Milieu Treatment For Cutting

For a person who has had no experience with intentional self-harm—or “cutting”—behavior, it is a confusing and frightening phenomenon—especially when one discovers that their own adolescent child is participating. Despite what many teens report in order to minimize their own alarm that that of their parents, cutting is not simply a normal adolescent act. It is a sign of serious underlying emotional issues.

Most of us avoid pain and seek pleasure, but the cutter seems to avoid pain by seeking pain. Like other compulsive or addictive behaviors, self-harm is often a method for avoiding unwanted and unpleasant emotions. In these cases it is an attempt to drown out emotional pain by engaging in more manageable physical pain. Many teens report relaxation and emotional numbness after self-harming. It is easy for parents to become so distracted by the cutting itself that efforts go toward directly controlling the behavior—which generally has poor results— instead of toward addressing the root problem that is leading to the behavior.

Environment and Cutting

The self-harmer’s environment is highly influential in either reinforcing or extinguishing the problem behaviors. For children exhibiting chronic cutting, I recommend a comprehensive therapeutic approach that addresses the act of self harm and the underlying issues fueling the self-harming behavior and ideation. Ideally, this happens in a residential setting, where the milieu can be managed and behaviors observed around the clock. Girls struggling with emotional regulation—a strong precipitator and reinforce of cutting behaviors—are best served when interventions can be administered both regularly and in real time—immediately before, during and after strong emotional reactions are experienced.

DBT and Cutting

Once such intervention is called Dialectical Behavioral Therapy, or DBT. At Sunrise, our DBT groups are conducted in a format that facilitates the generalization of emotional regulation skills into the participant’s environment. Milieu staff members are trained in the principles of DBT to help coach the young women in the moment and provide a culture that supports the use of DBT skills in their daily living. Sunrise takes an active approach to investigating the variables in the young women’s environment that may reinforce her acting-out behavior; armed with this information we are better equipped to develop behavioral strategies that extinguish self-harm.

Acceptance-based strategies (as opposed to punitive, strict behavioral or shame-based interactions) can help adolescents struggling with emotional regulation and cutting more effectively manage their overwhelming emotions. Unpleasant emotions are a normal part of the human experience; the rejection or denial of this kind of pain is what leads to real suffering and dysfunctional behaviors. Yoga sessions can create an opportunity for students to practice emotional and physical frustration tolerance—since holding poses and remaining quiet and mindful are excellent practice for this. The meditation skills taught in our DBT Skills Training Group and Yoga classes help teach them to be in control of their thinking rather than controlled by their thinking.

Mindfulness and Cutting

Mindfulness skills—which are at the core of DBT therapies—teach young people to effectively manage thoughts of self-harm and increase emotional awareness. DBT complements these mindfulness practices with “diary cards” to help the young person monitor self-harming behaviors and ideation. In a rigorous DBT treatment program, these cards can serve as an effective therapeutic staple in a girl’s treatment process. I have students utilize diary cards in their DBT Skills Training Groups, daily community groups, and individual therapy sessions.

In daily community groups, peers and milieu staff provide ongoing feedback to each student regarding their progress toward DBT target behaviors; DBT target behaviors are also an integral portion of the milieu’s twice daily medical charting of each student. Using DBT and other therapies, our young women not only learn distress tolerance and emotional regulation skills, but are also challenged to gain insight into the etiology of their self-harming urges. It’s critical to balance behavioral change with validation-based strategies to help young women confidently and effectively manage unpleasant emotions without resorting to cutting or other self-harm.

Jack Hinman, Ph.D., is a clinical psychologist and the director of the clinical program at Sunrise Residential Treatment Center, a treatment and transition program for adolescent girls in Hurricane, Utah.