PART II

helping your teen in treatment and at home

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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 it’s working. Psychotherapy may be a mixture of art and science, but it’s not some mysterious process that can’t 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 you’re 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, you’ll feel less anxious and you’ll be much more effective at supporting your child’s 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 it’s 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 won’t 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 child’s 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 child’s therapy.

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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 adolescent’s buddy in the service of establishing the relationship, I render myself useless as a resource and fall into the side of the tank that’s 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 tomorrow’s 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 tomorrow’s 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 I’ve 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. It’s 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 child’s 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-

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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 CHILD’S 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 child’s therapist doesn’t 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 they’re 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 won’t. 5. Outline how the parents are going to be included in the therapy.

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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 child’s 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 adolescent’s 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 adolescent’s commitment to therapy is an ongoing process that therapist and patient will revisit many times over the course of therapy. Parents can support their child’s 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 she’s 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 don’t think patients can work to change if the sole reason they’re 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 you’re going to do poorly at school. Do I have that right?” I asked.

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“Yes, that’s 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, I’m not sure if I really want to stop.” “We had no idea she was doing this! We’ve tried to talk with her about it, but we don’t get too far. All that happens is that we get into an argument,” Tiffany’s 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 won’t 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 Tiffany’s 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 you’re going to think of this, but I want to be a child psychologist. I think I might be good at it,” she offered. “That’s 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. “Don’t you think that might be a problem?” “I wasn’t 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 I’ll stop it when I’m 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 don’t know—maybe I’ll 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. “You’re 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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“Yes,” she said. “I don’t want this thing to get in the way of going to school and doing what I want to do.” “Great,” I replied. “It’s going to be hard work to change this kind of behavior, but together I know we can do it.”

Getting Everyone on Board
Tiffany’s 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 wouldn’t 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 one’s problems, including emotionally difficult ones. Emotionally vulnerable kids tend either to become dysregulated by the discussion and avoid therapy (i.e., drop out) or they’re going to speak only about the most bland and often less relevant issues in their lives

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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 what’s coming down the pike. The therapist’s commitWhen the proper initial work isn’t 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 they’re 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. “Let’s 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 don’t 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 don’t 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 didn’t 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 108–109). 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 she’s 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 110–111).

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

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Thursday

Friday

Saturday

Sunday

Rate urges or feelings on a scale of 1–5. 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 don’t 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

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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.

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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 balls—one slipup and you’ve 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 we’re 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 I’m 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 I’ve 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 wouldn’t be so overwhelmed by their emotions. I have also met some children who don’t think there’s anything wrong with self-harming since it helps them feel better and doesn’t hurt anyone else. This rationale usually develops because the child has given up any hope of stopping the behavior. As we’ve discussed, the legacy of your teen’s 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,

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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 he’s right. I obviously haven’t tried hard enough because I’m 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 you’ve told me about how hard you work in school and manage all those extracurricular activities, you don’t 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, you’re not someone who has to ponder your feelings—your response is almost immediate.” “Yeah, I think that’s true for me. Although sometimes I don’t know what I feel, I’m 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 it’s 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 you’re someone we would call an emotionally reactive person. That means you’re 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 haven’t developed the skills to manage our high-powered emotional systems. When we don’t 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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ates more on the logical and rational side of things, while you’re 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 don’t speak the same language,” he replied. “I wouldn’t 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 don’t know how your mom fits into this picture because we haven’t 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. It’s also a first step in undercutting their deeply held and painful notion The biosocial theory is a powerful way that they’re 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. David’s 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

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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 don’t know. It seems like a lot of work, and I’ve been in therapy a whole bunch of times and, no offense, but I think it is mostly B.S. Just talking about my problems doesn’t seem to help me,” David replied. “Well, I’m not surprised by that. Just talking about your problems doesn’t usually help someone like you. In fact, some kids tell me it makes them even worse. As I mentioned last week, we’re going to have to get you to do some things differently. So let’s talk about your problems and I’ll help you learn new skills to manage your life more effectively. You and I will agree on the behaviors you want to change—called “target behaviors”—and we’ll 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 aren’t going to let me go unless I stop cutting. And you know, I don’t think cutting is helping me, except in the short run. So I guess I’ve 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 I’m doing things that are annoying you, you have to be able to let me know; and if you’re 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 can’t help patients if they don’t 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 I’m giving you a lot of information about the therapy, but it’s important for you to truly understand what you’re 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 can’t 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. I’m 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. I’m good at what I do, but I sometimes need help.

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You should know that I’m part of a team of therapists who meet weekly to talk about our patients. If I think I’m losing my way, or if you think that I’m not being helpful, then I will get consultation from my team. Have I explained this clearly? Good. Now I’m 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 you’re feeling bad and have tried some skills, but you’re 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 don’t know. I wouldn’t 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 couldn’t agree more. That’s why you need my help with skills coaching when you’re in the midst of a crisis. Think about it this way: I’m like the orchestra conductor and you’re 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 rehearsals—that’s 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. “I’m 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 they’ve tried the skills I’ve been teaching them. Stephanie’s story is a good illustration.

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My pager goes off just after midnight on Saturday. It’s 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 can’t stand it anymore. I hate my boyfriend! He is just a real S.O.B. You can’t 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 didn’t give a damn. I just want to hurt myself. I hate him so much.” She sobbed into the phone. “I don’t 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 what’s most important is getting you safely through this crisis. Which of the crisis survival skills has been helpful in the past?” I asked. “I don’t know! I’m so angry. I don’t care what happens to me. He’s the one who—” “Stephanie,” I interrupted, “you called me for help. I can give it to you, but it doesn’t involve talking about your boyfriend right now. We’ve 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 pj’s. I’m going to turn off my phone because I’m not going to talk to my boyfriend anymore tonight or I’d cut for sure,” she said, clearly starting to calm down. “Great! You’re 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 she’d listened to some music and taken a shower before settling down to

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sleep—with 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 they’ve identified as target behaviors. First, the teens should try their new skills to manage the crisis. If that doesn’t work, they should page the therapist. In the very beginning of treatment, before they’ve been exposed to the DBT skills, paging before trying a skill is reasonable. After a short while, however, it’s 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. What’s your role in all this? The answer will be hard to hear: little or none. Once you’re 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 he’s in crisis. There’s more: The therapist can’t 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. “It’s important that we all understand what and how information is going to be shared.” “I don’t want to know every detail of what you talk about in therapy, but if he hurts himself I would like to know,” Manny’s 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. Here’s what I propose: if I don’t think we’re 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 he’s 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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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 I’m 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. Here’s the deal, however: whenever she calls I will always let you know what she told me. So, Isabella, I suggest that if you’re 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 I’m 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 child’s 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 it’s warranted if suicide or harm to others seem possible. It also has to do with the patient’s 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, it’s 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 term—it’s 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 child’s 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 kid’s 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 it’s not wise to share with you everything that happens in your child’s 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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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 they’ve 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 don’t 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 child’s 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. Here’s 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 you’re 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 I’m discussing in this chapter form a piece of the puzzle that, when completed, will yield some workable solutions to your child’s 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: “I’M RE ADY T O T RY S O M ET H I N G EL S E” “Let’s see, Shannon, on Thursday you cut yourself. When did that happen?” I asked. “I don’t 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 don’t really think I ever thought about it. It just happened. I can’t 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 Pj’s, 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 didn’t 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. “That’s 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. “I’m 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 analysis—a 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, let’s 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 you’re 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. Here’s what I think. You and I figured out earlier that interpersonal conflict—a fight with the boyfriend, troubles with parents—is 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 it’s 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 you’re starting to get into that mood?” I asked. “When I’m 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 paintings—I 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 doesn’t 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 family’s 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 you’re 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 what’s being worked on in your child’s therapy—but you’re reluctant to intrude. It’s 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 on—but that you don’t expect to hear all the details. Let her know that you’re 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 you’ll be better able to help your child use them. Do not however, offer this help until you’re 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 CHILD’S PROGRESS
It’s important for you to be able to assess your child’s progress in therapy. Unfortunately, you probably won’t 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 emotions—a 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. It’s 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 don’t 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 rate—it 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 let’s turn to a discussion of what you can do to help your child with emotion regulation.

6
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HOW TO HELP YOUR TEEN RESTORE EMOTION TO ITS PROPER PLACE

Jenny’s mom met her husband at the door. “Jenny’s 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 she’s in there cutting herself again.” “Damn it! This always happens when she goes out with that Mikela kid. I’m going up there and if I have to, I’ll bust the door in!” shouted Jenny’s 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. There’s 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 we’re 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. It’s not always the case, but often we feel we were more successful when our children were younger. When adolescence arrives, it’s 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. “What’s the matter?”

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“My friend Jamie doesn’t want to be my friend anymore because I wouldn’t 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, I’m sure you’ll make up [reassurance]. I have an idea: Why don’t 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. “What’s the matter?” “Nothing!” she shoots back at you with anger. “Hey, I’m just trying to help, and I know something’s 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, I’m sure you’ll be able to patch things up” [reassurance], you reply gingerly. “I’m sure if you and she talk about it, you can work it out” [problem solving]. “Screw Jamie! You’re an idiot!” Mary screams as she races to her room. Similar problem, same strategy—but 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 it’s not surprising that you often can’t figure out what to do when faced with your emotionally dysregulated kid. Try as you might, you’re likely to repeat formerly successful behavioral strategies that just don’t work anymore.

WHAT TO DO AND WHY
Having a child who engages in deliberate self-harm is especially challenging. You’re 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 Mary’s 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 you’ll 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 you’ll be surprised at how your child’s 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 child’s life versus when to let “natural” consequences play out. Finally, for the sake of “covering the waterfront,” I’ll review a few things that people often try that I just don’t 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 liner—it takes practice, patience, and perseverance. There’s just no way it can be done quickly. Psychologists refer to this process as “shaping behavior”—getting the desired behavior or skill down Learning new behavior is like turning pat through successive approxiaround an ocean liner—it takes mations or trials. This means practice, patience, and perseverance. deliberately acknowledging your child’s 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 behavior—that is, it will make it more likely that the new skillful behavior will occur again. Here’s 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, “What’s 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].

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“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. “I’m 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 Mary’s 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 child’s 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 Mary’s 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 you’re 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. Don’t 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 mind—you just want to keep getting more proficient at the skill you’re 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. You’re not likely to pick up new skills when you’re 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 won’t become an Olympic champ.

Patience
I can hear you now: “You want me to be patient while my child is selfinjuring? You can’t 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. I’ll discuss these in detail in Chapter 8.

Perseverance
Sometimes I think perseverance is best captured by the old adage that it doesn’t 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 it’s not. There are two main attitude of willingness—accepting ingredients in being able to perthe situation as it is and doing what severe. The first is cultivating is required—and 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 shouldn’t be the way they are. Don’t 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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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. I’m sure my family misses the old days when they could tease me about my inability to come to terms with an unpleasant reality, but—while I can’t say I like cold water—I 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. Let’s face it: it’s hard to keep going when we experience defeat and failure at every turn. Think about taking small steps toward your goals. For example, if you’re working on validation, decide in advance how many times per day or per week you’re 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 don’t 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, I’d like to tell you about some things that I don’t think work. Some clinicians are still advocating some of these strategies. If what I’m telling you goes against the advice you’re currently being given, then I’ve put you in a tough spot. It could be that these techniques work in your specific situation. If that’s the case, I

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know you’ll have the good sense to ignore what I have to say in this instance. If, on the other hand, you’re 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 it’s a bad idea for at least three reasons. First, there are an infinite number of things she could use, so it’s 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, it’s far more important for your child to learn how to accommodate to the world as it is—with razors, scissors, knives, pop-tops, and safety pins, to name just a few dangers—than 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 they’re in control of their child’s 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. Don’t get me wrong—I’m 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 don’t 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 child’s 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, it’s much closer to a punishment than to a reinforcement strategy (as encouraging more skillful behavior would be).

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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, it’s not a foolproof procedure, since a body check is usually done with the kid in undergarments, making it possible to hide some injuries. I can’t 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 don’t work. Now let’s talk about the ones that do.

WHAT WORKS AND WHY Validation
I’ve talked about validation before. It’s probably the single most important skill I can teach you. Validating your child’s 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 child’s experience or point of view is not the same as approving or agreeing; it only acknowledges that you have heard and understood what he’s 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 we’re frightened for our child and we want him to stop something dangerous, but teens must come to their own wisdom—finding 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 stilted—kind 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 you’re 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 can’t take it in. When that happens (and I can almost guarantee it will), don’t give up! Just try to understand that the moment wasn’t right for your kid to feel validated. There are several different ways to validate your child’s 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 child’s predicament and as comforting. You’ve had these moments in the past, and as you learn the new skills you need, you’ll find them occurring more often. In this chapter I’m 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.

Don’t Validate the Invalid
It is ineffective to validate what is patently not valid, as Robert’s mother tries to do. “I can’t 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,” Robert’s mother replied in her most gentle voice. Here are some other ways that Robert’s mother could have responded, rather than validate Robert’s feeling that he’s 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 you’re dumb when you get a C– on a test for which you had prepared.”

Avoid Personal References
“I can’t believe Jane would treat me this way! I thought we were best friends and then she goes and betrays me like this. I’m 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 don’t 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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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 person’s experience. Your past experiences can be useful, however, so here’s one way you can both validate your child and speak about your own experiences. “I can’t believe Jane would treat me this way! I thought we were best friends and then she goes and betrays me like this. I’m going to make her pay,” Elizabeth said through clenched teeth. “You’re really mad! What did Elizabeth do that got you so angry and hurt?” Elizabeth’s mom asked. “I don’t want to talk about it,” Elizabeth shot back. “Okay. Are you just too mad right now?” Elizabeth’s mom inquired. “Yeah. I don’t 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. What’s up with that?” Elizabeth said. “That’s awful! No wonder you’re 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 Elizabeth’s 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 doesn’t 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 don’t believe they can manage their own problems, so it feels like being kicked when they’re 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. Don’t 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 doesn’t work when you’re trying to be validating. Imagine you’re 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? Doesn’t 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 you’re mad, but you can’t carry on that way.” Both parts of these sentences can be true, and these statements probably wouldn’t be experienced as validating. That’s right—the magic word is and! If you’re going to offer reassurance or problem solving in the same sentence— and I suggest that you avoid that as much as possible—please 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 it’s difficult to determine whether you are being validating, so here’s a clue. The easiest way to know is when the person tells you she feels understood. If she doesn’t tell you directly, then notice whether she’s telling you in more detail about the situation, especially if she’s 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. It’s as if

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nothing else in the universe is of any consequence—the only thing that matters is what the other person is saying. As you’re listening, you’re working at seeing the situation from his perspective. You need to pay attention to any judgments you’re making. For example, are you telling yourself that he’s wrong to feel the way he does, or that he’s making too big a deal about his hurt or angry feelings? Judgments tend to distract us from truly being able to take another person’s 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. Mona’s 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, she’s liable to engage in self-harm. Judgments about Mona making too big a fuss over the matter enter Mom’s mind. “I hate myself! I wish I could disappear!” Mona complained. “Oh, Mona! Don’t you think that’s a little over the top? After all, it wasn’t that big a deal,” Mother interjected. “I can’t 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 Mom’s opinion that Mona’s problem wasn’t so important that she should hate herself, and for sure it wasn’t worth dying over. Had Mona’s 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. That’s a terrible way to feel. Can I help?” Mona’s mom asked. “Not really. I’ll 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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Attentive listening becomes active listening when we add the element of reflection or, as it’s sometimes referred to,“mirroring.” Reflection is simply restating the other person’s 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 she’s leaving,” Joan said. “I can see how down you are,” Joan’s 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 she’s leaving,” Joan said. “It sounds like you’re sad about Melissa moving to Dallas,” Joan’s dad replied. “Yeah, I am so bummed out.” In this example Joan’s father uses active listening to get clear about what Joan means when she says she’s “down.” Staying open and curious about your child’s 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 what’s happening. Our thinking loses any flexibility; we can’t be budged from our own point of view. We typically refer to such people as “stubborn.” “Mary did it again. I don’t believe her. She is having a sleepover and she didn’t 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 Kate’s dad. “No, I’m not mad, I’m humiliated,” Kate responded. “I don’t know—it seems like you’re 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. Kate’s 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 Kate’s position to feel mad at Mary—but that doesn’t seem to be her experience. Kate’s father’s refusal to amend his position is most likely going to make the situation worse. When you’re engaged in active listening as a

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validation strategy, it’s all about acknowledging the other person’s 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, don’t feel obligated to reflect every feeling as it arises in a conversation. Use your reflections just to let the other person know you’re following him or her or as a way to help you get more clarity about his or her experience.

When you’re engaged in active listening as a validation strategy, it’s all about acknowledging the other person’s 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 I’m 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 she’s telling you that goes beyond the words she’s using. It could be that as she’s 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. “I’m 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 didn’t 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.” Crystal’s mother noticed the quiver in her daughter’s 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?” Crystal’s mom inquired. “Yeah, it hurt my feelings! I think I’m both mad and sad about the whole thing,” Crystal replied. See how Crystal’s 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 curiosity—unlike Kate’s dad insisting that she seemed angry. It is very important that when using this validation skill, you don’t become attached to the “correctness” of your point of view. If the other person doesn’t confirm what you think she might have been feeling, let it go. If you don’t, 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 don’t. 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 child’s experience without assuming that you already understand it. Here’s 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 didn’t make it.” “Well, I guess your worries are over. Now you’ll be playing with your friends,” her mom gently replied. “Yeah, I guess you’re right,” Izzie said without much conviction. “Gee, Izzie, all week long this has been such a worry for you, and now it’s settled,” her mom continued. “I don’t know why I am unhappy, but I am,” Izzie said. “I wonder if you aren’t a little sad that you didn’t make the team?” her mom asked. “Yeah, that’s it. I’m glad I’ll 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 child’s 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 don’t forget to validate yourself for working hard at learning a new skill! In this chapter I’ve 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 you’ll learn a number of additional skills to help support your teen’s 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, it’s

not a problem-solving strategy. This chapter focuses on skills you can learn— or polish—to 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 child’s 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 don’t 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 Bonnie’s mother hears some upsetting news. “I’m going to see Kerri this Saturday night,” Bonnie told her mom matter-of-factly. “What! I can’t believe I’m hearing this. Every time you and Kerri see each other you get into trouble. What are you thinking?” Bonnie’s mom anxiously replied. “That’s not true! Besides, you can’t tell me who I can see and who I can’t,” exclaimed Bonnie. “This is a bad idea and you’re 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, there’s no chance for either party to explain her

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thinking. The situation has been made much worse between Bonnie and her mother overall, and the issue about Saturday night remains unresolved. Let’s take a look at another version of the conversation that doesn’t work for a different reason. “I’m going to see Kerri this Saturday night,” Bonnie told her mom matter-of-factly. “Oh, that’s nice, I think. Umm, wasn’t she the girl you had some trouble with? I don’t know, do you think it’s a good idea to see her?” Mom asked cautiously. “What are you saying? When are you going to trust my judgment? I don’t believe you!” Bonnie replied. “It’s not that I don’t trust you, uh, it’s just that I’m concerned,” Bonnie’s 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 Bonnie’s 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 I’ll 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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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 Here’s how this skill breaks down. Describe is used to orient the other person to the situation you want to talk about. It’s 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.” It’s more useful to limit the on the defensive, which won’t get discussion to one particular situation you what you want from them. rather than speaking in generalities like “You always miss your curfew” or “I’ve 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 you’re late for curfew, I both worry about you and I get angry” or “When you say you’re going to clean your room and don’t, 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 don’t do what you say you’re going to do.” When you’re expressing your feelings, it’s 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 you’re going to clean your room at a certain time, I want you to do it.” Your assertion needs to be clear and firm—no ifs, ands, or buts. One of the best ways to reach your goal is to spell out what’s 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 I’d be willing to extend your time out” or “When you clean your room as you agreed you would, I won’t 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, I’ll get you the sweater you’ve 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 they’re 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 I’ll 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 I’ll 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 you’re late picking me up from school? Do I make a fuss?” or “My room is a mess? Have you seen my sister’s? Why don’t you ever nag her about her room?” In the face of these often emotionally charged distractions, stay mindful of your objective. (I’ll give you more help with developing mindfulness skills in Chapter 8, and you’ll 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 goal—don’t 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 goal—don’t get sidetracked. up from school right after we finish the discussion about your curfew” or “You might have a point about your sister’s room. I’ll 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. It’s also important that you appear confident when making your request. Notice I said “appear”—you can feel like Jell-O on the inside; you just have to

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look the part. Let’s face it: sometimes it’s 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 you’d 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 it’s going to be difficult for you to look confident, try working at it in front of a mirror. If it seems that you’re not going to get exactly what you want and you’re willing to be flexible, then—and only then—try 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. Don’t move to negotiation too DEAR MAN is a very useful quickly—you 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 you’re ready, try it out in relatively neutral situations with friends or at work before bringing it home. Let’s see how Bonnie’s mother rewrites her daughter’s emotional script after she’s practiced this skill for a while. “I’m going to see Kerri this Saturday night,” Bonnie told her mom matter-of-factly. “When you announce what you’re 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],” Bonnie’s mom said calmly. “Okay, what are you going to say if I raise it as a question?” Bonnie asked warily. “I don’t know. My decision would be based on the conversation we have. I can tell you that I’m much more likely to agree if I have a sense that you’ve taken my concerns seriously [reinforce].” “What does this have to do with you? She’s my friend, and I should decide who I spend my time with, not you,” Bonnie said with some irritation. “In part that’s 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.” “I’d 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, I’ll drop you off at the mall for an hour or so [negotiate].” “I don’t really like it, but I’ll do it, I guess.” “Thank you.” Bonnie’s 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 people’s feelings. It’s 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 you’ll 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 you’ve 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 afternoon—as 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 don’t 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 don’t get addressed in an ongoing way. It’s 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 you’re sure you’ll 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 you’re able to be gentle, the next step is to bring a degree of interest in hearing the other person’s 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 doesn’t 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, I’m sorry that we had words this morning. I know you felt hurt and angry by my remarks. Do you think we could try again?” Jackie’s dad gently inquired. “I don’t want to talk about it! It’s over, done—that was this morning, this is now. Leave me alone. Anyway if we talk you’ll 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 didn’t 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 it’s ‘crap,’ I really get upset,” said Jackie. Jackie’s father doesn’t have to be interested in his daughter’s music one iota. He does, however, have to act interested to make sure the repair is effective. If you can’t 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 I’m not going to repeat the how-tos of this skill. Let’s 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 it’s ‘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 slack—I never grew out of the Beatles,” Jackie’s 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 you’re 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 don’t want to risk offending the other person.

Relationship Objective 3: Setting a Limit and Holding on to Your Self-Respect
It’s a tough job, but someone’s 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 don’t set limits, they’re 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 child’s 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 parent’s 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 don’t 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 you’ve 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 it’s 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, that’s not my problem. It just isn’t fair—you just can’t change the rules like that!” Sarah complained. “I can see how it might seem unfair, but the answer is still no,” Ruth replied. “I’m 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 daughter’s argumentativeness. I’m not suggesting that you be rigid and inflexible with your limits; just don’t change them in the face of your kid’s 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 daughter’s wish to see her boyfriend and the fact that changing the rules has an element of unfairness to it. When you’re being fair, you are

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undercutting any tendency to blame the other person—and when blame is out of the equation, limit setting goes more smoothly. No apologies really means no excessive apologizing. When you’re setting a limit, it works best if you’re direct and somewhat matter of fact. Avoid statements like “I’m really sorry to have to ground you. I wish I didn’t 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 don’t have to be burdened by guilt, just don’t set the limit, or she’s going to accuse you angrily of not being sorry at all. Just don’t go down that path. We often set limits when a particular value of ours has been crossed or is about to be. Ruth’s value is that it’s not okay. to be at a boy’s house without adult supervision. Sticking to your values requires you to be clear about what’s 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 it’s 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 there’s 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, it’s 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, it’s imhow conflicts can be resolved portant to remain truthful. Noreasonably. But don’t stage a heated tice how open Sarah’s mom is confrontation in front of your child. about her past behavior of letting her daughter be at the boyfriend’s house alone. I’m 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 don’t trust you to be alone, it’s just that we want you to spend the night with old Aunt Jennie.) If you’re avoiding the truth as a way of dodging an argument, you’re settling for a short-term solution to a longer term problem. Setting limits helps children learn how to manage disappointment, and wouldn’t 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 child’s individual therapy. Probably the single most effective action that you can take to help your kid is to make sure he’s in effective treatment. Once that’s 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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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! He’s not picking up his cell phone. I have to know what’s going on with us. I can’t take not knowing,” Tameka complained. “Have you tried his land line?” Tameka’s mom asked, sensing her daughter’s distress. “Of course! I’m not stupid,” Tameka angrily replied. “Try his cousin—you 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. Tameka’s 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. Tameka’s mother skips validation and begins to offer unsolicited advice—and gets the predictable negative result. In the second example, Tameka’s mom takes a longer view, modeling the capacity to tolerate distress. “I need to speak to Jimmie right now! He’s not picking up his cell phone. I have to know what’s going on with us. I can’t take not knowing,” Tameka complained. “It’s so hard to wait, especially about your relationship with Jimmie,” Tameka’s mom replied. “I’m going to jump out of my skin. Why doesn’t he answer my calls?” Tameka responded with sadness in her voice. “I’m sorry that he hasn’t returned your calls. Waiting is really hard. I tell you what, why don’t we bake some cookies while you wait? Maybe that will make the time pass by faster,” offered Tameka’s mother. “That’s not going to help! I can’t stand this!” Tameka shouted. “You’re right—it’s not going to get Jimmie to call you any sooner, but it just may make waiting easier,” said her mother. “I guess you’re right about that. Do we have any chocolate chips?” asked Tameka. This time Tameka’s mom does several things differently. First, she takes the time to validate her daughter’s 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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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 daughter’s 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 can’t be solved right now. By exhibiting these distress tolerance skills, she’s showing Tameka how to do the same. Obviously, it’s not easy to model distress tolerance if you, like your teenager, are relatively sensitive emotionally and you haven’t 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 aren’t 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 she’s in crisis through the use of validation, and to give her more privacy when you see that she’s more skillfully managing her emotions. Ask her how she’s feeling, gently inquire about what’s on her mind and how she’s doing—I 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 she’s doing. ments of relative calm, that when she’s in emotional turmoil, you expect her to let you in on it. Let her know very clearly that if she wants your help, it’s there for the asking; if she doesn’t, you expect her to use some technique or skill to help herself. Second, when she’s 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 she’s doing and whether she wants any help from you. Your intention is not to bug her but only to be supportive. Don’t expect your child to welcome your increased vigilance. She may

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even tell you that it won’t 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 she’s correct—it won’t 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 it’s 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 isn’t, let it go and just keep checking in. How often should you check in with your child? That’s something you’ll 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. You’ll 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 kid’s 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 can’t emotionally handle the problem, rather then helping her tolerate the distress that accompanies the problem. Watch what happens with Jody’s parents. “Jody’s school called today,” Jody’s mom told Jody’s 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 there’s a problem. What should we do?” “There’s no way I want the school to know that she cut herself again! If they find out, Jody won’t be able to play lacrosse this spring. You know they get rigid about this kind of stuff. Jody’s been miserable enough—she doesn’t need more stress,” Jody’s dad replied. “What are we going to do? I don’t feel comfortable lying about what’s going on. After all, the school has been pretty supportive so far. I don’t want to screw things up with them,” Jody’s mom responded.

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What would you do if you had to wrestle with this dilemma? Jody’s dad’s position seems entirely reasonable; he wants to protect his daughter and minimize the stress in her life. On the other hand, his wife’s worry that lying to the school could potentially backfire is also reasonable. The central question is how to make the best guess about what’s in Jody’s 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. It’s 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 he’s 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 Jody’s privacy No lacrosse Deprive Jody of school support Cons

Spend some time with your own ideas about Jody’s 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 Jody’s parent’s withholding information from the school is that it might move Jody’s 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 child’s 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 can’t help your child if you put too much pressure on yourself or your child to change quickly. When you’re 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 don’t 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 children’s 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 child’s 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 don’t protest or talk about how the lack of attention is affecting them because they’re sensitive to their parents’ worry. Their silence often misleads parents into thinking they’re just fine. It’s not unusual for some siblings to become anxious or withdrawn. Others make their protest known by their own behavior problems or academic difficulties. It’s extremely challenging and at times draining for parents to stay focused on the other children in the family, helping them understand what’s 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 you’re married, living with your partner, or living separately, your capacity to be effective in relationships goes out the window when you’re suffering from burnout. Relationships take care and attention. When we’re 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 it’s probably not burnout. It may be that you and your partner have a conflict that you’ve 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, you’ve tried to work things out and where you are with your partner is as good as it gets, then it’s 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 don’t feel your network of people would be supportive of your child who self-harms. If that’s 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, you’ll 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 can’t believe this is happening!” Kris’s mother said with a tinge of anger in her voice. “Kris never had any problems before. I thought she was doing so well—then she made these new friends, and the next thing we know, she’s cutting herself. It seems that nothing her dad and I do makes a difference. Some days I don’t even want to get out of bed.” I’m sure many of you can identify with Kris’s mother. At times it may seem that feeling resigned, angry, and hopeless is all you can expect. While it’s natural to experience these emotions, they needn’t take over your life. In fact, remaining in such a state will only lead to more exhaustion and a more depressed mood—increasing 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 don’t 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 feelings—just notice them and let them pass. For example, you may notice your thought that a stronger or more resilient person wouldn’t feel the way you do or that it isn’t 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 are—period.

Step 2: Letting Go
Once you have noticed what you’re 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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Here’s 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 hadn’t happened, then I wouldn’t 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 we’re likely to distract ourselves with an internal narrative that, while it could have been true, just doesn’t match what’s 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 what’s happening in the moment— whether it’s planning your child’s treatment, having a terrible argument with your spouse, or enjoying your dinner. Acceptance does not mean that you like what is happening or that you’re in agreement with it, only that the facts are what the facts are. Remember when Kris’s mom said she couldn’t 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, you’ll 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 can’t be happening. This just isn’t 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, she’d 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 couldn’t 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. There’s no way to avoid all of life’s painful situations: people die, people get sick, and decisions we make turn out badly. Suffering, however, is another matter. Often we suffer because we won’t 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 we’re 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 doesn’t 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 I’d 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! I’m stuck in traffic! This acceptance stuff is nonsense!” I shouted out loud. That’s when I remembered to repeat steps 1 and 2. Acceptance is not a problem-solving strategy, although it’s often the first step in effective problem solving. If you think about it, you really can’t 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 you’re like most people, you turn the key several more times, as if that will make a difference. You now have a choice: you You can’t 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 what’s happening in this moment.

EMOTIONAL MINDFULNESS
“You’re going to do what? There’s no way your mom and I are going to let you spend the night at Julia’s house,” Morgan’s 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. “Don’t 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 won’t happen again. I don’t have any money for beer. Remember, you stopped my allowance!” Morgan shouted.

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“That’s not the point! You really can’t be that dumb. When are you going to grow up?” Morgan’s father screamed. Most parents I know—whether they’re part of my clinical practice, friends, or relatives—have had the experience of becoming emotionally overwhelmed with anger and frustration in the face of some seemingly outlandish aspect of their teenager’s 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 down—you’re losing it,” but they just can’t harness sufficient restraint. Soon afterward, they feel guilt and remorse. Sound familiar? It’s 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 you’re 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 she’s fine. You persist, which only leads to a heated exchange. If you’d 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 we’re experiencing are building a kind of mental box more than one emotion at a time, to contain them safely—plus 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 you’d 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 we’re successful in this process, we’re 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 we’re 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 we’re 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 you’re getting emotionally charged up. Your task is to simply notice what you’re feeling; that’s it. Doing this simple exercise will decrease the chances of things escalating into an altercation. Notice whether you’re making any judgments about your emotions (“I am wrong to feel angry” or “It’s 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, you’ll find that you’re more likely to become more rational and balanced. For example, Ariel’s mom noticed new cuts on her daughter’s 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 you’ll 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 you’re 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 she’s 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 you’re 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 you’re like most people, when you’re feeling depressed and leYour goal is to change the way thargic your body tells you get in bed you’re 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 emotion’s 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 he’s gone to a friend’s house and won’t be back for several hours. After calling him and checking in, it wouldn’t 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 you’re 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. It’s not about denying what you’re feeling or judging what you’re experiencing—it’s 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 you’re 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 don’t 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 don’t 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 she’d seen on her daughter’s 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 we’re 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 you’re 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 isn’t 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 we’re 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 we’re 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 you’re afraid to do. Again, I suggest that you practice this skill on the small worries first. If you’re 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 situations—I 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 child’s 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 faces—that 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 shame—that 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 again—after 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 doesn’t 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. It’s 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 friend’s 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: it’s 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? Molly’s 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 can’t 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 she’ll 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. That’s 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 Molly’s guilt warranted or unwarranted? Most of the situations we encounter as parents are not clear-cut cases of warranted or unwarranted guilt, and this one’s no exception. Let’s 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 can’t see her friend, I don’t think we can hold Molly responsible for her daughter’s 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 shouldn’t 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 wouldn’t want more of that?

TAKE CARE OF YOURSELF
I really don’t want to sound like your guilty conscience, but it’s 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 don’t have the energy or feel we don’t 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 diet—after all, having some treats in your life is a good thing—I ask you to be mindful of your body’s 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 stressful—and living with a child who engages in deliberate self-harm certainly is among the most stressful—we 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 they’ve 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 child’s self-injurious behavior. Long-standing difficulties in communication that

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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 person’s 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 don’t 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 partner’s 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 don’t 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 wouldn’t have said the things I did if she hadn’t started in with me” may be 110% correct—but, 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
I’m 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 wonderful—and I encourage you to find those special moments when things just seem to happen—don’t 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 I’ve focused on the immediate triangle of you, your partner, and your child. In the final chapter, I’ll help you navigate your way in the wider sphere of the other children in the family, as well as your child’s friends and school.

9
how to speak with siblings, friends, and the school about your child’s troubles

Getting a grip on your child’s 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 I’ll share my advice on the complicated and delicate matters of communicating with your child’s siblings, friends, and school.

SIBLINGS
“Mommy, I know something’s wrong with Samantha. I heard you and Daddy talking last night. Is she going to be okay? Why does she hurt herself? Doesn’t 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. “I’m 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 she’s just a drama queen looking for attention! You and Mom are just being idiots and don’t see that. You know she doesn’t 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 isn’t doing anything and is costing a fortune.” “Slow down here, Bill,” his dad responded. “I know it seems like she’s doing this for attention, but we don’t think that’s 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 didn’t 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 sister’s seemingly crazy behavior, I can try to tell you about some other possibilities, and I think you’d feel better about how we’re 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 children’s 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 don’t 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 they’re 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 don’t 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 what’s going on with their sibling but they’ll 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 isn’t

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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 don’t 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. It’s hard to accept that you can’t do it all, but of course there will be times when you can’t. 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 you’re 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 child’s problems can make all the difference when you and the child’s 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 Sibling’s Self-Harm
The other kids in the family frequently don’t know if, or how, they should address the feeling that they’re getting less from you, or how to ask questions or give voice to their worries. If you decide to keep your teenager’s 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 child’s privacy, you may unwittingly create a number of additional problems. Kids are very perceptive. They probably know that something’s 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 something’s 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 child’s 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 Samantha’s dad is validating but firm. See how he does not back down in the face of Samantha’s 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 what’s going on, while children in middle and high school can probably tolerate a more factual version of their sibling’s behavior. Notice how Samantha’s father is very clear about how he and his wife are managing the situation and how he remains responsive to his son’s 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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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 we’re going to talk with Tommy about the problems you’re having,” said Samantha’s dad.

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“I don’t want you to say anything to him. It’s 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 don’t 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 he’s confused and worried,” Dad replied. “I have all these problems, and now you guys are making it worse. Why can’t you think about how I feel for once?!” Samantha said with anger and sadness rising in her voice. “The fact is, we’re 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 don’t like this one bit, but I didn’t know he was worried. Yeah, let’s talk with him together,” Samantha suggested. Finding a way to help the other children in the family understand what’s 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 let’s 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? It’s a difficult issue. Let’s start by figuring out why you’re 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, it’s important that before you share any information you let your teenager know with whom, what, and why you’re 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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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 I’m 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 child’s difficulties.

Can You Protect Your Teen’s 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 family’s 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 couldn’t go. The extended family knows that your daughter has been having some kind of emotional troubles, but they’re 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 do—it 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 I’m using the phrase “limited information.”

Is Lying Ever a Good Idea?
You’re 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 there’s no such thing as a psychological problem and that therapy is a bunch of hooey, being totally honest with that person about what’s 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 you’re 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 we’re 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 she’s doing is so horrible that it must be covered at all costs. Don’t you have enough to deal with already with this troubled child? My advice: Avoid lying whenever possible. That doesn’t 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, it’s 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, it’s 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 teen’s 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 teen’s 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 what’s going on. Also let her know that you’re 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 you’ll need to manage. There will be people who distance themselves from you or your child because they’re afraid of what he does. People can find self-injury frightening and deeply disturbing. You can’t educate everyone, especially while you’re also trying to take care of yourself and your family. If your child loses friends, or her friend’s parents won’t allow contact because they learn of the selfinjury, be validating to the loss. Over time these natural consequences may help channel some of your child’s 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. You’ll 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 you’ll 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 support—that is, request that they listen without giving advice, or ask specifically for help with problem solving. • If you’re concerned that sharing this information will change their opinion of you or your child, be open and talk it through with them.

THE SCHOOL
It’s 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 they’re 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, it’s time to access additional school services. In addition, school forms the basis of a teenager’s 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 child’s attitude toward school. It’s 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 child’s 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 you’re 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 kid’s treatment team. The bottom line is that when the school knows about your kid’s behavior, being straightforward with the facts is the best course of action. In those instances where the child’s deliberate self-harming behavior comes to light out of the purview of the school, parents are confronted with a

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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 you’re 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 you’ll 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 won’t 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 they’re obligated to find the most

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“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 child’s needs. Public school systems are obligated to do this. At the end of the evaluation, if it’s 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 don’t 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 don’t start with a “big stick” approach. You are your child’s 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 that’s 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 there’s no space available. Finally, if you and the school can’t 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

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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 child’s 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 can’t 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 don’t succumb to the pressure of having to complete high school in 4 years.

Looking Ahead
Now that you’ve 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 changes—the moment you’re 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 view—this 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 kid’s 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 Center’s (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 2005–2006. 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.

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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.

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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 treatment—at which time a less intensive therapy schedule (typically 1–2 hours

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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 child’s 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 child’s 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 don’t 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.

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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 child’s treatment needs to think hard about the clinical benefits and liabilities of such a treatment choice.

LONG-TERM PROGRAMS
Long-Term Residential Treatment Programs—When 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-

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ported that her school attendance was declining, along with her grades. Marnie’s 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 don’t know. Why don’t you ask them? Do I look like a mind reader?” she shot back. “I don’t know, let me see. No, you don’t look like a mind reader, but you do seem to be pretty angry. What’s up with that?” I wondered. “I don’t 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, it’s 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 they’ve caused, it turns out you’ll 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 child’s 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-

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mation. I have never read a brochure for anything that didn’t say its organization was the best at what it was providing!

Wilderness Programs
Sometimes when an adolescent is struggling, it’s 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 Bound–style 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 doesn’t 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 child’s 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

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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 child’s 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 you’re 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 child’s 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, she’d 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 aren’t. Some schools have a hefty clinical emphasis; others don’t. 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 teen’s 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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better, and (6) grief reaction. In all likelihood, Sutton’s 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 Lader’s 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 line—800-DON’TCUT—which 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 Favazza’s 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.

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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 Martinson’s 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

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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 alarming—such 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, 75–78 distress tolerance skills and, 84–85 siblings of self-harming child and, 180– 181 taking care of yourself and, 163–166 Action potential of emotions, 170–175 Active listening, 140–141 Acute short-term residential units, 197–198 Advice giving, 53–54, 137 Alcohol use interference of to quality of life, 123 myths regarding self-injury and, 20–21 peer pressure and, 19 All-or-nothing thinking, 71, 177 Aloneness, feelings of, 61–62, 63 Amount of self-injury, increases in, 59–60 Anger biological vulnerabilities and, 35 changing interpretations of events and, 44–45 dwelling on, 39–40 intensity of, 37–38 opposite action strategy and, 172 Anti-anxiety medications, 95–96 Anticonvulsant medications, 95 Antidepressants, 93–94 Antipsychotic medications, 95 Anxiety acceptance and, 165 medication and, 95–96 opposite action strategy and, 172–173 using self-injury to avoid something and, 64–65, 66 Apologizing to your child, limit setting and, 153 Assessment, psychiatric, 68–71 Attention seeking, myths regarding selfinjury and, 15–17 Attentional control, 81

Attentive listening, 138–139 Attribution theory, 22 Auditory hallucinations, 66–67 Avoidance, self-injury as, 64–65, 66 Balance, emotional, 57–65, 74–75 Behavior chain analysis, 81–82, 121–123 Behaviors chain analysis and, 81–82, 121–123 dependency of on mood, 41–42 dialectical behavior therapy (DBT) and, 81–82 emotion modulation and, 45–46 impulsive behavior and, 81–82 meaning and function of, 25, 72–74 natural consequences to, 154, 157–158 opposite action strategy and, 45–46, 170–175 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, 79–80 overview of, 33–37 psychiatric conditions and, 67 Biosocial theory, 79–80, 103, 114 Black-and-white thinking, 71, 177 Blame, 62, 79–80 Body checks, 134–135 Borderline personality disorder, 87, 193– 196 Brain functioning, 42–43, 168 Breathing, mindfulness and, 163–164 Bribery, reinforcement of behavior and, 147 Bullying, as a form of invalidation, 51 Burnout, parental, 160. See also Taking care of yourself

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parenting strategies and, 128–129 sensitivity and, 49 siblings of self-harming child and, 182– 183 Dialectical behavior therapy (DBT) acceptance and change and, 75–78 assessing your child’s progress in, 101, 126–127 attentional control and, 81 balancing act of, 102, 112 behaviors that interfere with, 123 benefits of, 74–82 components of, 103 developing a sense of identity and, 80–81 effectiveness of, 193–196 emotional balance and, 74–75 emotional dysregulation and, 80 finding a therapist to conduct, 89–91 goals of treatment and, 104–118 guilt and self-blame and, 79–80 history of, 86–87 how it addresses what your teen does and thinks, 72–74 insurance coverage and, 97–98 overview of, 2, 9, 26–31, 72, 85–88, 101, 102–103 parental involvement in, 102–103, 120–123, 125–126 psychiatric conditions that warrant therapy other than, 66 research on, 87–88, 193–196 skills training and, 82–85 supplemental therapies to, 91–97 what to expect from, 126 Diary cards, 103, 107–113 Diet, taking care of yourself and, 175–176 Disagreement between parents, 27–28, 77, 153, 176–178 Disappointment, limit setting and, 153–154 Distorted thinking, 73–74, 81 Distraction, 45–46 Distress tolerance skills, 84–85, 154–156 Divorced parents, 27–28, 161–162 Drug use interference of to quality of life, 123 myths regarding self-injury and, 20–21 peer pressure and, 19 Duration of feelings, behavior and, 45–46 Dwelling on feelings changing interpretations of events and, 44–45 emotion modulation and, 40–41 emotional illiteracy and, 39–40 Dysregulation, emotional dialectical behavior therapy (DBT) and, 74–75, 80 overview of, 34–35 understanding in your child, 57–59

Chain analysis, 81–82, 121–123 Change, 75–78 Charting your child’s progress, 101, 126– 127 “Checking in” with your child, 156–157 Checking your teen’s body for evidence of self-injury, 134–135 Coaching between sessions, 103, 116, 117–118 Cognitive distortion, 73–74, 81 Cognitive-behavioral therapies. See also Dialectical behavior therapy (DBT) anxiety and, 95 distorted thinking and, 73–74 overview of, 88 Commitment to therapy, 103, 104–118 Communication. See also Communication with your child patterns of, 54–56 between the therapist and your child, 102, 103 Communication with your child. See also Validation active listening and, 140–141 attentive listening and, 138–139 emotional illiteracy and, 37–46 family therapy and, 91–92 giving voice to the unspoken and, 141– 143 Confidentiality in therapy, 103, 118–120. See also Privacy Consequences, natural, 154, 157–158 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, 117–118 Curiosity in parenting, 141–143 Cutting, reasons for. See Reasons for selfinjury Day treatment, 198, 201 DBT (dialectical behavior therapy). See Dialectical behavior therapy (DBT) DEAR MAN acronym, 146–149 Decision making, attentional control and, 81 Dependency on parents, developmental stages regarding, 16–17 Depression, 88, 193–196. See also Sadness Development confidentiality in therapy and, 119 dependency on parents and, 16–17

index
Eating disorders, 123 Eating healthy, taking care of yourself and, 175–176 Emotion regulation skills brain functioning and, 42–43 family therapy and, 91–92 giving voice to the unspoken and, 141– 143 inability to engage in, 37–46 modeling to your child, 54 overview of, 40–41, 84 problem solving and, 43–46 Emotional balance, 57–65, 74–75 Emotional dysregulation. See also Emotion regulation skills dialectical behavior therapy (DBT) and, 74–75, 80 overview of, 34–35 understanding in your child, 57–59 Emotional illiteracy, 37–46, 61–62, 63. See also Vulnerabilities for self-injury Emotional mindfulness, 166–170. See also Mindfulness Emotional pain acceptance and, 165 emotional illiteracy and, 37–46 giving voice to the unspoken and, 141– 143 mindfulness and, 166–170 myths regarding self-injury and, 17, 21– 22 opposite action strategy and, 45–46, 170–175 overview of, 4, 8–9 physical pain and, 21–22 understanding, 30–31 vulnerabilities for self-injury and, 32–33 Emotional reactivity biological vulnerabilities and, 33–37 black-and-white thinking and, 71 developmental stages regarding, 48–49 emotion modulation and, 41 overview of, 33 Emotional vulnerability, 32–33 Empathy, 180–181 Emptiness, feelings of, 61–62, 63 Endorphin release, myths regarding selfinjury and, 21–22 Environmental factors balancing act of, 112 black-and-white thinking and, 71 dialectical behavior therapy (DBT) and, 79–80 overview of, 46–56 removal of sharp instruments or other tools used to self-injure and, 134 school, 187–191 vulnerabilities for self-injury and, 33

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Exercise, taking care of yourself and, 175– 176 Extended family, discussing the selfharming behaviors with, 184–187 External attributions, 22 Family, extended, 184–187 Family therapy, in addition to DBT, 91–92 FAST skill, 152–153 Fear, opposite action strategy and, 172– 173 Feeling alive, understanding in your child, 61–62, 63 Feelings. See Emotional pain Feelings, hiding of invalidation and, 55 overwhelming feelings and, 58 vulnerabilities for self-injury and, 32–33 withdrawing from family and, 55 Financial concerns regarding treatment, obtaining treatment and, 97–98 Frequency of self-injury, increases in, 59– 60 Friendships. See also Relationships discussing the self-harming behaviors with, 184–187 peer pressure and, 19–20 popularity of self-injury, 17–19 Function of the behavior, 25, 26–27. See also Reasons for self-injury GIVE skill, 149–151 Giving voice to the unspoken, 141–143 Goal setting in parenting, 133 Goals of treatment, 104–118 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, 79–80 limit setting and, 151–152 opposite action strategy and, 173–175 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, 66–67 Healthy eating, taking care of yourself and, 175–176 Hearing voices, 66–67 Help, asking for, 38–39

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Labeling of emotions emotional mindfulness and, 167–168 giving voice to the unspoken and, 141– 143 inability to engage in, 37–46 Legal assistance, obtaining services from the school and, 189–191 Limit setting, interpersonal effectiveness skills and, 151–154 Listening active listening, 140–141 attentive listening, 138–139 listening to other points of views, 29–30 Lithium, 95 Long-term residential treatment programs, 198–201 Lying, discussing the self-harming behaviors with friends and family, 185–186 Managed care, obtaining treatment and, 97–98 Masking of feelings invalidation and, 55 overwhelming feelings and, 58 vulnerabilities for self-injury and, 32–33 withdrawing from family and, 55 Media representation of self-injury, 19 Medication, in addition to DBT, 92–97 Mindfulness emotional mindfulness, 166–170 overview of, 82–83 taking care of yourself and, 163 Mirroring, active listening and, 140–141 Modulation of emotion brain functioning and, 42–43 overview of, 40–41 problem solving and, 43–46 Monitoring your child’s progress, 101, 126–127 Mood dependency, emotional illiteracy and, 41–42 Mood stabilizers, 94–95 Mustard test, 22 Myths about self-injury attention seeking, 15–17 everyone’s doing it, 17–19 failed suicide attempt, 23 overview of, 15–23 peer pressure, 19–20 physical pain and, 21–22 role of drugs and alcohol in, 20–21 Natural consequences, 154, 157–158 Negative feelings, emotional illiteracy and, 39–40. See also Emotional pain

Hiding of feelings invalidation and, 55 overwhelming feelings and, 58 vulnerabilities for self-injury and, 32–33 withdrawing from family and, 55 Honesty discussing the self-harming behaviors with friends and family, 184–187 limit setting and, 153–154 siblings of self-harming child and, 181– 184 Hospitalization, 96–97, 197–201 Identification of emotions emotional mindfulness and, 167–168 giving voice to the unspoken and, 141– 143 inability to engage in, 37–46 Identity development, 80–81 IEPs, 190 Ignored, feelings of being, 62–64 Impulsive behavior anti-anxiety medications and, 96 biological vulnerabilities and, 35–36 dialectical behavior therapy (DBT) and, 82–83 Indirect interpersonal skills, 154–159 Individual counseling for the parents, 162 Inpatient treatment, 96–97, 197–201 Insurance coverage, obtaining treatment and, 97–98 Integrative therapies, 88 Intensity of feelings, behavior and, 45–46 Intensive treatment programs, 96–97, 197–201 Internal attributions, 22 Interpersonal effectiveness skills DEAR MAN acronym, 146–149 indirect interpersonal skills and, 154– 159 limit setting and, 151–154 overview of, 83–84 parenting strategies and, 144–154 repairing or enhancing your relationship with your child, 149– 151 Interpretation of events, changing, 44–45 Invalidation. See also Validation black-and-white thinking and, 71 overview of, 46–56 patterns of communication that comes from, 54–56 saying “but” and, 137–138 snowball effect of, 54–55 Invisibility, feelings of, 62–64 Judgments regarding your child, 139

index
Negative reinforcement, 73 Negotiation with your child, DEAR MAN acronym and, 148–149 “No,” saying to your child, 146–149 Numbness, feelings of, 61–62, 63 Nutrition, taking care of yourself and, 175–176 Obsessive-compulsive disorder (OCD), 65–71 Openness in parenting, giving voice to the unspoken and, 141–143 Opposite action strategy, 45–46, 170–175 Other points of view, listening to, 29–30 Overwhelming feelings biological vulnerabilities and, 36–37 understanding, 57–59 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, 102–103, 120–123 supporting treatment and, 125–126 Parenting, single, 27–28, 161–162 Parenting strategies. See also Validation allowing natural consequences, 157– 158 DEAR MAN acronym, 146–149 developmental stages and, 128–129 disagreements regarding, 27–28, 77, 153, 176–178 emotional mindfulness and, 166–170 guilt and, 152 interpersonal skills and, 144–154, 154– 159 limit setting and, 151–154 modeling distress tolerance, 154–156 privacy and, 156–157 repairing or enhancing your relationship with your child, 149– 151 siblings of self-harming child and, 179– 184 supporting treatment and, 125–126 that are helpful and effective, 129–133, 135–143 that are NOT helpful or effective, 133– 135 validation and, 51–54 vulnerabilities for self-injury and, 33

211

Parents, therapy for. See Counseling for the parents Patience in parenting, 132 Peer pressure, 19–20 Perseverance in parenting, 132 Perspective, putting things into, 53 Physical pain, myths regarding self-injury and, 21–22 Picking at oneself, 67–68 Popularity of self-injury, 17–19 Positive reinforcement, 73 Posttraumatic stress disorder (PTSD), 66 Privacy. See also Confidentiality in therapy dependency on parents and, 16–17 discussing the self-harming behaviors with friends and family, 184–187 versus increased vigilance, 156–157 overwhelming feelings and, 58 Problem solving acceptance and, 166 developing the skills for, 69–70 emotion modulation and, 43–46 validation and, 51 vulnerabilities for self-injury and, 33 Pros and Cons Chart, 158, 189 Psychiatric assessment, importance of, 68– 71 Psychiatric conditions, 65–71 Psychiatric medication, in addition to DBT, 92–97 Psychodynamic therapies, 88 PTSD, 66 Pulling away from parents, 16–17 Putting things in perspective, 53 Quality of life, behaviors that interfere with, 123 Reactivity, emotional biological vulnerabilities and, 33–37 developmental stages regarding, 48–49 emotion modulation and, 41 overview of, 33 Reappraisals, 44–45 Reasons for self-injury. See also Vulnerabilities for self-injury dialectical behavior therapy (DBT) and, 26–27 drugs and alcohol use and, 20–21 everyone’s doing it, 17–19 failed suicide attempt, 23 to get attention, 15–17 peer pressure and, 19–20 physical pain and, 21–22 psychiatric conditions and, 65–71 understanding in your child, 24–31, 57– 65, 65–71

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index
validation and, 48–49 vulnerabilities for self-injury and, 32– 33 Services offered by schools, 189–191 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, 27–28, 161–162 Skills training in DBT. See also individual skills diary cards and, 103, 107–113 group sessions and, 92 learning to self-soothe, 124 overview of, 82–85 parenting strategies and, 129–133 practicing new skills, 103, 129–133 troubleshooting skills, 124–125 Skin picking, 67–68 Skipping school, 123 Sleep habits, taking care of yourself and, 175–176 Solution analysis, 123 Soothing oneself biological vulnerabilities and, 36–37 emotional illiteracy and, 37 skills training and, 124 Special education, 189–191 SSRIs (selective serotonin reuptake inhibitors), 93–94 Statistics regarding children who selfinjure, 4, 19 Stress acceptance and, 165 medication and, 95–96 opposite action strategy and, 172–173 using self-injury to avoid something and, 64–65, 66 Substance use interference of to quality of life, 123 myths regarding self-injury and, 20–21 peer pressure and, 19 Suicide, risk factors for assessment and, 69 overview of, 23 self-hatred and, 62

Reassurance, 33, 52–53 Reflection, active listening and, 140–141 Refusing your child’s requests, 146–149 Reinforcement of behavior, 73, 147 Relationships. See also Friendships; Interpersonal effectiveness skills balancing act of, 112 interpersonal effectiveness skills, 144–154 between the parents, 161–162, 176–178 taking care of, 176–178 between the therapist and your child, 102, 103, 114–116 validation and, 74–78 between you and your child, 146–149, 149–151 Removal of sharp instruments or other tools used to self-injure, 134 Requesting something from your child, 146–149 Residential treatment, 96–97, 197–201 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, 37–38 opposite action strategy and, 171–172 Saying “no” to your child, 146–149 Scars, visible, 186 School behaviors that interfere with, 123 discussing the self-harming behaviors with, 187–191 therapeutic day schools, 201 Secrecy, 181–184, 184–187 Selective serotonin reuptake inhibitors (SSRIs), 93–94 Self-blame, 79–80 Self-care. See Taking care of yourself Self-hatred, 62, 65 Self-injury, reasons for. See Reasons for self-injury Self-injury in general, 15–23, 25 Self-reflection, 82–83 Self-respect, interpersonal effectiveness skills and, 151–154 Self-soothing biological vulnerabilities and, 36–37 emotional illiteracy and, 37 skills training and, 124 Self-validation, 47–48. See also Validation Sensitivity. See also Emotional pain biological vulnerabilities and, 33–37 developmental stages regarding, 48–49

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, 60–61 Supporting treatment, 125–126 Taking care of yourself acceptance and, 163–166 emotional mindfulness, 166–170 opposite action strategy and, 170–175 overview of, 160, 175–176 relationships and, 176–178 Telephone skills-coaching sessions, 103, 116, 117–118 Therapeutic day schools, 201 Therapists balancing act of, 102, 112 finding a therapist to conduct DBT, 89– 91 goals of, 103 guidelines for choosing, 90–91 listening to their understanding of your child’s behavior, 25 neglecting the issue of self-injury by, 4 parental involvement in DBT and, 120–123 relationship with your child, 102 Therapy, 26. See also Dialectical behavior therapy (DBT) Therapy-interfering behaviors, 123 Thoughts, distorted, 73–74, 81 Treatment, 104–118. See also Dialectical behavior therapy (DBT) Treatment, inpatient, 96–97, 197–201 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, 184–187 limit setting and, 153–154 siblings of self-harming child and, 181– 184

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Two Brattle Center’s (TBC) Adolescent Intensive Dialectical Behavioral Therapy Program, 193–196 Understanding why your child is selfinjuring overview of, 24–31, 57–65 overwhelming feelings and, 57–59 psychiatric conditions, 65–71 Validation. See also Invalidation; Selfvalidation active listening, 140–141 attentive listening, 138–139 dialectical behavior therapy (DBT) and, 74–78, 81, 104 giving voice to the unspoken, 141–143 identity development and, 81 overview of, 30–31, 46–56, 130–131, 135–138 parenting strategies that interfere with, 51–54 siblings of self-harming child and, 180 Vigilance in parenting, privacy and, 156– 157 Voices, hearing, 66–67 Vulnerabilities for self-injury. See also Reasons for self-injury biological vulnerabilities and, 33–37 emotional illiteracy, 37–46 environmental factors, 33, 46–56 overview of, 32–33 Websites related to self-injury, 203–206 Why they cut. See Reasons for self-injury Wilderness programs, 200 Willingness in parenting, 132–133 Withdrawing from the family, invalidation and, 55 Worries of the parents, interference of to validation, 51–52

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.

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