Important Topics

A Comprehensive Approach to Self-Harm

Intentional self-harm—or “cutting”— is a confusing and frightening phenomenon for any parent. Despite what your child may report, cutting is not simply a normal adolescent trend that everyone is participating. It is a sign of serious underlying emotional issues that require treatment.

The cutter’s environment is highly influential in either reinforcing or extinguishing the problem behaviors. For children exhibiting chronic cutting, I recommend a comprehensive, round the clock residential therapeutic approach that addresses the act of self harm and the underlying issues fueling the self-harming behavior and ideation. Patients who have a hard time regulating emotions are particularly prone to chronic cutting and are best served when interventions are administered in predictable intervals as well as in real time—i.e. immediately before, during and after strong emotional reactions are experienced.

I prefer using DBT (Dialectical Behavioral Therapy) with cutters as a comprehensive milieu treatment approach. DBT combines eastern mindfulness practices with western cognitive behavioral therapies and has proven quite effective in the treatment of cutting and it’s underlying causes. DBT groups help facilitate the generalization of emotional regulation skills into the participant’s environment. Milieu staff should be trained in the principles of DBT so that they can help coach patients in the moment, providing a culture that supports the use of DBT skills in daily life.

Acceptance-based strategies (as opposed to punitive, strict behavioral or shame-based interactions) can help patients manage overwhelming emotions. These strategies help patients learn to treat unpleasant emotions as a normal part of the human experience—a critical skill since the rejection or denial of emotional pain leads to dysfunctional behaviors like cutting.

Yoga and meditation are also highly effective for helping patients learn emotional and physical frustration tolerance—since holding poses and remaining quiet and mindful are excellent practice for this. These traditional practices help the adolescent struggling with self-harm to be in control of her thinking rather than controlled by her thinking.

Diary cards are another DBT tool that can help patients monitor self-harming behaviors and precipitating thoughts. I have students utilize diary cards in their DBT Skills Training Groups, daily community groups, and individual therapy sessions. The cards provide opportunities for peers and milieu staff to provide ongoing feedback to each student regarding their progress toward DBT target behaviors.

Identifying and tracking DBT target behaviors is an integral portion of DBT treatment; I use them twice daily for our 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.