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Effective Therapies For Adolescent Cutting

Article three in a series of three about self-harm.

Self-Harm is an increasingly pervasive symptom of emotional distress among adolescent girls. Because it involves physical damage to the sufferer, cutting understandably evokes distress and fear in others. Viewed on a continuum, self-harming behavior can easily—though not always accurately—be interpreted as a precursor to suicidal behavior. Because self-harm is so pervasive and so disturbing, InnerChange program director Dustin Tibbitts, LMFT, has written a three part series to help parents better understand and address this behavior.

With the epidemic in cutting that has erupted in the past several years, adolescent therapies—and therapists—have had a tough time keeping up. There are, however, a number of tried and true, research-supported approaches to therapy that can help adolescents manage and overcome the impulse to cut or self harm.

Safety First

Before therapy can really begin, it’s critical to create situation where the adolescent is physically and emotionally safe. Relationships free from abuse and neglect are paramount in the treatment of self-harmers. Before assisting a girl with her self-harm, we must assess whether or not she is safe in her current situation. If she is not, the concerned therapist, friend or caregiver must report the abuse or neglect to the proper authorities and obtain professional counseling for the adolescent.

It is wise to remove as many sharp objects as possible, understanding that adolescent self-injurers will harm with whatever is around. Tiny screws in the light switch, a stray staple in the carpet, jagged rocks, and the sharp edges of construction paper – it is impossible to remove all of these from a home or school. So why try? Because therapists, parents and other caregivers send a message of compassion and concern when they remove the obvious, easily-accessible objects. We communicate that we are fully committed to the healing process, and we model safety in our physical surroundings. It sets us up perfectly to move into the most important part of therapy for self-harm: a nurturing, safe relationship.

Love vs. Shame

Unfortunately, parents are often so scared by their adolescent’s self-harm that they overreact. When parents overreact, they inadvertently shame their already ashamed child. Their assumption is that their child is going to take the “next step” and commit suicide. It is important to know that self-harm does not always lead to suicidal behavior. However, it is easy to understand why parents’ initial thoughts may be that their child wants to die, because, according to therapists and researchers, “wanting to die” is one of the top reasons for adolescent self-harm and some even use self-harm as a “practice run” for a future suicide attempt.

When I asked my young friend, Deanne, what advice she had for parents and therapists who are trying to help an adolescent who is struggling with self harm, she said, “. . . You definitely don’t want the person to feel shame about it ‘cause it will only make them want to do it more.” She insinuated that the young woman will have yet another reason to want to die.

Connection

For some girls cutting is a cry for someone to show compassion toward them. For these girls, psychotherapist and author Steven Levenkron writes, “talk, trust, healthy attachment, intimacy, and secure communication are the necessary building blocks for change.” He is quick to point out that “the prerequisite for the helper is to develop influence with the self-mutilator” and that influence comes from experiencing a trusting, safe relationship. This is the foundation which parents and therapists must lay before healing can begin.On their webpage dedicated to eliminating self-harm through education, the Mayo Clinic advises adolescent self-harmers that “expanding social networks” is a great way to help mitigate self-harm. Why is this? Because connection with other human beings is the primary way for adolescent girls who hurt themselves to reduce shame, feel valued, and fill time with healthy activities.

Other female adolescent clients of mine have found comfort in sharing their anxieties with a trusted friend. Having immediate access to their “self-harm Sponsor” at any time was a key to healing. Texting, Facebook, email, and cell phone calls make their friendships accessible and immediate. Additionally, the advent of social networking technologies, such as Twitter, make an entire group of healthy friends immediately accessible with a simple text message via cell phone.

Re-Engage Core Identity

Often, there is deeper meaning to adolescent self-injury than what might be readily observable. One young woman wrote the following after her therapist asked her to define her deeper reasons for self harm. She calls them her “deeper issues.”

“By deeper issues I meant that whoever is trying to help should deal with (or find someone who is qualified to deal with) the trauma/abuse, family issues, self-confidence issues, etc. Sort of like how when you’re helping someone with an eating disorder you don’t obsess about their weight, you figure out why they have developed an eating disorder and deal with those issues.”

One example of “deeper meaning” can be tied to an identity crisis. Adolescents struggle anyway with knowing who they are, but this is an even more difficult dilemma for teens engaged in cutting. Self-injury for these adolescents isn’t just a part of them, it is them—it defines their sense of self.

When a therapist or other caregiver helps a young woman reconnect with her identity, especially who she was as a child growing up, it can be a powerful entry point for effective therapy and can help correct the problem. Often, the pain with which she is trying to cope has blinded her to any positive events in her past. Scrapbooks, photographs, and stories about her can be touchstones she can return to when she forgets who she is or is confused by the turmoil that the immediate pain causes in her life.

Therapists and parents can seize upon quiet moments of reflection to take a “memory walk” with a struggling adolescent. Building on the foundation of an affirming relationship, she will be more likely to listen when we tell her what we think of her. If we tie our stories to concrete events, to things which she cannot deny have happened, it adds credibility to our opinion of her, and she will eventually return to a more complete memory of herself. I like to call it “re-memory.”

It’s not only identity which suffers when girls are in pain. The pain threatens the very idea of their self-worth. At her core, she begins to lose hope in the value she brings to the world and her family and friends. She loses touch with the infinite part of herself – the part which cannot be measured and which is invaluable.

Personal Power and Choice

As therapists and parents, we sometimes forget that our job is to influence adolescents in our care to make good decisions, not to manipulate, shame, or control them into more positive behavior. We become so anxious for the welfare of our clients and daughters, that we unthinkingly trade our respect for their individual agency for our need to reduce our own anxiety for their safety. At times like this, it’s important to remember that the only control we have over any human being, including our own children, is the power of persuasion that exists within our relationship with her. Our relationships should be built on alliance, not compliance.

Authoritarian forms of relationship will eventually produce the opposite of what we want. Why do I state this so strongly? I’ll give the most simplistic example: when the young woman leaves our presence, our immediate influence ends. Once she’s alone, she might think twice about hurting herself only if she has respect for someone else, wants to do the right thing, and cares that someone will be devastated if she hurts her body

The relationship is all we have.

Replace the Self-harm with Alternative Activities

Here is a long list of options for replacing self-harm, some of which I’ve found to work better than others:

  • Deep breathing
  • Relaxation techniques
  • Call a friend, your therapist or a crisis line
  • Try not be alone (visit a friend, go shopping, etc.)
  • Take a hot bath
  • Listen to music
  • Go for a walk
  • Write in a journal
  • Punch a bed or a pillow (when nothing but a physical outlet for your anger and frustration will work)
  • Hold ice in your hand (I don’t like this option, but some people say it works)
  • Avoid temptation (i.e., shave legs less or only around others, etc.)
  • Try to find your own creative ways as outlets for emotions
  • Learn to confront others respectfully/make your own feelings known instead of keeping them inside
  • Go outside and scream and yell
  • Take up a sport (a form of exercise can help you release tension)
  • Work with paint, clay, play-dough, etc. (The person who suggested this mentioned that she would make a big sculpture and then do whatever she wanted to it. She said it was helpful to calm the urge to self-injure, plus it gave others clues to what might be going on)
  • Draw a picture of what or who is making you angry
  • Instead of harming yourself, try massaging the area you want to harm with oils or creams, reminding yourself that you are special and you deserve to treat yourself and your body with love and respect
  • Go to church or your place of worship
  • Wear a bracelet or something that will fit on the places that you injure. One person did this as a way to remind herself that she could call someone instead of hurting herself and that she had other ways to cope
  • Break the object that you use to self-injure as a way to show that you have control over it
  • Write the phone number of a friend on your wrist
  • Write a letter to the person(s) that have hurt you and express how he/she/they made you feel. These letters do not have to be in perfect form and you do not have to please anyone but yourself. You do not have to give these letters to the people, but it is a great way to release the feelings that you are carrying. After you write the letters, you can decide then what to do with them. Some people find destroying the letters helpful (i.e., tear them up, throw them in a lake, burn them, etc.)
  • Do some household chores
  • Cook
  • Try some sewing, cross stitch, etc.
  • Use the object you typically use to self-harm in the way it is meant to be used
  • Recite a poem or prayer that comforts you
  • Write down all your positive points and why you do not deserve to be hurt
  • Write in your journal why you want to hurt yourself. If you have hurt yourself, write down what caused it to happen so in the future you can prevent it from happening
  • Play some kind of musical instrument. Even if you don’t really know how to play, picking out tunes is a way to concentrate and help get rid of the urge to harm yourself
  • Yoga
  • Allow yourself to cry. Getting the tears out can make you feel better
  • Take a shower
  • Sing a song about what you are feeling. You can even make one up
  • Scribble on paper. Clutch the pen in your fist. It’s a way to diffuse it on to paper. (Get a few sheets so that they don’t tear)
  • Make a list of reasons why you are going to stop cutting. Carry it in your pocket or tape it to the bathroom mirror. Every time you get the urge, read the list to remind yourself why you shouldn’t

Summary of Therapeutic Elements for Adolescent Cutters

So, we have established a physical environment that is safe. We have a healthy, affirming relationship with the adolescent. She trusts us enough to show her therapist and/or parents her scars and tell us how, when, and why she cuts. She explores the deeper issues that plague her. She is able to see value in her life. She expresses a desire to change and has proven, through a series of recent choices, that she means to follow through on her newfound commitment to life. And we’ve provided her with a slew of new options that work for her. Success is right around the corner!

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