Cutting, or self-harming, is intentional self-injurious behavior resulting in tissue damage, illness, and/or risk of death. Cutting is generally not done with suicidal intent, though teens who engage in self-harming behaviors are at a statistically a higher risk for suicide. Despite what your teen may report, these acts of self-mutilation do not represent typical or harmless adolescent behavior. Self-harming behavior is symptomatic of serious underlying emotional or mental health issues that should be addressed with the support of a mental-health professional.
TYPICAL FORMS OF SELF-HARM:
Cuts or scrapes with a knife, razor blade, or any sharp object
Scraping the skin with abrasive material, e.g. glass, fingernails, or metal
Burning the skin with a lighter or cigarette
Burning the skin with a chemical agent
Breaking bones
Recent research indicates that up to 46% of teens report having engaged in self-injurious behavior. This high surge in cutting behaviors may be due in large part to recent high-profile cutting cases. The media has made much recently of cutting behaviors described by such celebrities as Princess Diana, Angelina Jolie, and Johnny Depp. Like other coping or anxiety-based behaviors, cutting can spread as a copycat phenomenon. Many teens even seek validation and encouragement for self-harming from popular blogs and websites devoted to self-mutilation.
WHY DOES MY TEEN SELF-HARM?
The paradox of pain:
For a person who has had no experience with intentional self-harm, it is a confusing and frightening phenomenon. Most of us avoid pain and seek pleasure, but the cutter seems to avoid pain by seeking pain. Self-harming typically acts as a form of emotional avoidance and escape from unwanted unpleasant emotions. It is often an attempt to drown out emotional pain by engaging in more manageable physical pain. Many teens report relaxation and emotional numbness after self-harming. Self-harming can also serve as a tool to express strong negative emotions towards others or as an attempt to elicit help or attention from others.
Warning signs:
With the exception of those individuals whose cutting has an attention-seeking dimension, most cutters attempt to hide their cutting behaviors. Parents, educators, friends, and healthcare providers can, however, be alert to signs of cutting that include:
Wearing long sleeves or long pants or turtle necks when it is warm outside
Cutting a thumb-loop at the end of long sleeved shirt to keep arms covered
Suspicious scratches, burns, or bruises anywhere on body
Band Aids or tape on extremities
Leaving or stashing razor blades, glass shards, or other “sharps” in the bathroom, bedroom, drawers, backpack, etc.
Attempting to hide scars, burns, or other injuries
Dramatic or intense emotional outbursts
Difficulty expressing emotion appropriately
Self-directed anger
Cutting is a red flag for emotional distress:
In most cases, cutting itself is just a symptom of underlying emotional distress. It is easy for loved ones to become so distracted by the cutting itself that efforts go toward controlling the behavior instead of addressing the problems underneath. Because cutting represents both a physical danger and a deeper mental health issue, the involvement of a mental health professional is always an imperative. If cutting leads to infection or if cutting goes beyond superficial physical harm, medical attention should be sought immediately. Deep cutting may indicate that the young person dissociates during the act of self-harm; even if the intent is not suicide, this kind of cutting is extremely dangerous and can lead to permanent tissue damage or death.
Cutting can be an indicator of many mental health issues, including:
Depression
Anxiety
Suicidal ideation
Physical, sexual, or emotional abuse
Substance abuse
Related eating disorders
Personality and/or relational difficulties
EFFECTIVE TREATMENT FOR SELF-HARM:
Mental-health professionals experienced with adolescent issues and self-harming behaviors favor a variety of approaches in the context of a safe therapeutic relationship and/or milieu. These approaches include:
Cognitive Behavioral Therapies
Dialectical Behavioral Therapy
Pharmacotherapy
If you suspect your child of cutting or other self-harm it is vital to consult with a mental health professional. Your child’s self-harming behavior is a warning sign of an underlining mental-health problem that needs immediate professional attention.
Sources:
Linehan, Marsha (1993) Cognitive Behavioral Treatment of Borderline Personality Disorder, The Guilford Press
Miller, Alec (2007) Dialectical Behavioral Therapy with Suicidal Adolescents, The Guilford Press
Information compiled and edited by Jack Hinman, Psy.D.
She has been an educator of addiction counselors in many schools including the University of California at Davis in the Addiction Studies Program, and the University of Nevada/Bureau of Alcohol and Drug summer school for Employee Assistance Professionals for 15 years. Dr. Willis has studied and presented at national conferences on multi-generational trauma and addiction.”
We are pleased that Dr. Willis took the time to share her insights on the importance of trauma informed care:
Dr. Robert Cooley (founder and executive director of Catherine Freer Wilderness Academy) sat down with Dustin Tibbitts during a NATSAP conference earlier this year, and shared what it was like to start and lead a program.
According to Catherine Freer’s website “Dr. Cooley grew up on the McKenzie River in Oregon, where he learned to row a whitewater boat at age four. He made his way through college and graduate school by spending his summers logging, doing Forest Service trail work, and working as a river guide. He earned his PhD in counseling psychology from the University of Oregon in 1979 and has specialized in family and adolescent therapy. He has lived abroad several times and speaks French, Spanish, and German. Dr. Cooley developed and directed a family therapy program at Oregon’s child welfare department and had a private therapy practice, while taking summers off to run a whitewater rafting company. In 1988, he combined his outdoor and therapy interests in founding Catherine Freer Wilderness Therapy Expeditions. Dr. Cooley and his wife Ingrid, a family therapist, live in Albany, Oregon, and have four children.”
We are so pleased that Dr. Cooley took the time to talk with us:
Please follow along this week as we post more videos from our interview with Dr. Cooley:
We continue our series of videos taken from our interview with Lon Woodbury. Here Lon talks about why we need outcome studies in the residential treatment world:
We encourage you to check back here throughout the week to see more of Lon Woodbury’s interview. The posting schedule will go as follows:
We have become aware of various miscommunications about InnerChange over the last eight days. This press release seeks to clear up some of those misunderstandings.
InnerChange has a management services product which has been designed to support residential programs and therapeutic boarding schools. Management contracts of this kind involve sharing InnerChange’s human resource systems, marketing tools, accounting services and residential staff training, in an effort to supplement and strengthen client programs. InnerChange currently provides these services only to its owned programs, but plans to offer these services more broadly.
InnerChange is interested in rational, sustainable growth. InnerChange programs have grown organically, and growth opportunities may also involve the purchase of other entities, but only if those entities fit with InnerChange’s Mission, Vision and Values. We are wise enough to understand that the leaders in any successful organization we might purchase are to be respected and honored for the sacrifices they make to build and operate a good program.
InnerChange and its key leaders have always been collaborative and generous in the sharing of “proprietary” policies, programming and ideas. We currently share our expertise with others – even our competitors – free of charge. We have been criticized of late for doing this, but conjecture and gossip will not hinder us from keeping our focus on facilitating positive change in the lives of young women.
InnerChange programs – New Haven, Sunrise and Fulshear Ranch Academy – are all Joint Commission accredited and are led by experienced, practicing clinicians. We are known for having extremely high standards and for providing the highest quality education and treatment available. For example, we are unaware of any parent choice program that engages in the depth and duration of clinical research we apply in our work with young women.
We welcome our colleagues and critics alike to visit us and our programs. Please contact Dustin Tibbitts, LMFT or Kimball DeLaMare, LCSW with questions or comments.
We continue our series of videos taken from our interview with Lon Woodbury. Here Lon talks about just how harmful bootcamps can be if they are used as a therapeutic tool.
We encourage you to check back here throughout the week to see more of Lon Woodbury’s interview. The posting schedule will go as follows:
Lon Woodbury is the closest thing the parent choice residential treatment world has to an industry analyst. His LinkedIn profile states the following: “25 Years in the network of private emotional growth/therapeutic residential schools and programs: 5 as Admissions Director for Rocky Mountain Academy and 20 as an Independent Educational Consultant helping parents find the best placement for their Special Needs child. I still help individual parents in their search through consultations, but most of my work is in publishing the information to help parents decide the “if and where” of placement through the newsletter Places for Struggling Teens, an active website (Strugglingteens.com), and a directory, Parent Enpowerment Handbook, containing only those schools and programs with an overall positive reputation among professional Independent Educational Consultants.”
We are pleased that Lon took the time to share his insights with us, and will be posting videos from his interview all week. Here, Lon shares with us just how important it is to involve parents in a child’s treatment:
We encourage you to check back here throughout the week to see more of Lon Woodbury’s interview. The posting schedule will go as follows:
The verdict, based on a character from Lewis Carroll’s “Alice’s Adventures in Wonderland” states that every psychotherapeutic theory is equal, and no one theory reigns supreme. In the words of Carroll’s Dodo (after judging a foot race): ”Everybody has won and all must have prizes.” This verdict asserts that there are common factors among therapists which, if adhered to, will result in successful therapy no matter what model or technique the therapist applies to treatment.
I’ve recently been involved with a group called the International Center for Clinical Excellence (ICCE). Scott D. Miller, it’s founder, used to be one of the most ardent proponent of the Dodo Bird Verdict. In fact, in one of my recent posts entitled “What REALLY Causes Change in Teens“, I outline the common factors of therapy that Miller introduced me to. The common factors are: 1) things that happen outside of the therapy office; 2) the client’s orientation toward hope for change; 3) the strength of the client-therapist relationship; and 4) the therapist’s applied technique.
These four key common factors give us a descriptive sense of what is similar across the vast world of psychotherapy success. However, it is not a model of therapy in and of itself. In other words, if we were to focus our efforts around strictly enhancing the four common factors in our work with clients, we would find that we never improve beyond where we are today. Why?
The “Red Queen Principle” bears the answer. Again taken from a character in Carroll’s book, the Red Queen tells Alice, “It takes all the running you can do, to keep in the same place.” Evolutionary theorists use these words from the Red Queen to elucidate the Red Queen Principle. The Principle explains the necessity of all organisms to adapt or become extinct. In other words, if a predator does not adapt, but its prey does adapt, then eventually the predator will cease to exist. For example, if rabbits become faster and foxes don’t, then foxes will eventually become extinct. The Red Queen Principle states that while groups of organisms must do “all the running [they] can do” just to keep up with other organisms and avoid extinction, individual organisms within those groups often exceed the evolutionary advances of the group. For example, one fox may become exceedingly fast and cunning and it will pass those genes on to its offspring.
So what does this have to do with therapy?
Well, if the common factors are true of every successful treatment outcome, then it doesn’t really matter which model of therapy you use, does it? It would follow that every therapist who focused on those factors would have similar successful outcomes, wouldn’t they? But research shows that this simply isn’t true. Some therapist are vastly more skilled at inching their clients toward health than other therapists. Why? What is different about these “supershrinks“? (Click on the “supershrinks” link. Read the article. You won’t regret it. In fact, it may change your life.)
The difference, according to Miller, lies in the work of K. Anders Ericsson. Internationally renowned as the “expert on expertise”, Ericsson’s research shows that the truly great in any field have things in common – they improve themselves through deliberate practice. And they do much more deliberate practice than other relatively “good” performers – up to as much as 10,000 hours more!
Expert therapists know where they are weak. This means that they are measuring themselves constantly. They are following up with their clients. They are soliciting feedback. They know exactly what they need to improve upon. And then they act to improve it.
In evolutionary terms, supershrinks adhere to the Red Queen Principle. They far exceed the psychotherapeutic advances of their time. They adapt and improve and reach and stretch far more than groupings of their “adequate” peers.
The truly excellent are humble enough to know they are limited, smart enough to seek feedback, passionate enough to act on that feedback, and stubborn enough to engage in deliberate practice over and over and over again.
I overheard someone telling one of our students that she loved her. 40 of us were packed into a room at a transition ceremony. We had formed a big circle, standing up, and the graduating student was going from person to person, hugging each one goodbye. As the student approached my right, she hugged my friend (staff) and my friend said, “I love you.” The student, crying, said, “I love you too.” Their hug lasted about 10 seconds. Was this appropriate? What would I say when it was my turn to say goodbye? After all, I was a 30-plus-year-old man and she was a 16-year-old young woman.
Why does the word “love” carry such a taboo in treatment? Do we really think that we can wall-off our hearts to those we serve? Do we really think that we can remain unaffected by their journeys, their stories?
As a relationship progresses, I believe it’s important to define what is happening. It’s especially important because many young women in treatment have had inappropriate, unhealthy relationships and they become confused about what they are feeling. Particularly as a male therapist, I have to be constantly aware that the intensity of the emotions shared during healing process can be confusing to young women. So I am constantly defining what I mean and why I choose to use the words I do.
For example, if I tell a client, “I care about you very much,” I will immediately clarify that statement. ”You realize that this is not a sexual kind of caring,” I’ll say. ”The feelings I’m expressing are like those I might feel for my own daughter.” Usually, the girl will become uncomfortable: ”I know it’s not sexual! Why do you even have to say that?!”
I’ll press forward. ”You’ve certainly noticed where my eyes look.” ”Yes,” she’ll usually say . “Your eyes never leave my face.”
“Why is that?” I’ll ask. And we’ll talk about how my feelings toward her are fatherly, as if she were a daughter. We’ll define the differences between platonic love and amorous love. We’ll dissect the friendship that is developing.
I tell her that I am okay with the conversation being uncomfortable as long as we can take use that moment to be clear with each other about what kind of relationship is developing between us. I submit that this is good therapy.
One student I worked with years ago had had a boyfriend ten years older than I. It was difficult for her to reconcile her growing feelings of love for me with what she’d experienced with her perpetrator boyfriend. As we grew closer, it was vital that I teach her the differences between what she’d felt for him and what she was beginning to feel towards me.
At times the conversations were painfully direct. ”I am not aroused by you,” I recall saying when she provocatively suggested that there might be more to her feelings than would be appropriate. Whenever I noticed confusion in her eyes during a group where a male staff member might have expressed compassion for her situation, we would take a moment to define what was going on for her and for him.
Years after treatment she came to an alumni reunion. We had a few quiet moments to catch up on her life and she said, “You’re about the only man I trust.” I was taken off-guard by that statement. She explained that she’d caught her father looking at pornography, that she’d been “used” in every intimate relationship she’d had since treatment, and that she just couldn’t look at men without feeling sexually unsafe. ”But not you,” she said. I attribute that to the hours and hours we spent working at understanding the difference between appropriate and inappropriate love.
All of this and more flashed through my mind as I stood in that circle during that transition ceremony and anticipated how I would say goodbye to one of my favorite students. It only took a few seconds for her to hug the person at my right and then be standing directly in front of me, but I relived every moment we’d shared during treatment. I felt my heart swell in my chest. I felt my eyes sting. This was a student who would have been dead, had she not received care. I thought back to the day she had arrived. Images of her – angry, bitter, depressed – flashed in my mind: her dark clothing, her darker countenance; her fear of connecting, her fear of others never wanting to connect to her.
I thought of the arguments we’d had, the times she’d screamed at me until she was hoarse. I thought of the quiet moments when she’d trusted me enough to tell me something she’d never told anyone before.
The feelings within me burned stronger as I reminisced about the magical moment when something had seemed to “click” for her. I remembered her change of heart. I recalled the light that shone in her eyes that I hadn’t seen before, but which her mother said had been there up until only a few years ago. Her face and demeanor had relaxed and she had become gentler with others – and with herself.
And so, as she stepped in front of me and reached up to hug my neck, without shame or pretense I wrapped my arms around her back and pulled her tight to my shoulder and said, “I love you.” There was nothing sexual about me using that word, and she knew it. ”I love you too,” she said. There was no confusion in my mind about what she meant. For five seconds we enjoyed the connection of that hug. We felt the bond of friendship forged in the heat generated by months and months of intensive psychological and emotional healing.
Then she pulled away and moved on to the person at my left. I’m pretty sure I overheard them use the word “love” as well, but I can’t be sure. I was distracted with trying not to cry.
“I messed up,” the text message began, “and I just wanted you to know that I cut myself today. But I’m back on track.”
Is this a relapse? She’d been free from self-harm for over 13 months. How would you have responded to her?
In my mind, there is a big difference between a momentary lapse and a full-blown relapse. I had the following conversation with parents at a Family Weekend years ago, an event we hold for three intense days every other month of the year. All of the parents in my group that weekend had girls who were coming home soon.
“I can’t wait for my daughter to come home,” one father said. “New Haven has been wonderful! All of her problems are fixed.” I find that all too often parents expect their kids to be “fixed” when they return home. Even after spending time at New Haven, arguably the most systems-focused residential treatment center in the country, they still believed that treatment is an event and when it’s over, they were done working. “Oh, no,” I told him. “Your journey has just begun!”
“What happens when your daughter returns home and you find her spending hours on the internet? What happens when she skips her curfew? What happens when you find pot in her backpack?” He began to sweat. He stewed. Finally, he couldn’t take it anymore. He lunged across the room at me, red-faced and yelling. “What is the point of this? I came here to feel better about my daughter!” He accused me of doing “poor therapy”, then sat down.
“I’m trying to prepare you for the inevitable,” I said. And we had a robust discussion about how his daughter, in particular, was going to bring home a young man he didn’t like, was going to accelerate into sexual behavior faster than he would be comfortable, and they would have to deal with it.
“I’ll kick her out on the street!” he said. “I won’t tolerate it.”
“But what if it’s not a relapse? What if it’s a one-time screw up? I doubt you’d kick her out if you knew it was an honest mistake. She might ‘lapse’ but not ‘relapse’. So how will you define the difference between a ‘lapse’ and a ‘relapse’?” I asked.
In the end, the group decided together that a lapse is a one-time event which is reminiscent of past behavior. A relapse, on the other hand, is a persistent pattern of the behavior we thought we left behind.
It’s easy to recover from a lapse. Yet it’s also easy to allow a lapse to become a relapse.
So, what stops a lapse from becoming a relapse? They wanted to know!
Two things will keep a lapse from becoming a relapse: #1) consistent, healthy relationships with parents and friends; #2) parents unified and consistent about implementing rules and structure in accordance with established family values.
We spent the balance of that Family Weekend session outlining ways to keep their relationships with their daughters fresh and alive. We outlined rational rules and boundaries which were neither too permissive nor too restrictive.
About ten months later at another Family Weekend, the angry father returned. He sought me out during a parent group and apologized for his attitude. “You were right,” he said . Turning to the other parents in the room, he laid out his daughter’s lapses and how he’d helped her keep them from becoming relapses. He never “kicked her out on the street” and she was doing reasonably well.
He’d realized the truth: our journey does not stop with the end of treatment. We continue on, we fall down, we scrape our knees. It’s how fast we get back up that matters.
So here’s how I responded to the text I mentioned at the beginning of this post: “Thanks for staying connected. As long as you are back on track, that’s what matters. Call if you need to talk.” After all, it was just a lapse.
