Why do Adolescents Cut (Self-Harm) & Effective Treatments

Cutting is a form of self-harming behavior or non-suicidal self-injury (NSSI), and, unfortunately, not uncommon, particularly in the adolescent population. If you are a parent discovering that your child is engaging in this behavior, it can be terrifying. Older studies estimate that 4 per cent of young adults in the US have engaged in some form of self-harm at some time, although the actual number is uncertain.  (Gratz, Conrad, and Roemer 2002, Paivio and MCulloch 2004; and Zoroglu et al. 2003).  More recent studies indicate up to 20 percent of high school and 40 percent of college students have engaged in self-harming behavior. Other studies indicate 1/3 to 1/2 of adolescents in US have engaged at some time.  (Petersen, Freedenthal, Sheldon & Andersen, 2008) . Until recently, it was believed that girls were more likely to self-harm, but we now believe that boys are equally engaging in self-harm. However, girls are more likely to be in treatment, so those numbers are higher.  I’ll be using the terms self-harm and non-suicidal self-injury (NSSI) interchangeably in this article.  Children younger than adolescence and adults also engage in self-harm. However, this article will focus on adolescence.



What is self-harm?  Deliberate self-harm is causing intentional damage to one’s own body WITHOUT an intent to die.  This doesn’t include smoking, drug use, bingeing, purging or behaviors that may be harmful but are not a suicide attempt.  Self-harming behavior besides cutting can be burning, skin picking, biting, head-banging, interfering with wound healing, ingesting toxic substances, breaking bones, punching or hitting oneself with the intent to injure or wound but not die. I’ve worked with individuals who have engaged in all these types of behavior but cutting is the most common in my experience. Individuals who self-harm tend to be impulsive, engaging in self-harm with less than an hour of planning, highly reactive, sensitive to real or perceived criticism, may be victims of bullying or intense peer pressure and frequently exhibit and engage in highly dramatic behaviors.  While intentional self-harm is deliberate without an intent to die, it can become addictive in some individuals. This can increase the likelihood of suicidal behavior.



The good news is people who self-harm usually don’t want to die, although self-harming behavior is a risk factor for suicide.  They self-harm for various reasons and while it’s important to understand why they do it, in my opinion, and according to experts on the topic, it’s even more important to know what they gain from it. The why and the what usually aren’t the same thing. Knowing what is gained helps us understand why they continue to engage in the behavior. All behavior has a cause and some sort of reward.  Another bit of good news is that understanding what is gained provides an opportunity to help the individual obtain the result by learning healthier, more adaptive coping strategies. 



Even though finding out your child is self-harming will naturally cause extreme distress, maintaining a calm and supportive attitude can help you help them.  I’ll be providing some information, guidance and tips. Recognizing and seeking treatment for your adolescent as well as support for yourself will provide the best outcome.  


Sometimes the why and what are congruent. So we consider why and what is gained (the reward) which reinforces the behavior. Some of the reasons kids say they self-harm are:  1) To stop suicidal ideation or suicide attempts; 2) It is calming; 3) It helps manage distressing thoughts by distraction due to focus on pain; 4) It helps regulate emotions as a coping strategy, decreases arousal and heart rate; 5) It is numbing (Some say they don’t feel pain.) likely due to release of endorphins which react with the opiate receptors in the brain to reduce perception of pain and act similar to drugs like morphine and codeine; 6) It causes them to “feel real,” for those who feel numb; and 7) It provides positive attention from adults who may decrease pressure to do chores, homework and other responsibilities for fear of upsetting the adolescent and contributing to NSSI.


Associated with NSSI are borderline personality disorder (BPD), depression, post-traumatic stress disorder (PTSD), generalized anxiety disorder, oppositional defiant disorder, eating disorders, and substance use disorders. There is no diagnosis for NSSI. However, it may be a symptom as part of another emotional disorder and often associated with BPD.



While not the only treatment available, dialectical behavior therapy (DBT) is considered the gold standard treatment for managing impulsive self-harming behavior.  Developed by Marsha Linehan in 1980 as a treatment for suicidal women who also self-harmed without an intent to die. It has been rigorously researched in scope and depth. The scope DBT treatment has expanded and is successfully being used to help individuals with a variety of issues, including depression, anxiety and impulse control disorders. While the original population was adults with suicidal ideation or NSSI, the treatment was adapted and thoroughly researched to work with adolescents with these problems. It is still the first choice and continues to offer help and successful results for adolescents and families.



DBT focuses on dialectics which is finding the value in two seemingly opposite or opposing points of view - or creating a balance between validating thoughts, emotions, urges and behavior and teaching healthier more adaptive ways to cope with those thoughts, emotions and urges. We look for the synthesis, the kernel of truth to create pathways to change.  We validate the reason for engaging in the behavior without validating the behavior. Other types of therapies may focus primarily on validation while others emphasize change. In working with individuals with high sensitivity and emotional reactivity, Marsha Linehan discovered they respond more successfully when both validation and change are balanced; when the therapist can be aware of what is needed and adjust the approach. 



DBT provides comprehensive treatment for the adolescent and family members. While there are variations in the way it is implemented, comprehensive DBT for adolescents and families will provide the following components:  1) Weekly individual therapy for the adolescent with optional family therapy as needed; 2) Weekly skills group sessions for the adolescent and at least one caregiver (parent); 3) Coaching calls for the adolescent to help reinforce use of skills and coaching for the participating caregiver; 4) Weekly consultation team meetings for the DBT therapists providing DBT.  Adolescent and family DBT skills group teach Core Mindfulness skills to help recognize and manage thoughts, Distress Tolerance Skills to learn to recognize, manage and survive crisis situations without resorting to NSSI, SI or other extreme or maladaptive behavior, Emotion Regulation Skills to learn ways to practice self-care and healthy life patterns, Interpersonal Effectiveness Skills to teach individuals to manage and keep current relationships, end unhealthy relationships, learn & practice asking for what they want and saying no in a way that allows them to maintain their self-respect. Lastly, The Middle Path, which is unique to Adolescent & Family DBT, helps adolescents and parents examine the dialectical dilemmas they face, specifically between Making light of problem behavior vs. Making too much of typical adolescent behavior; Forcing independence too soon vs. Holding on too tightly; Being too loose vs. Being too rigid.


Adolescents are expected to keep a daily diary card tracking and logging emotions, urges, behaviors and skills used each week. This will be reviewed with the DBT individual therapist to help the adolescent recognize helpful and unhelpful behavior and to learn and practice skills.



What can you do as a parent/caregiver to help your child? Here are a few guidelines and suggestions.  

• First, don’t panic!  You’ve probably already done that as most of us would if we found out our child was hurting him/herself. After you panic, take a breath and a mental step back. If you are reading this blog, you’ve likely gained some new and hopefully helpful information. 

 

• Don’t try to remove all the sharp objects from the house. Of course, if your child has a knife or weapon in their room, remove it, but they must learn to live with and be around knives, razors, scissors and the like. It’s important that they gain skills and find other ways to manage their distress.

 

• Don’t do body checks. It will increase the adolescent’s sense of shame and humiliation which is likely already high. It may seem like a punishment and may trigger more maladaptive behavior.

 

• Keep communication open with your adolescent  by using validation to let them know you recognize they are in emotional distress, and you want to help and support them.  Last month’s blog went into detail about the importance of validation and how to do it.  It’s worth reading or re-reading again:

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•  To recap here, validate only what is valid. Don’t validate what is invalid. For instance, you discover your child has been cutting.  She tells you she had a fight with her best friend who told other kids about her recent suicide attempt and hospitalization. You saying, “That’s ridiculous to get so upset about something silly that you would intentionally hurt yourself.” That invalidates the depth and intensity of her feelings. Alternately saying, “Of course, you cut yourself. What else could you do?” That’s validating the invalid. You don’t approve of her cutting, but you want her to know you understand her emotional distress. Instead say, “Of course, you were upset and were hurting. I suspect you felt hurt, embarrassed and betrayed. Who wouldn’t? I want to keep you safe and learn other ways to manage your distress. I’m here for you.” This opens the door to communication and shows understanding, attention and puts words on the experience. It may also offer comfort and a sense of support. You would, of course, assess the severity and attend to the wounds. 

 

• Find a therapist who understands and works with adolescents and families and have your child evaluated.  Finding a DBT therapist would be my recommendation, preferably someone who has trained with Behavioral Tech (Founded by Marsha Linehan) or more locally here in Missouri with Ronda Reitz who is a trainer with Behavioral Tech and has trained with Marsha Linehan.  You can search behavioraltech.org, dbt-lbc.org or http://www.dbtmo.org (Missouri) for names of therapists and programs.

 

• Patience, persistence and perseverance are required. Most parents don’t find out about cutting when it first starts. It will take time to help your child learn skills needed to change this behavior, particularly if it has become habitual. When our children are hurting, we want to fix it immediately.  That’s natural but, unfortunately, not realistic.  However, behaviors are learned and can be unlearned, or rather healthier and more skillful behaviors can replace unhealthy ones.

I have been working with individuals who struggle with emotional intensity including suicidal ideation and self-harm for over 20 years.  For the past 10 years, my primary orientation has been using DBT as I have found it the most effective and beneficial treatment for this population. At Elephant Rock Counseling, we offer a comprehensive DBT program for adolescents and families.  We teach, guide and support providing adolescents with the ability to learn healthy, adaptive coping skills vs. maladaptive skills that may provide them with short-term relief, i.e., self-harming behaviors, but lead to long-term suffering.  It’s not a “quick fix” and won’t solve the problem overnight. We include and require one parent/caregiver to attend group sessions with the individual to learn along with the adolescent and provide support to help them as well. In my experience, the individuals who enter and complete a DBT program stop engaging in self-harming behavior and begin to move toward the goal of DBT which is “a life worth living”.  



I hope this blog has provided you with helpful information. If you have a child who you suspect is engaging in self-harming behavior, please seek help.  We would be happy to provide an assessment and further information about our program.



San Mueller, M.Ed., LPC, LBC-DBT Certified
Elephant Rock Counseling 
​Kirkwood, MO

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San is a Licensed Professional Counselor with Elephant Rock Counseling, LLC.  San specializes in therapies that utilize mindfulness based principles such as Dialectical Behavior Therapy (DBT).  She enjoys teaching yoga, spending time with her family, and working with her clients.