remembered, an
intense wave of sadness came over her and, with it, a powerful
urge to pull the covers up and go back to sleep. She felt
extremely fatigued. She knew she had to get up to go to work, but
her body was telling her to stay in bed. She recalled the skill
of opposite action to current emotion and decided to try it. She
turned on some music and began to stretch.
Opposite Action to Anger: Do Something Nice
When were angry we want to strike out and go on the attack.
Sometimes this is just what the situation requires, but often
attacking will only make the situation worse. We feel stuck in
our anger and begin to ruminate on the unfairness of the
situation. We imagine what we would like to do or say to the
person with whom we are angry. We cook our anger until it takes
over our mind and ruins our day. If youre angry and can
take an appropriate action to improve the situation, then by all
means do so. For example, if you feel slighted by your spouse and
think that a discussion will resolve things, then do it. In those
instances where there isnt any effective action you can
take, however, rather than cook your anger into a spicy ragout,
try opposite action. In the case of anger, opposite action would
be doing something kind for yourself or for another person. Send
someone flowers or make your spouse a special dinner or inquire
after an old friend. Trust me: getting involved in acts of
kindness will help dissipate your angry feelings.
Opposite Action to Fear: Face It
When were frightened or worried about something, we have a
tendency to avoid those situations that are likely to elicit this
emotion. For example, parents who have a child who is engaged in
self-harm often become fearful of confronting him or her about
something out of the worry that it will cause an argument that
will lead to self-harming behavior. When we give in to fear and
avoid situations that require action, we now have two problems
instead
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of one: the original problem plus the sense of diminished
self-regard that we typically feel when we know were
avoiding something because of our worry. So if fear is making you
avoid something that really needs to be addressed and you are
troubled by a sense of diminished self-esteem, approach the
problem head on. Do what youre afraid to do. Again, I
suggest that you practice this skill on the small worries first.
If youre afraid of telling a bossy friend that you have to
cancel a dinner engagement, for instance, take a deep breath and
just do it. Let yourself have the experience of knowing what it
feels like to approach and master fearful situationsI
guarantee it will work wonders on building your confidence to
tackle the harder issues.
Opposite Action to Shame: Expose Yourself to It
Shame is such an awful emotion. Shame makes us want to disappear
and hide. Parents who have a child who engages in self-harm
frequently experience this emotion in situations where they have
to explain something about their childs status to a friend
or relative or to the school or another institution. People work
very hard to avoid the experience of shame. Sometimes when
parents avoid shame they are unwittingly cutting off their noses
to spite their facesthat is, they may be depriving
themselves of the much needed help and support available from
friends, relatives, and institutions. The trick is to make the
best assessment you can about who in your world can be trusted
with this very sensitive information and speak with them. You
want to avoid sharing information with people who are going to
induce shamethat is, those who are likely to negatively
judge you or your kid. Once you have figured out whom you can
trust, then I suggest that you deliberately speak with these
folks about your situation. When you do this, expect that shame
will rise to the surface and, as it does, just notice the
experience without avoiding it. The psychological principle at
work here is known as exposure. It turns out that when we are
racked with shame, exposing ourselves to the experience without
judging ourselves or avoiding the experience will diminish the
intensity of the shame. The same principle is at work if we
listen to a favorite song over and over againafter a while
it loses its charm for us. The more you do this exercise, the
less shame will be a factor in your life.
Opposite Action to Guilt: Repair or Tolerate It
What parent doesnt feel some guilt about his or her
parenting? A certain amount of guilt just seems to be an
occupational hazard, but being overrun by
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guilty feelings will leave you feeling awful about yourself and
put a black cloud over your life. Here are some ways you can
manage your guilt. There are two central questions to ask
yourself that will help you figure out whether your guilt is
warranted or unwarranted. Its an important differentiation
to make because warranted guilt requires you to make a repair and
an apology, while unwarranted guilt requires you to tolerate your
distress without the repair and apology. 1. Are you responsible
for having done something, either unwittingly or intentionally,
that has been harmful to your child, or does your guilt arise
from some judgment about yourself that is less reality-based?
Here is an example of what I mean. On Sunday night your son asks
if you can pick him up after school on Tuesday rather than his
having to take the bus. He tells you that he wants to get to his
friends house as early as he can because all his friends
are getting together to play a new video game. You agree and tell
him that you will be there. That is the last time you and he
discuss the arrangement. Tuesday comes and you are swamped at
work. Your agreement to pick him up just falls out of your head.
Around 3:30 the phone rings: its your son asking where you
are. In all likelihood you are going to feel a little guilty
about having forgotten to pick him up. In this situation it would
make perfect sense that you would feel guilt. 2. Have your
actions violated your ethics or values? Mollys 14-yearold
daughter has come in way past curfew over the last several
weekends without any good explanation. An important value in
their family is that members keep their word about the
commitments they make, and that if they cant keep a
commitment they will let people know about it in a timely manner.
Furthermore, Molly is pretty certain that some drinking may have
occurred on these occasions. The last time she was late, Molly
put her on notice that the next infringement would result in a
grounding for the following two weekends. The girl acknowledges
that she understands the consequences for being late. The next
Friday night she comes home 2 hours late with no phone call. She
understands that shell be grounded. Several days later,
however, she informs Molly that next weekend her former best
friend, a girl who moved away years ago, is coming back to town
for just one night. She pleads with Molly to cut her some slack,
but Molly holds her ground in what turns out to be a very
upsetting interchange, leaving the girl sobbing in her room for
hours. Thats when the guilt starts bubbling to the surface,
pushing Molly to reconsider the limit she set. Her guilt is
getting
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the best of her and she wonders whether sticking to her guns is
the right choice. Is Mollys guilt warranted or unwarranted?
Most of the situations we encounter as parents are not clear-cut
cases of warranted or unwarranted guilt, and this ones no
exception. Lets take the example apart. I think everyone
would agree that Molly was well within her parental rights to set
the limit and that the conditions for grounding are fair. In
fact, I think we would say that she would have been remiss in her
duties had she not set the limit she did. Furthermore, at the
time the limit was set, the daughter seemed to understand and
accept the consequences for her lateness. So far so good, but now
it gets tricky. While it is true that her daughter is hurt by the
limit because she cant see her friend, I dont think
we can hold Molly responsible for her daughters hurt
feelings, nor can we say that Molly has done something that is at
variance with her own values or ethics. The daughter is
responsible for her response to the punishment; her mother may
feel understanding but shouldnt feel guilty. Consequently,
the guilt that Mom feels is unwarranted, and she should act
opposite to the emotion and not apologize and/or undo the
consequences. Her daughter will not be able to see her old
friend. In short, warranted guilt requires a repair and an
apology, and unwarranted guilt requires that we tolerate our
distress and stick to our guns. Opposite action to current
emotion is a powerful skill that, when effectively used, will
help turn down the temperature on negative emotions and increase
moments of calmness, happiness, and pleasure. What parent wouldnt
want more of that?
TAKE CARE OF YOURSELF
I really dont want to sound like your guilty conscience,
but its just a fact that managing your life with balanced
sleep, healthy eating, reasonable exercise, and avoiding
excessive use of alcohol and other substances reduces your
susceptibility to the negative emotions. For example, in times of
stress our bodies need good nutrition to manage the extra
workload. All too often in such times, we just dont have
the energy or feel we dont have the time to eat right. We
skip meals, eat more fast food than usual, and/or soothe
ourselves with rich desserts. While all of this is understandable
and I certainly would not encourage you to move to a Spartan dietafter
all, having some treats in your life is a good thingI ask
you to be mindful of your bodys nutritional requirements.
You will feel better and have more resilience to get through the
hard times if you do.
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Living somewhat off the mark can limit your capacity to fully
experience moments of happiness too. Just think how tough it is
to enjoy your day when you are sleep-deprived or hung over. Often
when our lives become more stressfuland living with a child
who engages in deliberate self-harm certainly is among the most
stressfulwe often resort to coping strategies that may work
in the moment but leave us more depleted in the long run. Having
that extra drink or glass of wine are examples of strategies that
may promise short-term relief but generally work against us in
the overall scheme of things. The stress associated with a child
who has emotional troubles can cause you to lose sight of the
healthy things you need to do for yourself as you throw yourself
into the process of helping and getting help for your child.
Exercise, healthy eating, and activities you find fulfilling are
often casualties of the process. You may sacrifice doing the
things you enjoy in order to be more available to your child.
When I meet with parents who have a child who is selfharming, I
routinely ask them what they are doing to lower the stress level
in their lives. If they tell me that theyve given up almost
everything they used to enjoy, I encourage them to get back into
those activities that make life a little more worth living.
SIGNS THAT YOU NEED TO TAKE BETTER CARE OF YOURSELF
1. Are you eating more fast food or junk food because it just
seems easier or quicker? 2. Are you feeling tired all the time?
3. Are you feeling pressured and stressed by things or events
that you ordinarily have taken in stride? 4. Are you more
irritable? 5. Do you have the sense that there is no time for you
anymore?
RELATIONSHIP MAINTENANCE
As the song goes, You always hurt the one you love,
or, in some cases, the one you used to love. Relationships are
always tested in times of stress, and parenting relationships are
no exception. At the very time when the parenting partnership is
most in need of protection and maintenance, it often falls by the
wayside when a child has emotional difficulties. All too
frequently different parenting styles that have been overlooked
in the past are now called into question as possible causes of or
at least contributors to the childs self-injurious
behavior. Long-standing difficulties in communication that
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177
were annoying at worst now become major points for concern. As
the relationship worsens, the possibility that it could be a
source of comfort goes down the drain. Parents feel wronged,
alone with their worry, and angry. Keeping the parenting
relationship alive, vital, and a source of comfort are of
critical importance in helping you stay balanced.
Coming to a Meeting of the Minds
It seems to be a human tendency that when we are stressed, we
fall into black-and-white thinking. If one parent is right, then
the other parent must be wrong. Discussions can quickly
deteriorate into heated battles over whose position is true and
why the other persons is false. Feelings are hurt, and
anger and frustration take the day. The relationship, no longer a
source of support, becomes yet another problem to be solved. One
way to avoid this awful situation is to work at maintaining a
dialectical discussion (see Chapter 4 for a review). The
following pointers will help you avoid those dead-end
discussions: 1. As hard as it may be to believe, you dont
have the corner on the market on truth, nor does your partner. 2.
Ask yourself, Do I want to be right or do I want to be effective?
3. Work at finding at least the grain of truth in your partners
point of view without giving up on the grain in yours. 4. Look
for what each of you is leaving out of the picture. 5. When the
discussion gets back on track, validate your partner and
yourself. Validation at this point might just accomplish two
things. First, it may smooth the way for the discussion to
continue in a reasonable manner, and second, it may reinforce
more effective communication.
Repairing the Relationship
In order for you to use your relationship, whether it is with
your primary parenting partner or not, as a source of comfort,
you have to know how to make a repair when things have gone
south. I can almost guarantee you that being skilled at this will
maximize the support and comfort you get to reduce the stress in
your life. The good news is that you dont have to learn a
new skill; the GIVE skill I outlined in the previous chapter is
the one to reach for. Often the hardest part of making a repair
is overcoming your aversion to making the first move. If you ask
yourself questions like Why is it always me
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who has to apologize first? or I wouldnt have
said the things I did if she hadnt started in with me
may be 110% correctbut, again, the essential question is:
Do you want to be right or do you want to be effective? Effective
in this case means working at repairing the relationship so you
can get more of what you need. The choice is up to you. I urge
you to find the willingness to move in the direction of doing the
things that will help you get the comfort, support, and
pleasurable moments that you need.
Keeping the Relationship Strong through Action
Im going to end the chapter with a section on maintaining
your primary adult relationship. When that relationship is
running smoothly, you are in a better position to weather the
hard times with your kid. Relationships work best when time is
set aside just for the couple. Keeping the couple strong and
vital goes a long way toward preventing parental burnout and
helps you to create times of comfort, pleasure, and support.
Keeping your primary relationship strong takes deliberate action.
While spontaneity is wonderfuland I encourage you to find
those special moments when things just seem to happendont
let your relationship slide for lack of planning. Make time for
going out to dinner, seeing a Whatever happens for your movie,
or, if possible, going away children, there will most likely for
a weekend. Whatever happens come a time when they will leave for
our children, there will most home. When that time comes it
likely come a time when they will be just you and your partner,
will leave home. When that time so protecting the relationship
now is comes it will be just you and your a wise investment in
your future. partner, so protecting the relationship now is a
very wise investment in your future. Remember that this is not a
dress rehearsal, but time in your life that you are not going to
get back. Taking care of your relationship is taking care of
yourself. Your child will be better off for your efforts. In this
chapter Ive focused on the immediate triangle of you, your
partner, and your child. In the final chapter, Ill help you
navigate your way in the wider sphere of the other children in
the family, as well as your childs friends and school.
9
how to speak with siblings, friends, and the school about your
childs troubles
Getting a grip on your childs problem by understanding
where it came
from and how it can be treated is a giant step. Self-harm is a
difficult enough problem for you, your child, and the therapist.
But you also need to negotiate your way in the wider world during
the time your child is being treated. In this chapter Ill
share my advice on the complicated and delicate matters of
communicating with your childs siblings, friends, and
school.
SIBLINGS
Mommy, I know somethings wrong with Samantha. I heard
you and Daddy talking last night. Is she going to be okay? Why
does she hurt herself? Doesnt she like herself? Is she
going to have to go to the hospital? asked 8-year-old
Tommy. Samantha is having some worries now, and Dad and I
are making sure she gets the help she needs, his mom
replied. Im glad you asked, because we know you have
noticed how upset she gets sometimes, and how your dad and I have
been worried about her. Are you worried about your sister?
Yes! I get kind of scared when everybody gets so upset and
worried, Tommy said. Sometimes it seems like you guys
just forget about me and only think about Sam. Another
sibling of a teen who self-harms, 16-year-old Bill, had this to
say about his sister: I think shes just a drama queen
looking for attention! You and Mom are just being idiots and dont
see that. You know she doesnt even try to
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stop, and all you guys do is give her the attention she wants.
Plus you send her to that shrink, who isnt doing anything
and is costing a fortune. Slow down here, Bill,
his dad responded. I know it seems like shes doing
this for attention, but we dont think thats the whole
story. We know this makes you angry. Your sister is pretty
unhappy right now. Please do me a favor and just open your mind
to other possibilities about why she cuts herself. Like
what? That she enjoys the pain or that it makes her feel cool?
Bill replied sarcastically. Actually, I didnt have
those in mind. I know how upsetting this is to you, and I think
more information would help. Your mom and I are concerned about
how this is affecting you. If you can find a way to open your
mind to your sisters seemingly crazy behavior, I can try to
tell you about some other possibilities, and I think youd
feel better about how were handling it, Dad replied.
A child who self-injures affects every other member of the
family. If you have other children, it can be very hard not to
allow the one who self-harms to become your primary focus. I
encourage you to stay mindful of the other childrens needs
for your time and understanding. Knowing that your other sons or
daughters are angry or jealous because one child is getting all
the attention hurts. Naturally you dont want them to
suffer, and you hope they could feel empathy toward the troubled
sibling. Let me make it clear that their reactions of anger and
worry about whether theyre going to get their own needs met
are totally normal. They may even be angry with you for not being
able to fix this problem quickly. In the following
pages I offer some guidelines for how to deal with your other
children so that they dont feel ignored.
Validate Siblings Experience
The best tool to help you, once again, is validation. If you can
validate how hard it must be for them and be nonjudgmental about
their anger or other negative feelings, not only will it be
easier for them to manage whats going on with their sibling
but theyll also stay connected with you. Maintaining that
connection will help them get what they need from you and be more
resilient in the long run.
Drop Guilt and Turn to Empathy
Let me say something about guilt. Every parent has it, whether or
not his or her kids are struggling. We have it because we all
have limitations. There isnt
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one of us who parents perfectly at all times. Good parenting
actually involves being aware of our limitations so that we dont
push ourselves further than we can go. When you have a child who
is not doing well, worry about whether you have been a good
parent can expand to huge proportions. Add other children who may
have to sacrifice some of your time and energy to their troubled
sibling and the situation is ripe for guilt. Its hard to
accept that you cant do it all, but of course there will be
times when you cant. Be aware of your guilt and respond to
your children with empathy rather than trying to make it up to
them with gifts or material things.
Stay Involved in Your Other Kids Lives
Of course having a child who self-injures is going to demand more
of your time, but make sure to find ways to be part of the other
kids school and extracurricular activities. On those
occasions when you have to miss an event because of an
appointment or because youre just worn out and need time
for yourself, be sure to offer the other child an alternative
time when you can be together. Think about involving other adults
in their lives to add to their support system. While no one can
take your place, having another caring adult available who is
aware of your childs problems can make all the difference
when you and the childs other parent are stressed and
temporarily distracted. Consider informing teachers or guidance
counselors that the family is under stress so that school
personnel can be on the lookout for problems and available to
step in to offer more support should they need it.
Talking about Their Siblings Self-Harm
The other kids in the family frequently dont know if, or
how, they should address the feeling that theyre getting
less from you, or how to ask questions or give voice to their
worries. If you decide to keep your teenagers deliberate
self-harm a secret from the other children in the family in the
hopes that it will protect them from undue stress or safeguard
the injuring childs privacy, you may unwittingly create a
number of additional problems. Kids are very perceptive. They
probably know that somethings going on, but the climate of
secrecy will deter them from getting information that might help
them manage their concerns. So the secrecy only results in
depriving them of adult help, leaving them to struggle with their
anxieties alone. In addition, being aware of a secret may
communicate to the other kids that somethings going on that
is so awful as to be unspeakable. Consequently, the secret,
rather than protecting them, may create more worry than is
warranted.
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How much the other kids in the family are affected depends on a
number of variables, including their ages, the kind of
relationship they have with one another, and their resiliency.
Sometimes the other kids let you know about their feelings, and
sometimes they remain silent. Knowing how to explain to the other
children in the family about deliberate self-harm and how you as
parents are getting the child the help he or she needs, and
inviting the siblings to express whatever concerns they may have
will reduce the tension in the family and help you all function
in a healthier way. The following three factors are critical in
helping you to establish guidelines that will steer you through
these tricky waters. 1. Before you speak to the other kids in the
family, you and your troubled adolescent must have a clear
understanding about what information is going to be shared.
Respect the self-injuring childs need for privacy, but at
the same time address the needs of the other children in the
family. Negotiate what information is going to be shared and with
whom, and whether the adolescent is going to be part of the
discussion. What is nonnegotiable is whether information is going
to be disclosed or not. Notice below how Samanthas dad is
validating but firm. See how he does not back down in the face of
Samanthas rising emotions. Balancing validation with
clarity and calm firmness is the path you seek. 2. What you say
to the sibling depends on his or her age. Kids in elementary
school need a more global but clear version of whats going
on, while children in middle and high school can probably
tolerate a more factual version of their siblings behavior.
Notice how Samanthas father is very clear about how he and
his wife are managing the situation and how he remains responsive
to his sons worries without burdening him with too much
information. The most important principles with younger children
are (a) to be honest without giving them more information than
they can handle, and (b) to convey the sense that while things
are troubling, you are in charge and capable of managing the
situation. Adolescents may know other kids who self-injure and
may subscribe to some common misconceptions about the behavior,
or they may harbor critical judgments about what kinds of people
resort to self-injury. Often adolescents, especially boys, use
anger and contempt to distance themselves from their worry and
concern for their sibling. On the other hand, they may have some
real capacity for empathy and concern that might translate into
support for their self-injuring sibling. Early adolescents may
need a slightly different approach than kids who are 16 and
older. Kids in this age group (middle school) vary, sometimes mo-
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183
ment to moment, between being adolescent and being more like a
younger child. Consequently, how much information you share with
them depends on your assessment of their level of maturity.
Children who are closer in maturity to younger children need the
information in more general terms, while the more mature kids can
use more detailed information that might include a discussion
about the function of self-injury and how their sibling is
getting the help he or she requires. In either case, adolescents,
like younger children, need to be made to feel that there is room
for their questions and their concerns. 3. Be careful in gauging
the capacity and resiliency of the children to manage the
information about their sibling. Some things you need to take
into consideration are how much stress the child is currently
under, whether he or she is an emotionally sensitive person who
is likely to be overwhelmed by too much troubling information,
and whether he or she has other outlets that may help in
modulating these worries. Taking these factors into consideration
will make you better able to think through how and what you want
to say to the other children in the family. The following lists
will help you assess how much stress your child may be
experiencing currently.
CHECKLIST IN APPROACHING YOUR ELEMENTARY SCHOOL CHILD
1. 2. 3. 4. Is your child more silent and withdrawn than usual?
Does your child seem clingy and needy? Does your child have
school or behavioral problems? Is your child having trouble
sleeping or falling asleep?
CHECKLIST FOR OTHER TEENS IN THE FAMILY
1. 2. 3. 4. Does he or she seem more withdrawn than usual? Is
your teen staying away from home more than is customary? Does he
or she seem irritable with you? Has there been an increase in
behavioral or school difficulties?
Samantha, your mom and I need to speak with you about how
were going to talk with Tommy about the problems youre
having, said Samanthas dad.
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I dont want you to say anything to him. Its
none of his business, and anyway he will blab things all over the
neighborhood! Samantha angrily replied. Your Mom and
I want to protect your privacy and help Tommy with any worries or
questions he may have, Dad answered. I dont
want him to know! Samantha countered quickly. While
we want to be sensitive to what you want, Tommy, let Mom know
that he knows something is going on for you and that hes
confused and worried, Dad replied. I have all these
problems, and now you guys are making it worse. Why cant
you think about how I feel for once?! Samantha said with
anger and sadness rising in her voice. The fact is, were
all worried and concerned. Tommy needs some taking care of too.
Do you want to be part of the discussion? Then you can tell him
how important your privacy is to you, Dad replied in a calm
but firm manner. All right, I guess. I dont like this
one bit, but I didnt know he was worried. Yeah, lets
talk with him together, Samantha suggested. Finding a way
to help the other children in the family understand whats
happening with their sibling will go a long way toward easing
your mind and helping you feel a little less overwhelmed. The
trick is to find the middle path between not burdening the
children and respecting their capacity to manage a difficult
situation. Keeping these guidelines in mind will help you come to
the right decision for your family members. Now lets talk
about dealing with people outside the immediate family circle.
EXTENDED FAMILY AND FRIENDS
What, and how much, should you tell extended family members and
friends about your child who self-injures? Its a difficult
issue. Lets start by figuring out why youre talking
to them about this delicate family matter.
What Is the Goal of Sharing the Information?
The best way to think about sharing information with extended
family and friends is to get clear about your goals for doing so.
As with speaking with siblings, its important that before
you share any information you let your teenager know with whom,
what, and why youre sharing this very sensitive information
about her. So take a little time and ask yourself a couple of
questions that will help you get clear about your goals.
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185
First ask yourself, What is my objective in sharing this
information? Am I looking for a source of support? Do I expect
the person or people with whom Im going to share this
information to be understanding and supportive or judgmental and
critical? Are these people likely to be supportive to me but
critical and judgmental of my child? For example, a friend might
convey support for you by blaming your kid for putting you under
so much stress. Conversely, he or she might be supportive of your
teen but blame you for the childs difficulties.
Can You Protect Your Teens Privacy Adequately?
Second, can I trust them not to share this information with other
family members or friends who may not be supportive? Or do I need
to provide just enough information about the situation to protect
our familys privacy? For example, your child has cuts on
her arms and she and you feel that it could be awkward to go to
the family reunion at the lake this year. Her brother and sister
have been looking forward to the reunion for months and would be
terribly disappointed if they couldnt go. The extended
family knows that your daughter has been having some kind of
emotional troubles, but theyre not aware that she
self-injures. What are you going to do? You and your daughter
might be more willing to be forthcoming if you were pretty sure
that the response from others was going to be warm, supportive,
and understanding. If that were the case, disclosing the
information beforehand might be the right thing to doit
would make it easier for your daughter to attend the reunion, and
you might feel taken care of by your relatives. On the other
hand, if sharing information were likely to make the situation
worse, then the best course of action might be to give very
limited information about your daughter and see if you could make
arrangements for her to do something else during the reunion.
That way her brother and sister would not be penalized because of
her troubles and you would not lose out on going to the family
gathering. Let me explain how Im using the phrase limited
information.
Is Lying Ever a Good Idea?
Youre in a tough situation, and there may be some
circumstances that would make you want to lie about the troubles
at home. For example, if you know that someone holds the belief
that theres no such thing as a psychological problem and
that therapy is a bunch of hooey, being totally honest with that
person about whats going on with your child is most likely
to lead to an awk-
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ward conversation at best. If you think that all youre
going to get from this person is judgment and grief, but you do
need to provide some explanation, lying might seem like a
reasonable strategy. I believe, however, that lying brings with
it a whole host of unforeseen problems. It compromises our sense
of integrity, and that erodes our selfesteem. For most people the
usual emotional response to telling a lie is feeling guilty, and
nobody enjoys that emotion. Furthermore, when were caught
in a lie, we most often feel ashamed. And it almost goes without
saying that lying complicates our interpersonal relationships. If
the self-injuring teen becomes aware of the lie, it could give
her the message that what shes doing is so horrible that it
must be covered at all costs. Dont you have enough to deal
with already with this troubled child? My advice: Avoid lying
whenever possible. That doesnt mean you have to disclose
everything about the situation at home, just enough to be
effective in achieving your goals. When you hide the full story,
its generally better to stick with some partial truths
rather than fabricating untruths. So what should you say? Most
people know at least a little about depression from news stories
or from people they know who have suffered with it. Because kids
who self-injure are often depressed, its not such a stretch
to focus on that aspect of their troubles. It lets someone know
the general realm of the problem (mental health) without
violating your teens privacy. You can talk also about
difficulties with coping and problems with
self-esteem, both of which, again, tell a partial truth
without revealing too much. Of course, these partial truths will
work only in those situations where the teens scars are not
visible. Most kids are reluctant to allow other people to see
their wounds. There are, however, a minority of kids who do want
people to see them, either as a communication about their
distress or as an expression of anger or rebellion. I would
suggest that you have a discussion with your child about the
impact of her scars on other people and why you believe
discretion is advised. If she insists on displaying her scars,
then I would let her know that it will be her responsibility to
explain to people whats going on. Also let her know that
youre going to be open with people and give your version of
events. If she continues to show her scars, you will be in a
position of having to be honest with people and to educate them
as best you can, but you should also suggest that they speak
directly with your daughter. Be mindful of using your distress
tolerance skills, as this is potentially a very stressful
situation. You always have the option of not allowing the child
to see these people if that seems the most prudent strategy.
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Accepting Others Limitations
No matter how careful and skillful you are, there are some harsh
realities youll need to manage. There will be people who
distance themselves from you or your child because theyre
afraid of what he does. People can find self-injury frightening
and deeply disturbing. You cant educate everyone,
especially while youre also trying to take care of yourself
and your family. If your child loses friends, or her friends
parents wont allow contact because they learn of the
selfinjury, be validating to the loss. Over time these natural
consequences may help channel some of your childs energy
into change and recovery.
What to Say to Those You Trust
You need to hold on to the relationships that will be most
sustaining for you, and that means trusting your instincts about
whom you can talk to openly and honestly. Most parents find it
comforting to have a select group of people with whom they can be
honest. Talking with too many people in an attempt to get support
will usually leave you feeling exposed and vulnerable. Youll
probably have a few people in your life with whom you will want
to share this problem, and in order to elicit support, you might
have to demystify it.
Here are some guidelines for those few close friends and extended
family members youll want to share this with:
Explain that self-injury is most often a way for a person to cope
with overwhelming emotions. Counter any misconceptions
they may have about self-harm, such as it being a suicidal
gesture. Be clear about what you need in terms of supportthat
is, request that they listen without giving advice, or ask
specifically for help with problem solving. If youre
concerned that sharing this information will change their opinion
of you or your child, be open and talk it through with them.
THE SCHOOL
Its not uncommon for kids who self-injure to have problems
in school. These difficulties can be of a social nature, an
academic nature, or both. Kids who
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self-injure are often mood-dependent. Consequently, when theyre
feeling sad, angry, or overwhelmed, they may have great
difficulty paying attention in the classroom or completing
homework assignments. Caught in a downward spiral of missed
assignments and poor grades, their attitude toward school
deteriorates. As soon as you become aware that your child is
falling into this pattern, its time to access additional
school services. In addition, school forms the basis of a
teenagers social life. It is the primary place where kids
develop and learn how to manage interpersonal relationships.
Often, when a child begins to self-harm, rather than being
supportive, other children may withdraw from the friendship. This
can also have a negative effect on the childs attitude
toward school. Its important that you find ways to make the
school environment as positive an experience as it can be. This
may require working with the school to make an individualized
education plan, or IEP. The key is to respond quickly when you
notice that school is becoming a problem, either academically or
socially, for your child.
How and When to Have the Discussion
School personnel may very well be the first adults to find out
about your childs self-harm. Another student might get
concerned and alert them, or a teacher may notice the wounds.
Once this happens, the school is required to take some kind of
action. Schools are very worried about the copycat effect that
self-injury sometimes generates in a community of adolescents. In
my experience, schools respond in a variety of ways, from simply
notifying you and asking you to take your child to the
pediatrician to requiring the child to take a medical leave until
the behavior is resolved. In any case it is likely that you will
be in an ongoing dialogue with the school. In situations where
the school knows about the self-injury, your best course of
action is to be forthcoming with information about the treatment
youre getting for your child and the progress he or she is
making. Always maintain a good working relationship with the
school, as you may need to access their services in the future.
Depending on how sensitive and understanding your school
personnel are and how your child feels about bringing the school
more into the know, it can be a good idea for the school
counselor to have periodic updates from your kids treatment
team. The bottom line is that when the school knows about your
kids behavior, being straightforward with the facts is the
best course of action. In those instances where the childs
deliberate self-harming behavior comes to light out of the
purview of the school, parents are confronted with a
siblings, friends, and school
189
very different situation. The question then becomes, Do you tell
the school or not? Making this decision is similar to deciding
whether and how to tell friends and extended family. The first
step is to get clear about your objective in disclosing the
information and then make some Pros and Cons Charts about the
various options. For example, if your child is going to be out of
school for a couple of weeks, you are going to have to say
something to the school. If your objective were to let the school
know so that the teachers could provide missing schoolwork for
your child, but youre concerned that the school may be less
than sensitive about the issue of self-injury, then you would
evoke the limited information guideline. You might
say something about serious personal problems that your child is
experiencing that are being actively addressed and that youll
let the school know when your child will return. On the other
hand, if you believe that the school would be more supportive and
understanding if they had a fuller picture of the circumstances,
then you should be more explicit about the problem. As you can
see, sharing the information will require you to make a judgment
call. Work hard at noticing and tolerating any shame,
embarrassment, or guilt you feel that may compromise your
abilities to make a decision in the best interest of your child.
This will help ensure that you make the right decision and wont
second-guess your course of action.
Finding the Right Placement
The high school experience is as much about learning how to
socialize, to be part of a community, and to develop appropriate
romantic relationships as it is about getting an academic
education. Learning how to negotiate these rather complex matters
is part of the task of any adolescent. Consequently, whenever
possible, the educational setting should mirror the one that the
child would have been in had she not developed these
difficulties. If the child was headed toward a vocational or arts
high school, you should try as best you can to make that match.
At this point you are probably saying, This sounds great,
but how do I make it happen? Good question. Only a few of
us will have the means to pay privately for the educational
setting that is best for our child. Most of us will have to rely
on the special educational services provided by our local school
system. School systems are required to provide special
educational services to children who are having difficulties
being educated due to physical or psychological reasons. The laws
around special education mandate schools to educate children in
the least restrictive setting. What that means is that theyre
obligated to find the most
190
HELPING YOUR TEEN
normal school that your child can manage. That can
translate into a mainstream setting with some extra counseling,
at one end of the spectrum, to a therapeutic boarding school, at
the other end. Parents can access these services by requesting in
writing that the school undertake an evaluation of the childs
needs. Public school systems are obligated to do this. At the end
of the evaluation, if its determined that your child
qualifies for service, the school will develop an IEP. The IEP is
a binding contract that the parents and school sign. If you dont
agree with the services spelled out in the IEP, do not sign it!
This is where knowing how to talk with the school gets critical.
Special Programs
The first thing you need to keep in mind is that the laws are
written in your favor so, with the right strategy, odds are you
are going to get pretty close to what your child needs. So dont
start with a big stick approach. You are your childs
advocate, while the school has other concerns: they need not only
to match your child with the right services but also to consider
available program spaces and financial constraints. While thats
not your problem, being sensitive to it is an important part of
being effective. Second, do your homework. Educate yourself about
all the different programs the school district offers. Then make
an assessment about the one you think is best suited for your
child and which ones might be reasonable alternatives if theres
no space available. Finally, if you and the school cant
seem to get on the same page, several courses of action are open
to you. First, you can work with an educational advocate who will
help you negotiate with the school system. Some advocates provide
services for free, and others work on a fee-for-service basis.
You can probably get a list of advocates from the school system,
from the yellow pages, or off the Internet. Or, you can hire a
lawyer who specializes in helping parents get the help they need
for their children. The American Bar Association (ABA) website
(www.abanet.org) contains links to referral services in each
state, many of which will help you identify lawyers with
experience in special education and disability law. In my
experience this step almost always makes the process adversarial,
and should be used only as a last resort. The take-home message
is that with knowledge and perseverance, you will most likely
come very close to getting what your child needs. One way to get
started in locating educational advocates and/or lawyers to help
you in this process is use the Internet and search for
educational advocates. This
siblings, friends, and school
191
search will produce any number of sites that will guide you in
locating someone in your area.
More Than 4 Years
One of the biggest stumbling blocks for parents and kids is
thinking about high school in a time frame other than the
customary 4 years. I really want to help you get past this view.
While there are some downsides to your childs not
graduating with her class, these are usually minor in comparison
with either not getting the treatment she needs or being in an
educational setting that stresses her beyond what she can
reasonably do. Not graduating with your class is a short-term
problem. I cant tell you the number of kids I have seen who
did not graduate with their class, received the help they needed,
and in a few short years were right back up to speed. Take the
long view on this issue and dont succumb to the pressure of
having to complete high school in 4 years.
Looking Ahead
Now that youve read this book, I hope you have the
understanding and the tools to help your child and yourself. I
have no doubt that practicing the skills that I have outlined
will, over time, help you to manage your own feelings and to be
more useful to your child. Remember to practice validation before
problem solving; use your mindfulness skills to help you see
things as they are, without judgment or being pushed around by
your emotions; and count off the distress tolerance skills to
help you through times of crisis. In your darkest, most painful
moments, remember that everything changesthe moment youre
in will change too. You now know that while there is no quick fix
and that eventually your child can get the problem under control,
deepening selfknowledge and learning important lifelong skills
along the way. One last reminder: Always keep the long viewthis
is not a sprint, but a long-distance run. I believe that with new
tools, perseverance, and, whenever possible, a little humor, you
will come out of this with a better appreciation for your kids
strengths, more confidence in yourself, and a better relationship
with your teenager. You can do this!
A P P E N DI X A
effectiveness of adolescent intensive dialectical behavior
therapy program
Two Brattle Centers (TBC) Adolescent Intensive Dialectical
Behavioral Therapy Program is designed to improve the
psychological, behavioral, and social functioning of adolescents
experiencing emotional dysregulation and/or self-injurious or
selfdefeating behaviors. TBC is committed to providing
evidence-based treatment and to monitoring clinical change over
the course of treatment to ensure that clients are improving in
desired ways. Toward this end, we conduct bi weekly assessments
with all clients in this program and provide the results to
clinicians and families so that they can track and ensure desired
change over the course of treatment. We measure changes in
psychological distress, symptoms of depression and borderline
personality disorder (BPD), emotion regulation skills,
self-injurious thoughts and behaviors, and overall functioning
within the family, socially, and at work. Presented below is a
summary of the change observed for a consecutive series of 42
clients treated in the adolescent DBT program during 20052006.
The purpose of this brief document is to provide objective
information about the average amount of change experienced by
adolescents and families participating in our program (individual
results vary).
OVERALL PSYCHOLOGICAL SYMPTOMS
Over the course of treatment, adolescents reported a significant
decrease in the overall experience of psychological distress
(depression, anxiety, anger, etc.), as measured by their report
on the Brief Symptom Inventory (BSI), a commonly used
psychological measure of psychological symptoms. Scores changed
from an average of 90.77 before
From Hollander, M., Wheelis, J., Photos, V. I., & Nock, M. K.
(2005, November). Intensive outpatient models of adult and
adolescent DBT: Development and initial evaluation. In J. H.
Rathus & M. K. Nock (Chairs), Bridging the lab and clinic:
Advances in the measurement and training of emotion regulation,
mindfulness, and interpersonal skills. Symposium conducted at the
annual convention of the Association for Behavioral and Cognitive
Therapies, Washington, DC. Reprinted by permission.
193
194
appendix a
treatment to 68.10 after treatment, moving from the very high end
of the clinical range to a level that falls within the normative
range for outpatient clients. This amount of change in only a
4-week period compares very favorably to that observed in other
treatments.
DEPRESSION
Over the course of treatment, adolescents reported a significant
decrease in the experience of depressive symptoms, as measured by
the Beck Depression Inventory, a commonly-used measure of
depressive symptoms. Scores changed from an average of 29.23
before treatment (which represents the Severely Depressed
range) to 20.76 at posttreatment (which represents the Mildly
to Moderately Depressed range). Here too this amount of
change in only a 4-week period compares very favorably to changes
observed in other outpatient treatments.
SYMPTOMS OF BORDERLINE PERSONALITY DISORDER
Adolescents in our program endorse an average of 6.8 symptoms of
BPD at the start of treatment (five out of nine are needed to
meet diagnostic criteria for a BPD diagnosis), and this decreases
to 4.8 symptoms at the end of our 4-week program.
appendix a
195
SELF-INJURIOUS THOUGHTS AND BEHAVIORS
Adolescents in our program report a decrease in the experience of
thoughts and behaviors of nonsuicidal self-injury (cutting,
burning, etc.) as well as suicidal thoughts and attempts. The
figure shows the average number of each behavior reported in the
2 weeks before treatment compared to the last 2 weeks of
treatment.
Overall, adolescents participating in this program report
significant improvement in each of these domains, as well as in
the development of emotion regulation skills and functioning at
home, socially, and at work (additional data available upon
request). Of course, changes in each area are not absolute, and
most adolescents continue to experience some psychological and
behavior problems at the end of this 4week treatmentat
which time a less intensive therapy schedule (typically 12
hours
196
appendix a
per week) often is recommended. However, the changes obtained
during this 4-week period are substantial and are much larger
than those reported in most other outpatient treatments. We hope
this information is helpful in providing data on the average
amount of change that is to be expected in our program. We
encourage you to ask additional questions about this treatment
and its effectiveness, and we are pleased to provide further
information to the fullest extent possible.
A P P E N DI X B
intensive treatment programs
In this appendix I want to familiarize you with treatment
programs that run the gamut from 24/7 programs in an inpatient
setting to those that meet multiple times a week for a few hours.
INPATIENT PROGRAMS
In this day of managed care, most inpatient hospital stays are
relatively short, from a couple of days to a week or two. The
task of an inpatient stay is crisis stabilization, medication
adjustment, and aftercare assessment and planning. Inpatient
hospital units are the most restrictive level of psychiatric
care. The doors are locked, and the childs freedom is
significantly curtailed. While each unit has its own protocol for
treatment, generally the child is seen once a day by a
psychiatrist who will be assessing and possibly altering the
psychopharmacological regimen. There are nursing staff members
available for check-ins throughout the day. Parents usually meet
with a social worker, who is most likely meeting with your child
too. The social worker has the major responsibility for
developing and coordinating the childs after care plans. If
the treatment team has questions about diagnosis, they may call
in a psychologist to administer some psychological testing. Today
psychological testing is not routinely part of the treatment
protocol, so dont expect it to be done unless you advocate
for it. Short-term hospital stays can be very useful in helping
to develop a more effective outpatient program, in changing
medications, and sometimes just providing a time out for you and
your child. This kind of inpatient hospitalization, however, in
all likelihood will not be long enough, nor geared directly
enough, to resolve deliberate self-harming behavior.
ACUTE SHORT-TERM RESIDENTIAL UNITS
Short-term residential units are often used as a step-down from
an inpatient setting or as an alternative to inpatient care.
These units are accessed when the clinicians in charge of
admission determine that the child can be managed in a slightly
less restrictive setting. Unfortunately, these units are not as
widely available as inpatient programs, so there may not be one
in your area.
197
198
appendix b
The typical length of stay on these units ranges from a week to a
month. By and large these units are slightly less restrictive
than inpatient settings. Kids have a bit more freedom for passes
and privileges, but still have a very structured treatment
schedule. Typically there are fewer psychiatrists and nurses than
on an inpatient unit, but often more social workers and
psychologists. The clinical task of the short-term residential
unit is similar to that of an inpatient unit, but the longer stay
can sometimes build a stronger foundation for the outpatient work
to come.
DAY HOSPITALS AND INTENSIVE OUTPATIENT PROGRAMS
Day hospitals and intensive outpatient programs (IOPs) are
nonresidential and less restrictive than inpatient and acute
residential programs, but still provide a very structured
therapeutic environment. Length of stay is quite variable,
ranging from a few days to several months or more. At this level
of care the patient, the clinicians, the parents, and the managed
care people (if they are involved) often have some flexibility as
to how many days a week the child will attend the program, how
many hours a day, and how long a stay it will be. Some day
hospitals and IOPs are generic programs, which means they accept
adolescents who have a wide range of behavioral and psychiatric
issues. Others are more focused on a narrow range of problems and
provide a specific treatment approach. For example, the IOP that
I oversee is a DBT-focused program primarily for kids who
selfinjure or engage in other types of self-harming or
self-defeating behaviors. Assuming that the adolescent has a
chance to stay for several weeks or more in an IOP or day
hospital, some invaluable therapy work can get started. In
addition, the longer time frame allows for medications to be
reviewed and changed as necessary. Furthermore, the longer stay
often makes parental guidance work and/or family therapy a much
more viable option. A downside of these programs is a direct
outgrowth of their upside: longer stays and multiple meetings per
week make the transition back to school or work complicated.
Everyone who is connected to the childs treatment needs to
think hard about the clinical benefits and liabilities of such a
treatment choice.
LONG-TERM PROGRAMS
Long-Term Residential Treatment ProgramsWhen All Else Has
Failed
Marnie and her parents requested a meeting with me to discuss her
lack of progress in therapy. Marnie was a 15-year-old girl who
had been depressed, suicidal, and selfinjuring since she was 12.
Recently her parents had become concerned because Marnie was
lying about her whereabouts, had taken up with an older group of
kids who were known to use hard drugs, and had run away from home
for several days at a time. They re-
appendix b
199
ported that her school attendance was declining, along with her
grades. Marnies parents told me that she had been
hospitalized about eight times, had had multiple therapists,
including in family therapy, and had been in a DBT program. The
parents were exhausted and on the brink of despair. Every effort
they had made had resulted in a dead end. No therapist or program
had been able to contain her dangerous behavior or elicit even a
modicum of collaboration in therapy. As you will see, I was no
exception. So, Marnie, what is your understanding about why
your parents wanted this meeting? I asked. I dont
know. Why dont you ask them? Do I look like a mind reader?
she shot back. I dont know, let me see. No, you dont
look like a mind reader, but you do seem to be pretty angry. Whats
up with that? I wondered. I dont talk to
morons, Marnie replied, and she got up and left my office.
Unfortunately there are situations that require an adolescent to
be sent for longterm residential care. When the child and her
family have availed themselves of all the local resources but the
situation just continues to worsen, this may be the only other
option. For parents and children alike, its an awful
moment. The idea of your adolescent child being gone for months
at a time for treatment may make you feel like failures, and
guilty ones at that. Plus, in spite of all the trouble and
heartache theyve caused, it turns out youll miss them
like crazy! For the kids, being away from their home and friends
can feel like the end of the world. As painful as these moments
are, they are sometimes the new beginning that kids and parents
desperately need. In a somewhat arbitrary way, I am defining
longterm programs as 18 weeks to several years. These programs
always have some kind of school component (the exception might be
some wilderness programs, which I will describe next). In fact,
these kinds of programs run the gamut from school-based settings
with clinical services to intensive clinical programs with a
school component. These programs break down into two categories:
those funded with public money and those funded with private
money. Sometimes the publicly funded programs accept private
funding, and occasionally a privately funded program will accept
public dollars. As you can see, this gets complicated. For this
and many other treatment programs, it can be useful to hire an
educational consultant to help you think through all your
options. Educational consultants can be accessed through the web.
Often these professionals visit programs several times a year,
and therefore are in a good position to make a match between your
childs needs and a program. Whenever possible, plan a visit
to the program yourself, or at least speak directly to the
admission staff. Many programs have a list of parents who would
be willing to speak with you about their experience with the
program. Remember, however, that these are likely to be the
parents who had a good experience, not the ones with major
disappointments. By the same token, brochures and websites offer
limited useful infor-
200
appendix b
mation. I have never read a brochure for anything that didnt
say its organization was the best at what it was providing!
Wilderness Programs
Sometimes when an adolescent is struggling, its a good idea
to shake up his routine. Wilderness programs do just that. The
essence of these programs is twofold. First, the idea is to take
the child out of his or her comfort zone and create an
environment in which group members have to trust and rely on one
another. Kids learn just how strong and resilient they can be
when they only have the barest of creature comforts available to
them. Second, within this Spartan existence the adolescents
usual defensive and ineffective coping strategies break down,
opening the possibility for new and more effective strategies to
develop. The length of stay at a wilderness program can vary from
a couple of weeks to several months. Similarly, the degree of
physical hardship runs the gamut from an Outward Boundstyle
experience to that of a summer camp. Wilderness programs can
become the first step toward helping your child regain some
confidence and hope. In my experience, however, they need to be
followed by an ongoing therapy program. When this doesnt
happen, the gains made at wilderness program tend to vanish
quickly. I strongly recommend if you are considering these kinds
of programs that you work in conjunction with an educational
consultant to find the program that best matches your childs
needs.
Long-Term Residential Therapeutic Programs and Schools
Sometimes for kids like Marnie, when all else has failed, parents
need to consider long-term residential programs. This is always a
tough decision for parents to make. Sending your child away from
home is always a loss, and parents should expect to feel some
combination of relief and sadness. There is a wide variety of
long-term programs available for adolescents. Some are funded
through public state agencies and others are privately funded.
These are no easy options, though: the privately funded programs
are very expensive (think college tuition, plus room and board),
and those funded by public agencies generally have long waiting
lists. The majority of privately funded programs are located in
the southern and western parts of the country and are best
accessed with the help of an educational consultant. The
privately funded long-term residential programs form a continuum
from those that are highly restrictive with very structured
behavioral and clinical programming to those that are more like
boarding schools with clinical services. There are programs that
emphasize outdoor activities and those that concentrate on the
arts. For parents who are going to access publicly funded
programs, the good news is that these programs are generally
closer to home; the bad news is that they usually
appendix b
201
have a very long waiting list and treat a broad range of
children. Consequently, adolescents who are involved in
self-harming behaviors may be in the same program with kids who
have very different types and severity of problems. It is very
important that you ascertain what kinds of troubles are being
treated in the program and whether a differentiated approach is
taken depending on the childs diagnosis. Often publicly
funded programs use a cost-share model between the department of
education and the department of social services and/or department
of mental health. It is sometimes hard to figure out the system.
If youre having trouble navigating the system, most states
have educational advocates who work with parents and kids to make
sure the child is getting the right kind of services. You can
obtain a list of educational advocates through the special
education department at your childs school.
Nonresidential Long-Term Placements: Therapeutic Day Schools
Lakisha had been attending a high-powered independent school
until the school nurse noticed that she had been self-injuring.
Following school policy, the nurse notified the school counselor
and the dean of students, and a meeting was held with Lakisha and
her parents. At that meeting the school determined that Lakisha
needed to take a medical leave and would be allowed to return to
the school the following year if her self-injurious behavior had
been adequately treated. Lakisha was glad to hear that she could
return to school, but what was she to do in the meantime? Before
attending her independent school, shed been at a large
public high school and found the size and overall commotion a
trigger for her self-harm. What now? Lakisha should consider a
therapeutic day school. These are publicly funded schools that
typically have small classroom settings, teachers who are
sensitive to their students mental health needs, and
clinicians on staff. Generally these schools have the required
academic accreditations to keep students up to date with credits
and required courses. Therapeutic day schools are often ideal
next steps for kids who are leaving more restrictive programs
(long- or short-term settings) and who might lose ground if they
returned to a mainstream high school environment. Like the longer
term programs, these schools offer a range of educational and
clinical services. Some schools are geared toward those who are
college bound; others arent. Some schools have a hefty
clinical emphasis; others dont. When thinking about
therapeutic schools, make sure you know about the academic as
well as the clinical programming and about the kinds of children
who attend the school. For example, does the school generally
educate kids with severe behavior disorders or is it more geared
toward adolescents with depression, anxiety, and self-injurious
behavior? The idea, as always, is to find the best fit for your
child. Your teens therapist or an educational advocate can
be a good resources to help you find that fit.
RE SOURCE S
websites related to self-injury
The scores of websites that focus on self-injury fall into two
main categories: (1) websites designed by professionals to assist
self-injurers, and (2) websites created by self-injurers intended
to offer peer support. Brief descriptions of several of the more
prominent websites of both types are provided below. This review
is meant to be representative, not exhaustive.
WEBSITES DESIGNED BY MENTAL HEALTH PROFESSIONALS
Self-Injury and Related Issues (SIARI) www.siari.co.uk The SIARI
website is the creation of Jan Sutton, who is based in the United
Kingdom. She is the author of Healing the Hurt Within: Understand
and Relieve the Suffering Behind Self-Destructive Behaviour (How
To Books, 1999) and several other books. The multifaceted
website, with its many links, provides many helpful suggestions
regarding coping skills and alternatives to self-injury, a
self-assessment questionnaire for self-injurers, and first aid
information. It also offers information for family and friends,
references to many publications regarding self-injury, and a
bookstore. An interesting and unusual feature is that the website
offers an online support group for professionals who work with
self-injurers. I am not aware of any other website that has this
feature. There is a well-designed moderated message board for
self-injurers, with guidelines for participants about the dangers
of posting triggering information and a request to label it as
triggering to forewarn others. The website presents a cycle
of self-injury that includes the steps of (1) mental agony,
(2) emotional engulfment, (3) panic stations, (4) action
stations, (5) feel
From Walsh, B. W. Treating self-injury: A practical guide.
Copyright 2006 by The Guilford Press. Reprinted by permission.
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resources
better, and (6) grief reaction. In all likelihood, Suttons
cycle does not apply to all selfinjurers but primarily to trauma
survivors and those who tend to dissociate. The SIARI website
provides an article by Sutton regarding the link between
self-injury, dissociation, and trauma. Although some of the
content of the SIARI site may not be relevant for self-injurers
from the general population, the suggestions regarding coping
skills and alternatives to self-injury are relevant for all.
S.A.F.E. Alternatives www.selfinjury.com The S.A.F.E.
Alternatives website is the creation of Karen Conterio and Wendy
Lader, authors of Bodily Harm (1998). This website offers concise
material about selfinjury, a brief summary about the components
of successful treatment, a bibliography, and links to purchase
Conterio and Laders book and video. The website also
provides a link for admission to their inpatient unit at Linden
Oaks Hospital at Edward, in Naperville, Illinois. This program is
the only inpatient unit devoted exclusively to the treatment of
self-injury in the United States. Optimally, the length of stay
for this program is 30 days. Conterio and Lader also operate the
national information line800-DONTCUTwhich has
been an invaluable resource for self-injurers for many years.
This line receives about 16,000 calls per year and their e-mail
address (wladersafe@ aol.com) another 5,000 contacts (Wendy
Lader, personal communication, 2004). That Conterio personally
responds to the phone calls and Lader to the e-mails indicates
their heroic level of commitment to help self-injurers. American
Self-Harm Information Clearinghouse www.selfinjury.org This
website is the creation of Deb Martinson, the author of the
notable Bill of Rights for People Who Self-Harm. It
is a strong statement of affirmation for selfinjurers that
clients and therapists should read. The website carries Favazzas
endorsement and offers a brief description of the reasons for
self-injury, a discussion of myths regarding self-injury,
self-help suggestions, and several links. There Is No Shame Here
www.palace.net/~llama/psych/injury.html This is another website
by Deb Martinson. It is a complex site that offers information
about causes of self-injury, self-help, diagnoses, treatment, and
information for families and friends. There is a lengthy list of
references and many links. The site offers a monitored message or
web board for self-injurers that carefully addresses the issue of
triggering content.
resources
205
The site provides many suggestions for replacement behaviors,
although some are questionable, such as slashing a plastic bottle
or heavy piece of cardboard. Such aggressive modes place a weapon
in the hands of self-injurers and may make self-harm more likely.
The website takes great pains to be accepting, supportive, and
nonjudgmental toward self-injurers. Self-Injury
www.mirror-mirror.org/selfinj.htm This simple one-page website
presents some basic information about self-injury and
concentrates on presenting a long, useful list of alternatives.
WEBSITES CREATED BY SELF-INJURERS OFFERING PEER SUPPORT
LifeSIGNS: Self-Injury Guidance and Network Support
www.lifesigns.org.uk This website is run by a set of directors,
some of whom self-injure, some have beaten self-injury, and
some have never self-injured (quotation from the home page
of the site). (I have classified this site under the
self-injurer-generated category because some of the directors
have considerable experience with self-injury.) This
comprehensive site is very professional in appearance. It offers
extensive information about self-injury and suggestions for
eliminating the behavior. It has a chat room with clearly
articulated rules about avoiding triggering content. The authors
of the site have written several pamphlets on self-injury,
designed for schools and universities, that are available through
the site. A monthly electronic newsletter is offered to members.
Many links are provided. The site also offers a Self-Injury
Charter, which is similar in some ways to Deb Martinsons
Bill of Rights. This appears to be among the best of the
peer-generated sites in terms of offering positive, supportive,
nontriggering, solution-focused content. RecoverYourLife.com
www.recoveryourlife.com This website (formerly RuinYourLife.com)
offers a complex combination of benefits and risks. This site is
dedicated to exploring self-destruction in all
its forms. There is no doubt that websites of this type
help some self-injurers feel that they are not alone and that
their problem can be discussed with others. This multifaceted
site offers self-help suggestions, a first aid section (which may
be triggering because of its level of detail), and a gift shop
selling RYL journals, mouse pads, mugs, teddy bears, and
clothing. Of concern are the poetry and artwork. Some of the art
includes graphic color
206
resources
photos of wounds and drawings of lacerations, wounds, and blood.
One drawing depicts a person who has died by hanging. In my
opinion, the risks that this site takes in terms of triggering
cannot be justified. I did consider not drawing attention to it
in this appendix, but the site does come up on the first page or
two of a Google search of self-injury. Self-Injury: A
Struggle www.self-injury.net This website is said to have been
generated by a young adult self-injurer named Gabrielle. She
states she has been self-injuring for 7 years. Although
attractively designed, some of the content is alarmingsuch
as the section titled Gallery of Pain. This category
contains artwork that depicts razor blades, wounds, blood, and
the like. There is also poetry describing acts of self-injury and
at least one short story that culminates in a completed suicide.
The site has sections on famous self-injurers and a memorial
section for self-injurers who have died. The categories on
stopping self-injury, helping family and friends, and finding
resources seem less developed than the more negative content
areas. There is a message board offered, but I could not find
rules or even a statement pertaining to concerns about triggering
content. This is the type of site that provides some support for
young self-injurers, but also contains a great deal of triggering
material that could do harm. Aspects of this website run the risk
of normalizing and even glamorizing self-injury. The content is
weighted heavily in the direction of describing and depicting
self-injury rather than solving the problem of self-injury.
Self-Injury Support www.sisupport.org This rather simple
peer-generated website is based in California. The mission of the
site is to offer a positive and productive self-injury
support site providing alternatives to self-injury, referrals,
support groups, affirmations and interactive opportunities
(from the homepage). This site was developed in response to sites
such as the two described immediately above. The Self-Injury
Support website states, Much to our dismay we have
discovered that many [self-injury websites] . . . are triggering
and not exactly the type of material we wanted to read about when
we were struggling ourselves, usually late at night, with
thoughts of self-injury. So, we have decided to focus on positive
information regarding self-injury and hope that you will find our
site to be both educational and supportive in a positive and
reassuring manner to help those in need. Consistent with
these goals, the site emphasizes understanding self-injury and
how to recover. There are lists of references and programs that
serve self-injurers. There is no chat room.
index
Abuse, sexual, 62 Acceptance dialectical behavior therapy (DBT)
and, 7578 distress tolerance skills and, 8485
siblings of self-harming child and, 180 181 taking care of
yourself and, 163166 Action potential of emotions, 170175
Active listening, 140141 Acute short-term residential
units, 197198 Advice giving, 5354, 137 Alcohol use
interference of to quality of life, 123 myths regarding
self-injury and, 2021 peer pressure and, 19 All-or-nothing
thinking, 71, 177 Aloneness, feelings of, 6162, 63 Amount
of self-injury, increases in, 5960 Anger biological
vulnerabilities and, 35 changing interpretations of events and,
4445 dwelling on, 3940 intensity of, 3738
opposite action strategy and, 172 Anti-anxiety medications, 9596
Anticonvulsant medications, 95 Antidepressants, 9394
Antipsychotic medications, 95 Anxiety acceptance and, 165
medication and, 9596 opposite action strategy and, 172173
using self-injury to avoid something and, 6465, 66
Apologizing to your child, limit setting and, 153 Assessment,
psychiatric, 6871 Attention seeking, myths regarding
selfinjury and, 1517 Attentional control, 81
Attentive listening, 138139 Attribution theory, 22 Auditory
hallucinations, 6667 Avoidance, self-injury as, 6465,
66 Balance, emotional, 5765, 7475 Behavior chain
analysis, 8182, 121123 Behaviors chain analysis and,
8182, 121123 dependency of on mood, 4142
dialectical behavior therapy (DBT) and, 8182 emotion
modulation and, 4546 impulsive behavior and, 8182
meaning and function of, 25, 7274 natural consequences to,
154, 157158 opposite action strategy and, 4546, 170175
that interfere with therapy or quality of life, 123
understanding, 25 Between-session coaching, 103, 116, 117
118 Biological vulnerabilities. See also Vulnerabilities for
self-injury dialectical behavior therapy (DBT) and, 7980
overview of, 3337 psychiatric conditions and, 67 Biosocial
theory, 7980, 103, 114 Black-and-white thinking, 71, 177
Blame, 62, 7980 Body checks, 134135 Borderline
personality disorder, 87, 193 196 Brain functioning, 4243,
168 Breathing, mindfulness and, 163164 Bribery,
reinforcement of behavior and, 147 Bullying, as a form of
invalidation, 51 Burnout, parental, 160. See also Taking care of
yourself
207
208
index
parenting strategies and, 128129 sensitivity and, 49
siblings of self-harming child and, 182 183 Dialectical
behavior therapy (DBT) acceptance and change and, 7578
assessing your childs progress in, 101, 126127
attentional control and, 81 balancing act of, 102, 112 behaviors
that interfere with, 123 benefits of, 7482 components of,
103 developing a sense of identity and, 8081 effectiveness
of, 193196 emotional balance and, 7475 emotional
dysregulation and, 80 finding a therapist to conduct, 8991
goals of treatment and, 104118 guilt and self-blame and, 7980
history of, 8687 how it addresses what your teen does and
thinks, 7274 insurance coverage and, 9798 overview
of, 2, 9, 2631, 72, 8588, 101, 102103 parental
involvement in, 102103, 120123, 125126
psychiatric conditions that warrant therapy other than, 66
research on, 8788, 193196 skills training and, 8285
supplemental therapies to, 9197 what to expect from, 126
Diary cards, 103, 107113 Diet, taking care of yourself and,
175176 Disagreement between parents, 2728, 77, 153,
176178 Disappointment, limit setting and, 153154
Distorted thinking, 7374, 81 Distraction, 4546
Distress tolerance skills, 8485, 154156 Divorced
parents, 2728, 161162 Drug use interference of to
quality of life, 123 myths regarding self-injury and, 2021
peer pressure and, 19 Duration of feelings, behavior and, 4546
Dwelling on feelings changing interpretations of events and, 4445
emotion modulation and, 4041 emotional illiteracy and, 3940
Dysregulation, emotional dialectical behavior therapy (DBT) and,
7475, 80 overview of, 3435 understanding in your
child, 5759
Chain analysis, 8182, 121123 Change, 7578
Charting your childs progress, 101, 126 127 Checking
in with your child, 156157 Checking your teens
body for evidence of self-injury, 134135 Coaching between
sessions, 103, 116, 117118 Cognitive distortion, 7374,
81 Cognitive-behavioral therapies. See also Dialectical behavior
therapy (DBT) anxiety and, 95 distorted thinking and, 7374
overview of, 88 Commitment to therapy, 103, 104118
Communication. See also Communication with your child patterns
of, 5456 between the therapist and your child, 102, 103
Communication with your child. See also Validation active
listening and, 140141 attentive listening and, 138139
emotional illiteracy and, 3746 family therapy and, 9192
giving voice to the unspoken and, 141 143 Confidentiality
in therapy, 103, 118120. See also Privacy Consequences,
natural, 154, 157158 Consultation team, 103, 116 Counseling
for the parents, 162 Couple therapy, 162 Crisis survival
strategies distress tolerance skills and, 85 overview of, 116
telephone skills-coaching sessions and, 117118 Curiosity in
parenting, 141143 Cutting, reasons for. See Reasons for
selfinjury Day treatment, 198, 201 DBT (dialectical behavior
therapy). See Dialectical behavior therapy (DBT) DEAR MAN
acronym, 146149 Decision making, attentional control and,
81 Dependency on parents, developmental stages regarding, 1617
Depression, 88, 193196. See also Sadness Development
confidentiality in therapy and, 119 dependency on parents and, 1617
index
Eating disorders, 123 Eating healthy, taking care of yourself
and, 175176 Emotion regulation skills brain functioning
and, 4243 family therapy and, 9192 giving voice to
the unspoken and, 141 143 inability to engage in, 3746
modeling to your child, 54 overview of, 4041, 84 problem
solving and, 4346 Emotional balance, 5765, 7475
Emotional dysregulation. See also Emotion regulation skills
dialectical behavior therapy (DBT) and, 7475, 80 overview
of, 3435 understanding in your child, 5759 Emotional
illiteracy, 3746, 6162, 63. See also Vulnerabilities
for self-injury Emotional mindfulness, 166170. See also
Mindfulness Emotional pain acceptance and, 165 emotional
illiteracy and, 3746 giving voice to the unspoken and, 141
143 mindfulness and, 166170 myths regarding self-injury
and, 17, 21 22 opposite action strategy and, 4546,
170175 overview of, 4, 89 physical pain and, 2122
understanding, 3031 vulnerabilities for self-injury and, 3233
Emotional reactivity biological vulnerabilities and, 3337
black-and-white thinking and, 71 developmental stages regarding,
4849 emotion modulation and, 41 overview of, 33 Emotional
vulnerability, 3233 Empathy, 180181 Emptiness,
feelings of, 6162, 63 Endorphin release, myths regarding
selfinjury and, 2122 Environmental factors balancing act
of, 112 black-and-white thinking and, 71 dialectical behavior
therapy (DBT) and, 7980 overview of, 4656 removal of
sharp instruments or other tools used to self-injure and, 134
school, 187191 vulnerabilities for self-injury and, 33
209
Exercise, taking care of yourself and, 175 176 Extended
family, discussing the selfharming behaviors with, 184187
External attributions, 22 Family, extended, 184187 Family
therapy, in addition to DBT, 9192 FAST skill, 152153
Fear, opposite action strategy and, 172 173 Feeling alive,
understanding in your child, 6162, 63 Feelings. See
Emotional pain Feelings, hiding of invalidation and, 55
overwhelming feelings and, 58 vulnerabilities for self-injury
and, 3233 withdrawing from family and, 55 Financial
concerns regarding treatment, obtaining treatment and, 9798
Frequency of self-injury, increases in, 59 60 Friendships.
See also Relationships discussing the self-harming behaviors
with, 184187 peer pressure and, 1920 popularity of
self-injury, 1719 Function of the behavior, 25, 2627.
See also Reasons for self-injury GIVE skill, 149151 Giving
voice to the unspoken, 141143 Goal setting in parenting,
133 Goals of treatment, 104118 Group psychotherapy, in
addition to DBT, 92 Group sessions in addition to DBT, 92 skills
training and, 82, 88, 125 Guilt dialectical behavior therapy
(DBT) and, 7980 limit setting and, 151152 opposite
action strategy and, 173175 parental burnout and, 160
parental involvement in DBT and, 121 sexual abuse and, 62
siblings of self-harming child and, 180 181 using
self-injury to avoid something and, 65 Hallucinations, 6667
Healthy eating, taking care of yourself and, 175176 Hearing
voices, 6667 Help, asking for, 3839
210
index
Labeling of emotions emotional mindfulness and, 167168
giving voice to the unspoken and, 141 143 inability to
engage in, 3746 Legal assistance, obtaining services from
the school and, 189191 Limit setting, interpersonal
effectiveness skills and, 151154 Listening active
listening, 140141 attentive listening, 138139
listening to other points of views, 2930 Lithium, 95
Long-term residential treatment programs, 198201 Lying,
discussing the self-harming behaviors with friends and family,
185186 Managed care, obtaining treatment and, 9798
Masking of feelings invalidation and, 55 overwhelming feelings
and, 58 vulnerabilities for self-injury and, 3233
withdrawing from family and, 55 Media representation of
self-injury, 19 Medication, in addition to DBT, 9297
Mindfulness emotional mindfulness, 166170 overview of, 8283
taking care of yourself and, 163 Mirroring, active listening and,
140141 Modulation of emotion brain functioning and, 4243
overview of, 4041 problem solving and, 4346
Monitoring your childs progress, 101, 126127 Mood
dependency, emotional illiteracy and, 4142 Mood
stabilizers, 9495 Mustard test, 22 Myths about self-injury
attention seeking, 1517 everyones doing it, 1719
failed suicide attempt, 23 overview of, 1523 peer pressure,
1920 physical pain and, 2122 role of drugs and
alcohol in, 2021 Natural consequences, 154, 157158
Negative feelings, emotional illiteracy and, 3940. See also
Emotional pain
Hiding of feelings invalidation and, 55 overwhelming feelings
and, 58 vulnerabilities for self-injury and, 3233
withdrawing from family and, 55 Honesty discussing the
self-harming behaviors with friends and family, 184187
limit setting and, 153154 siblings of self-harming child
and, 181 184 Hospitalization, 9697, 197201
Identification of emotions emotional mindfulness and, 167168
giving voice to the unspoken and, 141 143 inability to
engage in, 3746 Identity development, 8081 IEPs, 190
Ignored, feelings of being, 6264 Impulsive behavior
anti-anxiety medications and, 96 biological vulnerabilities and,
3536 dialectical behavior therapy (DBT) and, 8283
Indirect interpersonal skills, 154159 Individual counseling
for the parents, 162 Inpatient treatment, 9697, 197201
Insurance coverage, obtaining treatment and, 9798
Integrative therapies, 88 Intensity of feelings, behavior and, 4546
Intensive treatment programs, 9697, 197201 Internal
attributions, 22 Interpersonal effectiveness skills DEAR MAN
acronym, 146149 indirect interpersonal skills and, 154
159 limit setting and, 151154 overview of, 8384
parenting strategies and, 144154 repairing or enhancing
your relationship with your child, 149 151 Interpretation
of events, changing, 4445 Invalidation. See also Validation
black-and-white thinking and, 71 overview of, 4656 patterns
of communication that comes from, 5456 saying but
and, 137138 snowball effect of, 5455 Invisibility,
feelings of, 6264 Judgments regarding your child, 139
index
Negative reinforcement, 73 Negotiation with your child, DEAR MAN
acronym and, 148149 No, saying to your child,
146149 Numbness, feelings of, 6162, 63 Nutrition,
taking care of yourself and, 175176 Obsessive-compulsive
disorder (OCD), 6571 Openness in parenting, giving voice to
the unspoken and, 141143 Opposite action strategy, 4546,
170175 Other points of view, listening to, 2930
Overwhelming feelings biological vulnerabilities and, 3637
understanding, 5759 using self-injury to avoid something
and, 65 Paging therapist between sessions, 117 118. See
also Crisis survival strategies; Telephone skillscoaching
sessions Parental burnout, 160. See also Taking care of yourself
Parental involvement in DBT. See also Parenting strategies
overview of, 102103, 120123 supporting treatment and,
125126 Parenting, single, 2728, 161162
Parenting strategies. See also Validation allowing natural
consequences, 157 158 DEAR MAN acronym, 146149
developmental stages and, 128129 disagreements regarding,
2728, 77, 153, 176178 emotional mindfulness and, 166170
guilt and, 152 interpersonal skills and, 144154, 154
159 limit setting and, 151154 modeling distress tolerance,
154156 privacy and, 156157 repairing or enhancing
your relationship with your child, 149 151 siblings of
self-harming child and, 179 184 supporting treatment and,
125126 that are helpful and effective, 129133, 135143
that are NOT helpful or effective, 133 135 validation and,
5154 vulnerabilities for self-injury and, 33
211
Parents, therapy for. See Counseling for the parents Patience in
parenting, 132 Peer pressure, 1920 Perseverance in
parenting, 132 Perspective, putting things into, 53 Physical
pain, myths regarding self-injury and, 2122 Picking at
oneself, 6768 Popularity of self-injury, 1719
Positive reinforcement, 73 Posttraumatic stress disorder (PTSD),
66 Privacy. See also Confidentiality in therapy dependency on
parents and, 1617 discussing the self-harming behaviors
with friends and family, 184187 versus increased vigilance,
156157 overwhelming feelings and, 58 Problem solving
acceptance and, 166 developing the skills for, 6970 emotion
modulation and, 4346 validation and, 51 vulnerabilities for
self-injury and, 33 Pros and Cons Chart, 158, 189 Psychiatric
assessment, importance of, 68 71 Psychiatric conditions, 6571
Psychiatric medication, in addition to DBT, 9297
Psychodynamic therapies, 88 PTSD, 66 Pulling away from parents,
1617 Putting things in perspective, 53 Quality of life,
behaviors that interfere with, 123 Reactivity, emotional
biological vulnerabilities and, 3337 developmental stages
regarding, 4849 emotion modulation and, 41 overview of, 33
Reappraisals, 4445 Reasons for self-injury. See also
Vulnerabilities for self-injury dialectical behavior therapy
(DBT) and, 2627 drugs and alcohol use and, 2021
everyones doing it, 1719 failed suicide attempt, 23
to get attention, 1517 peer pressure and, 1920
physical pain and, 2122 psychiatric conditions and, 6571
understanding in your child, 2431, 57 65, 6571
212
index
validation and, 4849 vulnerabilities for self-injury and,
32 33 Services offered by schools, 189191 Sexual
abuse, self-hatred and, 62 Shame lying and, 186 opposite action
strategy and, 173 parental involvement in DBT and, 121 sexual
abuse and, 62 Showing scars to others, 186 Siblings of
self-harming child, 161, 179 184 Side effects of
medications anti-anxiety medications, 96 antidepressants, 94
learning about, 93 mood stabilizers, 95 Silent treatment,
invalidation and, 55 Single parenting, 2728, 161162
Skills training in DBT. See also individual skills diary cards
and, 103, 107113 group sessions and, 92 learning to
self-soothe, 124 overview of, 8285 parenting strategies
and, 129133 practicing new skills, 103, 129133
troubleshooting skills, 124125 Skin picking, 6768
Skipping school, 123 Sleep habits, taking care of yourself and,
175176 Solution analysis, 123 Soothing oneself biological
vulnerabilities and, 3637 emotional illiteracy and, 37
skills training and, 124 Special education, 189191 SSRIs
(selective serotonin reuptake inhibitors), 9394 Statistics
regarding children who selfinjure, 4, 19 Stress acceptance and,
165 medication and, 9596 opposite action strategy and, 172173
using self-injury to avoid something and, 6465, 66
Substance use interference of to quality of life, 123 myths
regarding self-injury and, 2021 peer pressure and, 19
Suicide, risk factors for assessment and, 69 overview of, 23
self-hatred and, 62
Reassurance, 33, 5253 Reflection, active listening and, 140141
Refusing your childs requests, 146149 Reinforcement
of behavior, 73, 147 Relationships. See also Friendships;
Interpersonal effectiveness skills balancing act of, 112
interpersonal effectiveness skills, 144154 between the
parents, 161162, 176178 taking care of, 176178
between the therapist and your child, 102, 103, 114116
validation and, 7478 between you and your child, 146149,
149151 Removal of sharp instruments or other tools used to
self-injure, 134 Requesting something from your child, 146149
Residential treatment, 9697, 197201 Risk factors for
self-injury. See Vulnerabilities for self-injury Risk factors for
suicide assessment and, 69 overview of, 23 self-hatred and, 62
Sadness. See also Depression intensity of, 3738 opposite
action strategy and, 171172 Saying no to your
child, 146149 Scars, visible, 186 School behaviors that
interfere with, 123 discussing the self-harming behaviors with,
187191 therapeutic day schools, 201 Secrecy, 181184,
184187 Selective serotonin reuptake inhibitors (SSRIs), 9394
Self-blame, 7980 Self-care. See Taking care of yourself
Self-hatred, 62, 65 Self-injury, reasons for. See Reasons for
self-injury Self-injury in general, 1523, 25
Self-reflection, 8283 Self-respect, interpersonal
effectiveness skills and, 151154 Self-soothing biological
vulnerabilities and, 3637 emotional illiteracy and, 37
skills training and, 124 Self-validation, 4748. See also
Validation Sensitivity. See also Emotional pain biological
vulnerabilities and, 3337 developmental stages regarding,
4849
index
Suicide attempts antidepressants and, 94 assessment and, 69
confidentiality in therapy and, 120 medication and, 96 mistaking
self-injury as, 18, 23 Suicide prevention, self-injury as, 6061
Supporting treatment, 125126 Taking care of yourself
acceptance and, 163166 emotional mindfulness, 166170
opposite action strategy and, 170175 overview of, 160, 175176
relationships and, 176178 Telephone skills-coaching
sessions, 103, 116, 117118 Therapeutic day schools, 201
Therapists balancing act of, 102, 112 finding a therapist to
conduct DBT, 89 91 goals of, 103 guidelines for choosing,
9091 listening to their understanding of your childs
behavior, 25 neglecting the issue of self-injury by, 4 parental
involvement in DBT and, 120123 relationship with your
child, 102 Therapy, 26. See also Dialectical behavior therapy
(DBT) Therapy-interfering behaviors, 123 Thoughts, distorted, 7374,
81 Treatment, 104118. See also Dialectical behavior therapy
(DBT) Treatment, inpatient, 9697, 197201 Triggers
that set off your teen, biological vulnerabilities and, 37
Trouble shooting, skills training and, 124 125 Truthfulness
discussing the self-harming behaviors with friends and family,
184187 limit setting and, 153154 siblings of
self-harming child and, 181 184
213
Two Brattle Centers (TBC) Adolescent Intensive Dialectical
Behavioral Therapy Program, 193196 Understanding why your
child is selfinjuring overview of, 2431, 5765
overwhelming feelings and, 5759 psychiatric conditions, 6571
Validation. See also Invalidation; Selfvalidation active
listening, 140141 attentive listening, 138139
dialectical behavior therapy (DBT) and, 7478, 81, 104
giving voice to the unspoken, 141143 identity development
and, 81 overview of, 3031, 4656, 130131, 135138
parenting strategies that interfere with, 5154 siblings of
self-harming child and, 180 Vigilance in parenting, privacy and,
156 157 Voices, hearing, 6667 Vulnerabilities for
self-injury. See also Reasons for self-injury biological
vulnerabilities and, 3337 emotional illiteracy, 3746
environmental factors, 33, 4656 overview of, 3233
Websites related to self-injury, 203206 Why they cut. See
Reasons for self-injury Wilderness programs, 200 Willingness in
parenting, 132133 Withdrawing from the family, invalidation
and, 55 Worries of the parents, interference of to validation, 5152
about the author
Michael Hollander, PhD, a recognized expert in the treatment of
self-injury, has worked with adolescents and their families for
more than 30 years. He maintains a private practice in
psychotherapy, conducts dialectical behavior therapy with
adolescents at McLean Hospital in Belmont, Massachusetts, and
serves on the psychiatry teaching faculty of Massachusetts
General Hospital and Harvard Medical School.
214