Helping Teens Who Cut
Understanding and Ending Self-Injury
By Michael Hollander
The Guilford Press Copyright © 2008 The Guilford Press
All rights reserved.
FACT VERSUS FICTION
BRINGING SELF-INJURY INTO THE LIGHT
Caitlin's parents were at their wit's end. Whose wouldn't be? Their daughter had been cutting herself several times a week for the past year and a half. All their well-intended attempts at helping her had failed.
"I just don't know what to do at this point," said Caitlin's dad. "We've tried everything: individual therapy, family therapy, all sorts of different medications. We even sent her to a different school. We tried grounding her. We got so desperate we even locked up all the sharp objects in the house. Nothing has worked. I don't think she wants to stop—she must like the attention or something."
Caitlin's mom chimed in: "She's such a good kid. I know she's unhappy. I just wish that she and her therapist could find the reason for her cutting. What does it mean to her? I think if she knew why she did it, she'd be able to stop."
Most of the parents who have sought my consultation, like you, have been caring and loving people who are frustrated and worried sick. It's hard to stay calm when your children seem to be stuck in scary behavior. You experience strong emotions that feel nearly unbearable. And when you're emotionally aroused in this way, the climate is right for you to make errors in thinking and judgment. Your need for answers to aid you through these troubled times can lead you to cling to erroneous conclusions that help lower your anxiety and make sense of the emotional chaos but take you off the right path.
This atmosphere of confusion and misunderstanding has given rise to numerous myths that circulate among lay people and in the media. Therapists themselves have contributed to these myths in some cases because they've been struggling with a problem behavior that has been illuminated by very little scientific research.
Gaining a new understanding of why your children would do something so inconceivable as cutting themselves is much more important than you may believe right now. Of course, you may be much more interested in getting straight to what you can do to make this behavior stop. But acquiring a new perspective on the purpose that self-injury serves for your child is an important foundation for eliminating this disturbing behavior. A new perspective will direct you to effective treatment and help you to facilitate change in your child's behavior by doing some things differently yourself. That's why in this chapter we will examine some of the myths and misconceptions you might have about self-injury and some of the paths you may find yourself going down that keep you from truly understanding the troubles your child is having. The many misunderstandings that parents, pediatricians, and therapists have about deliberate self-harm are a primary reason why children don't get appropriate treatment in a timely way.
Consider Cynthia, a 22-year-old college student who has engaged in self-injurious behavior since the age of 13. Over the weekend Cynthia's roommate noticed the cuts on her arm and told the dorm counselor. Cynthia came to my office only because her dean ordered her to get a psychological consultation before she would be allowed to return to the dormitory.
"I've had therapy since I was a kid, and it hasn't helped with the cutting," Cynthia told me. "I've just become resigned to the fact that this is part of my life. You know, when I cut myself it really doesn't hurt, but it just seems to help. I'm not even sure I want to stop anymore."
"Cutting has been part of your life for almost a decade," I said. "You have been clear with me how it helps you calm down, so I can imagine you have mixed feelings about giving it up."
"Yes, in some ways it's like an old friend who is a bit troublesome but who is always there when you need her."
Cynthia's a little older than the patients I usually see. For the most part in this book I will be talking about teenagers, because the vast majority of people who engage in deliberate self-harm begin it in adolescence—and that's when you're most likely to be trying to understand and eliminate it from your child's life. I want to leave no doubt in your mind that you should seek professional help for your child if you know, or reading this book confirms your suspicion, that your teenager has been engaging in self-injury. While some kids only experiment with the behavior, for most it will continue into the early adult years and even into midlife and beyond unless prompt and effective psychological treatment is sought. That can be difficult to pursue when misconceptions get in the way.
Myths about Self-Injury
Please keep the following ideas in mind when you read about these myths. First, in psychology nothing is absolute or certain, so in a few instances what is a myth when applied to an entire population can be a fact in an individual case. Second, most of our behavior is influenced by many factors, including our past history, our current needs, and our long- and short-term goals. Not all these factors have an equal influence. Some have a minor role in keeping the behavior going, while others exert a powerful effect.
Myth 1: They Do It to Get Attention
According to some researchers, less than 4% of adolescents deliberately hurt themselves to get attention. Yet it's the most common reason that parents and some therapists give to account for the behavior—despite the fact that often an adolescent is self-injuring for months before an adult even notices. Misconceptions of this kind derail treatment and prolong both the adolescent's and the parents' distress, as it did for Erin and her family.
Erin: Not for Attention
Erin, age 13, was a very likable and extremely bright girl who seemed to have some anxiety in social situations. She had been hospitalized numerous times over the last 6 months for self-injury and suicidal thinking. The psychiatrist in charge of her care reported that Erin had been cutting herself for the past 2 years, but that it had come to her parents' attention only about 8 months ago. When I asked the psychiatrist if he had any ideas about why Erin injured herself, he replied with confidence that he, the previous clinicians, and Erin's parents were all convinced that she did it to get attention.
How could a young girl be seeking attention through a behavior that she kept secret for well over a year? When I posed this question to the psychiatrist, he realized immediately that he may have leapt too quickly to his conclusion. So how is it that smart, well-trained, competent clinicians and caring, loving parents so often make this mistake? It's hard to know for sure, but here are some possibilities.
Even "Delicate Cutting" Is Self-Soothing
First, the majority of self-injurious behavior involves relatively superficial wounds. Some clinicians refer to superficial cutting or scratching as "delicate cutting"—giving the impression that the adolescent is taking care not to hurt herself seriously, but only to cause enough damage to get people to notice. But these superficial wounds have the self-soothing effect that these adolescents seek. (I discuss the smaller group of more serious self-injurers later in this chapter.)
A second reason why parents might get off track about self-injury has to do with the context in which the behavior occurs. Once you realize that your child is self-injuring, you will probably become more vigilant about her mood changes and emotional states, thus keeping you near your child. If she hurts herself when you're close, it would be easy to assume she did it to capture your attention. Many parents have told me how they know their child is having emotional trouble, but when they try to help, the child often rebukes them or denies that anything is wrong. The parents know that this is untrue and so they stay close at hand. In a matter of minutes the child self-injures right in the next room, and the parents rush in to help. The child is a little calmer now and somewhat more willing to talk. The parents conclude that she hurt herself to get the attention she is now willing to accept.
Parents are often both relieved and annoyed by this sequence of events—relieved that their child was open with them but annoyed because they felt manipulated by the behavior. They conclude that the self-injury is a manipulative ploy to get them to pay attention. Their frustration is compounded because of their thwarted attempts to help.
There's another explanation for this sequence of events.
Adolescents Want Privacy
The alternative explanation rests on two factors. The first is the normal tendency for adolescents to seek privacy concerning their emotional lives. This is especially true for those in the early to middle stages of adolescence. For boys, early to midadolescence ranges from 13 to 16 years of age; for girls it's a little earlier, from 11 to 15. Hallmarks of this stage of development are the phrases "I don't want to talk about it" and "Everything is fine"—the second of which often doesn't square with what you see.
At this point in their lives, adolescents feel a real need to be separate and independent from their parents. As they negotiate these new waters, they often confuse asking for help with child-like dependency. These kids pull hard against any current that might make them feel like a younger child. They have not learned to differentiate between mature dependency, which includes the capacity to ask for help and advice, and a pseudoindependence that places a premium on going it alone. For the most part, kids in this stage of development try to keep their parents out of their business. While they may wear outlandish clothes and behave in ways that are "over the top," they rarely intend to promote tighter scrutiny from their parents. Ironically, it is just such behavior that often invites adults in to set limits.
More Emotion Than They Can Handle
The second point that supports an alternative explanation for Erin's behavior has to do with the way these kids experience emotional distress. By and large, adolescents who self-injure are extremely reactive people: they feel things very deeply and are prone to becoming emotionally overwhelmed quickly. They possess powerful emotional systems without the tools to manage them—it's as if they have Ferrari engines and Toyota Corolla transmissions. They have great difficulty harnessing their powerful emotions in the service of clear thinking and problem solving. When they're emotionally charged up, they lack the capacity to skillfully ask for help or to take in new information that may alleviate their current distress. What they want to solve, and to solve quickly, is how awful they feel in the moment.
Self-injury often provides immediate relief from this feeling of emotional turmoil. With that relief comes a degree of calmness that enables them to be more available and reasonable with their parents. The change in demeanor, coupled with the parents' presence, makes it seem as if they injured themselves to get attention, but it's almost always about getting immediate relief from emotional distress. (Those cases where it doesn't provide emotional relief are discussed in Chapter 3.)
Myth 2: Everyone's Doing It
Deliberate self-injury has been part of the adolescent scene for many years. My clinical experience and that of my colleagues suggest that it's on the rise, but we don't know for sure. We are uncertain for at least three reasons.
Deliberate Self-Injury Has Often Been Mistakenly Documented as a Suicide Attempt
Since suicide attempts appear to be on the rise, when self-injury gets mistaken for attempted suicide, it seems erroneously that self-injury is on the rise. Marie's story from the Introduction highlights the different experience teens have when they are actively suicidal, as opposed to using self-injury to soothe themselves.
I can't emphasize enough the importance of a thorough assessment by a qualified mental health professional to sort out this issue. Most of the adolescents I treat are quite clear about how different these two experiences feel for them. (Often the adults around them, who are worried, baffled, and at their wit's end, are inadvertently generating the confusion.) They tell me that they deliberately self-injure when they just can't stand how painful life feels a minute longer. They may wish they were dead, but they have no intention of killing themselves. In contrast, when they are feeling suicidal, they do intend to end their lives. But don't try to make this distinction in your own children. Seek a professional's help.
No Firm Criteria
Some researchers employ a rather narrow view of what constitutes nonsuicidal self-injury while others use the broadest of criteria. Consequently, the percentages given for adolescents in the general population who self-injure range from 9 to 39%; for adolescents who are hospitalized for psychiatric reasons, the range is 40 to 61%. As clinicians' and researchers' attention is drawn more and more to this area, I believe it won't be too long before we have more definitive answers to these questions.
Today's Kids Seem Less Secretive about It
While we don't know for sure whether self-injury is on the rise, in my experience adolescents used to be more secretive about it in years past; it would have been unusual for a child to speak about such behavior even to his closest friend. Parents often remained unaware of a child's self-injury until his psychiatric hospitalization for some other reason. As time went on, stories of self-injury crept into the media, both in news reports about teenage health issues and in the adolescent music and movie culture. In a way self-injury has been "normalized." As a consequence, adolescents are much more likely to disclose their self-injurious behavior to friends and to discuss how it makes them feel better in the short run. In addition, a number of Internet sites are devoted to self-injury. We don't know whether these sites help children to stop self-injury or induce them to keep it up, but it's another route by which self-injury has "come out of the closet."
The good news with self-injury coming out of the closet is that researchers began to study the problem in an attempt both to understand it and to develop more effective treatments. The not-so-good news is that as more adolescents became aware of the behavior, more tried it out in a moment of emotional turmoil. Unfortunately, for a significant number of adolescents, the behavior worked all too well in helping them regain their psychological equilibrium. In the media and in the adolescent culture, self-injury is often portrayed in ways that glamorize or romanticize it rather than address its devastating long-term consequences. You may even have come to believe from these portrayals that self-injury is a worrisome behavior that your children will outgrow once they're out of their teens. Sadly, this is not true. The child who self-injures is in significant emotional distress and needs professional guidance.
Myth 3: Peer Pressure Is the Main Culprit
While kids who cut themselves are often friends with other adolescents who do the same, peer pressure probably has little effect on keeping the behavior going. For adolescents, and in particular female teenagers, the peer group is a place to air their problems. It's not unusual for one teenager to tell another about her personal experience with self-injury or to let on that another friend has tried it. Teens can also find out about it from the media. In fact, preliminary data suggest that about 52% of kids learn about self-injury from a friend or the media.
Peer Pressure as Scapegoat
Peer pressure has been used to explain many kinds of adolescent behavior, often without merit. For example, it's often been cited as a reason adolescents use alcohol and drugs. While peer pressure can probably make someone use these substances on a few occasions, it's more typical for kids who are involved in substance use or abuse to seek each other out, thereby creating a new peer group. A similar pattern probably occurs with self-injury.
As adolescents describe it, only their friends have the insight and ability to understand and help them. It's true that cliques are an important part of adolescent life, and I don't want to downplay the importance of a child's feeling of belonging and support. I find, however, that a social group offers its members an abundance of understanding and compassion but not much in the way of helping one another change undesirable behaviors. The problem is more likely to be solved from the inside out: when kids stop self-injuring, they will be more likely to find new friends, rather than new friends in their group somehow helping them to stop self-injuring, as Melanie's story shows.
Melanie: "I Like these New Friends Better"
Melanie had been in treatment for 8 months and hadn't cut herself for the past three. She started the session with an upbeat story about a concert she had attended with some friends.
"Did you go with Dee and Nick?" I asked.
"No, I actually don't see them much anymore," she replied.
"I know your parents worked very hard to stop you from hanging out with them. Is that why?" (Continues...)
Excerpted from Helping Teens Who Cut by Michael Hollander. Copyright © 2008 The Guilford Press. Excerpted by permission of The Guilford Press.
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