Working with Self-Harming Adolescents

A Collaborative, Strengths-Based Therapy Approach

Matthew D. Selekman

Overview – Excerpt – Table of Contents

Introduction

The razor cuts into my skin, and this is how it

all begins! I blame myself for all of the fights

and cried a lot of lonely nights! The flowing

blood is on the floor, but I still cut me more

and more. I do the drugs to escape my pain

after all I have nothing to gain, drugs and

razors are my life. They take away my pain

and strife. When they’re with me I am glad,

and the best thing is, I don’t get mad.

—Rhiannon

Rhiannon’s powerful words graphically capture some of the reasons why adolescents have turned to self-harming behavior as a coping strategy. Her personal story is filled with many repeated experiences of being invalidated by key caregivers, feeling rejected and “not good enough,” and discovering that cutting and heavy abuse of alcohol, marijuana, and methamphetamines were highly effective ways to anesthetize her pain. Rhiannon’s experiences are no different than many other adolescents in this country who are struggling to cope with high levels of individual and family stress, toxic cultural environments, and a longing for connection with and validation from their parents and significant others in their lives.

Adolescent self-harming behavior appears to be on the rise today. Many of the mental health professionals and school social workers I provide consultation to on the local, national, and international levels are indicating that they have more self-harming adolescents on their caseloads than ever before. Unfortunately, research literature on the behavior is scant. And most of the research that has been conducted on this treatment population has been with adult samples or included only a small percentage of adolescents as subjects in the studies. Alderman (1997) found in her research that somewhere between 1 and 2 million youth and adults have engaged in self-harming behavior across the country. Research indicates that the majority of self-harming individuals are women or adolescent girls and that cutting and burning are the leading forms of this behavior reported (Alderman, 1997, Conterio & Lader, 1998, D. Miller, 1994). However, as Alderman (1997) has pointed out, there are probably as many adult men as women who are engaging in self-harming behavior but do not present themselves for treatment due to traditional male socialization practices and the belief that going for therapy would be perceived as a “sign of weakness.” Alderman’s research shows high rates of self-harming behavior among the male prison population. According to Dusty Miller, women are not socialized to express violence externally. She believes that women act out by “acting in” (D. Miller, 1994), whereas men find it much more culturally acceptable to externalize their anger and act out. In line with Miller’s observation about how women tend to “act in,” Favazza (1998) has found that fifty percent of the adolescents and women he has treated for self-injury had eating disorders as well.

In this introduction, I first dispel some common myths about self-harming adolescents, discuss five major aggravating factors that contribute to the development and maintenance of this problem among youth, and present an integrative and flexible solution-oriented brief family therapy approach for treating this population. I discuss four ways I have expanded the basic solution-oriented brief family therapy model to build in more therapeutic flexibility and options. The introduction concludes with a brief overview of the rest of the book.

Myths About Self-Harming Adolescents

“Self-Harming Adolescents Are Borderlines”

The intimidating and repulsive nature of adolescents’ deliberate brutalization of their bodies by burning or cutting themselves with sharp objects often leads therapists to gravitate toward an equally nightmarish diagnostic label for them: borderline personality disorder (Caplan, 1995; Kutchins & Kirk, 1997). Therapists who frequently use this diagnosis with self-harming clients are probably clinically informed by the adult borderline personality disorder literature, which indicates that self-mutilation and other forms of impulsive behavior are considered major diagnostic features of borderline clients (Linehan, 1993; Kernberg, 1975; Masterson, 1981). However, as indicated by leading authorities in the area of self-injury and as can be seen by the case examples described in this book, adolescent self-harming clients do not engage in this behavior because of an underlying personality disorder (Conterio & Lader, 1998; Alderman, 1997). There are a multitude of reasons why adolescents engage in self-harming behavior. Brown (2000) contends that the borderline personality disorder diagnosis is often assigned to clients who “create discomfort for the powerful [therapists]” (p. 302). Not only is the borderline label one of the most stigmatizing labels an adolescent can be given, but it also is inaccurate: According to DSM-IV, a client must be at least 18 years old to receive this diagnosis!

“Most Self-Harming Adolescents Have Been Sexually or Physically Abused”

More often than not, therapists who are referred self-harming adolescents tend to formulate diagnostic impressions and entertain possible labels for their new clients based on the available intake information, such as drawing the immediate conclusion that there must be a history of sexual or physical abuse in the clients’ backgrounds (Brown, 2000; Caplan, 1995; Dawes, 1994; Gergen & McNamee, 2000; Raskin & Lewandowski, 2000). After all, why else would these youth engage in such extreme self-destructive behaviors? However, much of the research on self-harming clients indicates there was no history of childhood sexual or physical abuse (Brodsky, Cliotre, & Dulit, 1995; Zweig-Frank, Paris, & Grizder, 1994).

I am not discounting the fact that there may be some self-harming adolescents who have experienced past sexual or physical traumatization and may or may not wish to address these issues. However, the clients ultimately must be invited to take the lead in determining what issues we focus our attention on and what their goals are. At all costs, therapists must avoid being privileged “experts” and editing their clients’ stories. I have worked with far too many adolescents who, pushed by their previous therapists to “work through” their past traumatic experiences, ended up increasing their self-destructive behaviors or tried to kill themselves.

“Self-Harming Adolescents Are Suicidal”

Most self-harming adolescents engage in self-injurious behaviors as an efficient way to gain quick relief from emotional distress or other major stressors in their lives. They do not want to die. When self-harming adolescents die, it is usually due to accidentally severing veins during a cutting episode. According to Armando Favazza, an internationally renown expert on self-mutilation: “Self-mutilation is distinct from suicide. Major reviews have upheld this distinction. A basic understanding is that a person who truly attempts suicide seeks to end all feelings, whereas a person who self-mutilates seeks to feel better” (p. 262).

In school settings, once these adolescents are identified as engaging in self-injurious behaviors, they are often perceived as being suicidal and in need of immediate psychiatric intervention. This may lead to the adolescents’ being admitted to a psychiatric hospital and placed on antidepressants.

“Adolescents Who Like to Pierce and Tattoo Their Bodies Have a Serious Problem With Self-Injury”

Body piercing and tattooing are a popular fad among youth today. For many adolescents, this type of self-decoration is a fashion statement. It also may serve as a membership card into the popular peer group the adolescent wishes to be a part of. Body piercing and tattooing are not a new phenomenon. Many ancient and modern cultures around the world have used tribal markings to communicate identity, status, and to convey a sense of belonging (Conterio & Lader, 1998; Favazza, 1998).

Self-harming adolescents, on the other hand, engage in this behavior not to make themselves more attractive but for quick relief from emotional distress or other stressors in their lives. This is the major distinction between true self-harming youth and those who are self-decorating (Alderman, 1997).

Major Aggravating Factors That Fuel Adolescent Self-Harming Behavior

The Tipping Point

The medical research area of epidemiology provides some useful tools for analyzing and understanding why we are seeing an increase in adolescent self-harming behavior today. One of these tools is the concept of the tipping point. For medical epidemiologists, a tipping point is the moment in the development of an epidemic at which only a small change in the presence of the germ produces a big change in the rate of infection. The tool also can be employed to help explain the evolution of social epidemics. For example, geographer Jonathan Crane found that when the number of “affluent leadership class” families drops below 6% in an urban neighborhood, there is a rapid increase in adolescent social problems such as delinquency, dropping out of school, and out-of-wedlock pregnancies (Crane, 1991).

In his fascinating and thought-provoking book The Tipping Point: How Little Things Can Make a Big Difference, journalist Malcolm Gladwell employs the tipping point framework to help explain how social epidemics often happen suddenly and unexpectedly. Gladwell (2000) contends that if you carefully analyze any social epidemic, you will find three particular personality types or agents of change who are the “natural pollinators” of new ideas and trends. He calls these three agents of change: the Law of a Few, the Stickiness Factor, and the Power of Context (p. 19). Individuals who fit into Gladwell’s Law of a Few personality type possess superb social skills, are energetic, and are quite knowledgeable or influential among their peers. One great historical figure that fit into this category was Paul Revere, who set in motion a word-of-mouth epidemic.

Revere was carrying a sensational and important piece of news: The British were coming. At the same time that Revere set out to warn people about the British invasion, a tanner by the name of William Dawes set out on the same urgent mission, with the same important information. So why did Revere make it into the history books instead of Dawes? According to Gladwell, the success of any kind of social epidemic is heavily dependent on the involvement of people with strong social skills. Revere’s news “tipped” and Dawes’s did not because the former had a much more dynamic personality and was highly respected in his community. The Reveres of this world are connectors. Connectors not only have a knack for creating an enormous social circle of friends and acquaintances, but they also manage to occupy many different worlds, subcultures, and niches.

Two other personality types or agents of change that fit into Gladwell’s Law of a Few category are the mavens and the salesmen. A maven is an information broker who shares and trades information about people, places, and products. Salesmen are individuals who master the art of persuasion and play a critical role in the tipping of word-of-mouth epidemics. They are the catalysts for the Stickiness Factor, as their uncanny ability to present their ideas in a simple, irresistible, memorable way moves people into taking action. However, epidemics are sensitive to the conditions and circumstances of time and place, and unless the Law of a Few and Stickiness factors are in order, social change will not occur. This is known as the Power of Context (Gladwell, 2000).

Gladwell’s tipping point framework can serve as a useful guide for understanding how self-harming behavior develops and spreads in peer groups and across entire schools. For example, I provided consultation to a junior high school that was plagued by student self-harming behavior. One could clearly identify the connectors, mavens, and saleswomen at this particular school: The main connector was a charismatic, outstanding student, a great actress, and one of the most popular and powerful teenagers in the school. However, despite her multitude of strengths, she had had several outpatient and inpatient treatment experiences for family problems, depression, and borderline personality disorder. For this teenager, cutting proved to be a much more effective medication than the Paxil and Depakote her psychiatrist had prescribed. Shortly after she discovered the powerful, endorphin-releasing effects of cutting, a word-of-mouth epidemic was set in motion at the school. Her popular saleswomen friends began to convince other students about how “cool” it was to “cut yourself.” To further complicate matters, one of the connector’s best friends, a true maven, turned her onto “witchcraft.” Soon, the connector and their inner circle of friends began engaging in blood- sharing rituals and got into trouble for drawing symbols of Satan in their school workbooks. As the cutting and witchcraft fever spread across the school, increasingly more students wanted to join this powerful social club.

Self-harming behavior can be as contagious as a measles outbreak. Moos (1979) calls this contagion effect among peer groups progressive conformity, that is, human behavior comes to reflect what is stimulated, encouraged, rewarded, and successful in a particular social context.

Family Breakdown

Adolescents today are suffering from a lack of intimate time with their parents. Due to financial reasons, both parents in many families increasingly are being forced to work and, in some cases, split shifts. In some families, children are raised by adult caregivers who are not relatives. Furthermore, people are becoming increasingly more isolated from their extended families. The rise in single-parent and divorce rates also is contributing to family disconnection. Research indicates that time spent together as a family is not only an important characteristic found in strong families (DeFrain & Stinnett, 1992; Stinnett & O’Donnell, 1996), but also that developmentally it is critical for adolescents to be able to turn to their parents for emotional support and validation, which greatly contribute to their feelings of self-worth and self-confidence (Doherty, 2000; Garbarino, 1995; Gilbert, 1999; Grotevant & Cooper, 1984; Papini & Roggman, 1992; Pipher, 1994; Reimer, Overton, Steidl, Rosenstein, & Horowitz, 1996; Taffel & Blau, 1999, 2001).

As one former self-harming client said about her parents: “I feel invisible in their eyes.” Alison was a Caucasian 14-year-old who had turned to cutting as a way to confirm her existence in the family. She further added: “I feel dead inside . . . cutting makes me feel like I’m alive!” Both of her parents were highly successful lawyers who regularly worked long hours. When the parents were around, they were quite irritable and preoccupied. They had failed to create firm boundaries between their work and home lives. In family therapy sessions, Alison would frequently complain about how her parents failed to listen or pay attention to her when she reached out for their support, which increasingly made her feel like her existence was meaningless to them. Alison’s experiences of feeling invalidated, “invisible,” and “emotionally dead inside” are frequently voiced by self-harming adolescents.

Renowned psychiatrist Robert Coles has this to say about the breakdown of today’s American family: “The frenzied need of children to have possessions isn’t only a function of the advertisements they see on TV. It’s a function of their hunger for what they aren’t getting—their parents’ time” (Mattox, 1991, p. 10). According to one study on adolescents, mothers tend to average 8 minutes per day of conversation time with their teens, and fathers only spend 3 minutes (Sparham, Roy, & Stratton, 1995). Cloud (1999) found in his research that parents are spending 40% less time with their kids now than 30 years ago. With statistics like these, it is no surprise that adolescents often report feeling disconnected from their parents.

Mary Pipher, author of Reviving Ophelia: Saving the Selves of Adolescent Girls, argues that therapists need to move away from family therapy models and instead begin “treating people’s schedules” (Simon, 1997). In fact, in my clinical practice with self-harming adolescents and their families I have found that many of the presenting problems “are directly or indirectly related to time” (Simon, 1997, p. 31). Research supports this idea. Califano (1998) found that children and adolescents who regularly have dinner with their parents tend to have reduced rates of use or no use at all of marijuana. His study demonstrates how simply having dinner together as a family can serve as an important protective factor for our children and adolescents, who are growing up in toxic cultural environments. Family therapy in the new millennium must incorporate the importance of time and daily family rituals into the treatment process to help strengthen family ties and preserve the sanctity of family life.

Hurried Teens

In today’s highly competitive, fast-paced cultural environment, adolescents are growing older younger. There is tremendous pressure put on teenagers to achieve academic excellence, to outperform their peers in classes and activities, and to devote their leisure time to intellectual pursuits—on top of all the stress involved in coping with much higher academic standards and heavy homework loads. Many parents pressure their teens to get involved in extracurricular activities or even take it upon themselves to over-schedule their children, all in the spirit of wanting them “to be the best they can possibly be!” These parents act as if life can be programmed or micromanaged, with the ultimate goal of their teenagers getting into the most prestigious colleges (Rosenfeld & Wise, 2000).

Another way adolescents are hurried today is through the process of parentification (Breggin, 2000; Elkind, 1994, 1988; S. Minuchin, 1974). The parentification process may be set in motion when a parent is under-functioning due to health, mental health, substance abuse difficulties, or a relationship breakup. With some families, long work days have forced single or dual-career parents to recruit their most responsible child or teenager to take on important adult responsibilities, such as taking care of their younger siblings for extended periods of time, cooking, cleaning the house, and so forth. Some parents cannot afford childcare and consequently rely on one of their children to take on the adult responsibility of caring for siblings. In some cases, the parentified child may become like a surrogate spouse, serve as a therapist for a single parent, or be triangulated (Bowen, 1978) into the parents’ marital relationship as a go-between or confidant. The following case example illustrates the emotional and social consequences of being a parentified child.

Jane, a bright and highly popular Caucasian 13-year-old, was referred to me by her school social worker for cutting and possible suicidal ideation. Jane began cutting herself following her parents’ divorce. The father had engaged in an extramarital affair and left his wife for the other woman. Jane was quite bitter about this. Her mother became extremely depressed after the breakup. She also was forced to get a job to support Jane and her other child, a 10-year-old girl named Lisa who had Down’s syndrome. The mother put a lot of pressure on Jane to take care of Lisa during the week due to her long work hours. Jane begrudgingly agreed and thus sacrificed her formerly busy after-school social life. Whenever she attempted to share her frustrations about her diminishing social life or voiced her anger about the father’s “wrecking the family,” the mother would start to cry and share her feelings of guilt rather than respond to Jane’s needs. In response to this regular invalidation process, Jane eventually found a powerful and effective way to avoid further burdening her mother and simultaneously keep a lid on her anger and frustration. One day, after a negative interaction with her mother, Jane took a razor blade into her bedroom and began cutting her arms. She found that not only did the cutting serve as “a friend,” but also, as she put it, “would quickly get rid of my anger.” In the context of this family, it is understandable why Jane gravitated toward cutting and was not eager to give up this behavior. Cutting helped her to cope with the family stressors and was a fast-acting solution that, like a good friend, she could always count on to be there for her when she needed relief.

The biggest tragedy of parentification is the sacrificing of young people’s childhood. Today’s parents often assume that their teenagers are more sophisticated and self-sufficient and can handle day-to-day stress better than they could have managed as teenagers. Unfortunately, the parentified child’s needs for support, validation, and security are often left unmet (Breggin, 2000; Elkind, 1994, 1988).

The Second Family

In their relentless search for connection, and disenchanted with their parents’ failure to adequately meet their needs, many adolescents have sought refuge in a “second family” (Taffel & Blau, 1999, 2001). The second family may take the form of a street gang, the rave/danceclub culture, or an unsavory peer group of teenagers who may engage in substance abuse or self-harming behaviors. The rave/danceclub culture is becoming one of the most popular second families. In this context teenagers feel empowered: There are no cultural or gender barriers; everyone is accepted. For many youth, the rave/danceclub scene has become their identity, defining their friends and style of dress and providing them with a world they can call their own. For example, Julie, a 17-year-old lesbian, cut herself to cope with her parents’ constant verbal abuse about what they perceived as her lifestyle choice and because she was underachieving in school. Her father was Middle Eastern and her mother was a staunch Catholic from Bolivia who frequently reminded Julie about how she was “sinning” and would “go to hell” for her lifestyle choice. For Julie, going to rave dances provided her with a context where she felt unconditionally accepted; as she put it, “I could leave my family problems at the door.”

According to parenting expert Ronald Taffel, “Adolescents turn to the second family to fill the void created by parents too busy to spend time with them. Today’s kids are angry because they feel invisible and ignored by parents who do not hear or see them. They are desperate to be seen and known, rather than scheduled or psychologized. They are craving one-on-one time. We are in a life-and-death struggle over who will connect with the core selves of our children—mothers or fathers, or the enveloping world of the second family” (Feldman, 2000, p. 16). While on their journey in search of a second family, many adolescents fall prey to the media and materialistic values. Teenagers find it difficult to resist or challenge the dominant cultural messages perpetuated and reinforced by the media and they end up buying an image—not a piece of clothing—that they believe will transform their lives, making them look better or more “cool” (Kilbourne, 1999). The world of advertisement promises teenagers products that can deliver what can only be generated in healthy interpersonal relationships.

In her scholarly critique of the advertisement business, Kilbourne (1999) applies the relational therapy theoretical framework of Jean Baker Miller (1976) to point out five ways advertisements artificially try to replace what we get naturally from meaningful relationships with others:

1. Zest and vitality. Ads promise that products will make us feel more alive and will help us to experience more intensely. Everywhere we look, we are offered false excite-pseudo-intensity. Not only does this promise inevitably disappoint us, but it also contributes to the general feeling in our culture that every moment of our lives should be exciting and fun and anything less is boring.

2. Empowerment to act. Ads also promise us that products give us courage, will empower us to act. “Just do it,” the slogan for Nike high-priced sneakers promises to help us to achieve our goals and perform with excellence. Ads define empowerment as power over other people.

3. Knowledge and clarity of self and others. Ads constantly tell us that products can help us find our identity, can make us unique, can help us understand ourselves better. Calvin Klein tells us, “Be good. Be Bad. Just Be,” as if somehow his perfume had something to do with our core identity. Ads also promise that products will lead instantly to better communication.

4. Sense of self-worth. One of the central messages of advertising is that products will enhance our self-worth. “And I’m worth it,” says actress Heather Locklear for L’Oreal hair products. Spend a little more money on hair coloring and this will improve your self-worth the slogan implies.

5. Desire for more connection. Ads are a key component of our consumerist culture, constantly exhorting us to be in a never-ending state of excitement, never to tolerate boredom or disappointment, to focus on ourselves, and never to delay gratification. These messages are a blueprint for how to destroy intimate relationships. (pp. 90–93)

Our consumerist culture also wreaks havoc in the lives of adolescents by means of popular high-tech products and constant bombardment of violent images in the media. Thanks to Game-Boys, play stations, computer games, and chat rooms, leading a socially disconnected lifestyle has become much more appealing than participating in extracurricular activities at school or maintaining and building new friendships. For some teenagers, computers have become a second family. However, staring at a computer or television screen does not teach adolescents how to be empathic, how to be loving, or the importance of showing concern for others. Naisbitt, Naisbitt, and Philips (1999) contend that, “Screens are everywhere, in every setting, directing us, informing us, amusing us. And without conscious awareness, they are shaping us” (p. 12).

Brazelton and Greenspan (2000) report that children and adolescents spend 5.5 hours per day in front of a computer screen or television set. Today, many teenagers have TVs, VCRs, and DVD players in their bedrooms, which greatly increase the opportunity for them to be exposed to violent images in the media. Over time, this constant exposure to violent images has a desensitizing effect on teenagers’ tolerance levels for violence, including self-harm. They become numb to it (Huston et al., 1992). Their heroes on TV shows, in the movies, and in rap or other types of music videos convince them that they are invincible. Singers such as Marilyn Manson, who cuts himself on stage with broken bottles, do a masterful job of glorifying self-mutilative behavior. Interestingly, when discussing his teenage years, Manson described himself as being disconnected from his parents and peers and often bullied. He says of teenagers today, “Teenagers are not considered human beings in some ways. Until you turn 18, you really don’t have any rights, so in a sense you really don’t have any soul. You’re not really a real person” (Carlson, 2000, p. 77). This view of teenagers and Manson’s description of disconnection is very similar to the stories self-harming adolescents have shared with me.

Disconnected, frustrated youth who gravitate toward unsavory peer groups often end up being mentored by equally troubled, disconnected, and frustrated teenagers who head such groups. To further complicate matters, the other members of the group may share similar psychological and family background profiles, and are also seeking new families to connect with. These teenagers soon learn that there are benefits to being loyal followers. They get a lot of attention, they feel powerful, they have control, they are connected to a group that seems to care about them, and they may receive immediate rewards like money or material items. The peer-group second family meets many of their basic human needs. Once an individual is totally immersed in this peer group subculture, there is no turning back.

Some adolescents’ peer groups today are much more powerful than their nuclear families. If there is any hope for parents to reclaim their sons and daughters from a negative peer group, they must figure out a way to neutralize the powerful influence this group has on their teens. In my clinical work, I often invite adolescents to bring their closest friends into our family therapy and individual sessions (Selekman, 1991, 1993, 1995b). I also strongly encourage them to bring in the leader of their peer group. Once I have been able to establish some leverage and mutual respect with the peer group leaders and their high-ranking followers, I have been able to steer my adolescent clients in a different direction socially, as well as help the parents and their teenagers to establish more nurturing and meaningful relationships. Another added bonus to collaborating with an adolescent’s peer group leader and other high-ranking peers is that they may decide to become clients themselves!

It is important to point out that not all self-harming adolescents gravitate toward a negative peer group. Some of these adolescents are quite resourceful and resilient and have carefully selected a supportive peer group in an effort to help themselves to better cope and self-heal.

Societal “Quick-Relief” Solutions

We live in a feel-good, quick-relief society. Legal mood-altering drugs such as Prozac and Ritalin have become magic bullets in our cultural landscape. Major pharmaceutical companies own our politicians and our healthcare industry. No other presidential administration has endorsed with such great fervor and financial support the use of mood-altering medications for the mental health problems of children and adolescents than the Clinton administration had (Breggin, 2000).

Following the Columbine High School tragedy, President Clinton called for a White House conference on mental health, where Steven Hyman and Harold Koplewicz, both expert biologically based psychiatrists, totally dismissed the role of “childhood traumas,” “inadequate parenting,” or “absent fathers,” that possibly lie at the root of why children and adolescents become violent. Instead, they successfully sold the Clintons and the Gores on their scientific views that violent kids have biochemically disordered brains, which can best be treated by mood-altering medications. They neglected to mention the fact that one of the Columbine shooters, Eric Harris, was already on Luvox, a drug that is rarely prescribed today because of its awful side effects. They also did not mention that in the United States there are close to 6 million children already taking antidepressants, Ritalin, Dexedrine, and Adderall (Breggin, 2000).

Congress subsequently funded a federal initiative aimed at providing nationwide training programs to help school systems and communities to identify “troubled” children and youth and provide them with better school mental health services. Sadly, this federal initiative ended up spreading an even larger “psychiatric net” over our nation’s schools with the aim of drugging increased numbers of students (Breggin, 2000). Some federally funded school districts manage “troubled” students, including self-harming youth, by referring them to a psychiatrist for a comprehensive evaluation. More often than not, these students are placed on medication in an attempt to biochemically stabilize their mood and behavioral difficulties. Such a school protocol for “troubled” students may alleviate the administrators’ and other personnel’s headaches and worries about the safety of students, but what about the identified students’ personal needs? Surprisingly, biologically based psychiatrists and school officials seem to be oblivious to the fact that the outcome research on the effectiveness of medications for child and adolescent behavioral problems is sparse, and studies have not indicated that in the long term the use of medications has led to improvements in social functioning or academic achievement (Greenberg, 1999). Many of these psychiatrists also assume that medication treatment regimes for children and adolescents should be no different than those for adults (Breggin, 2000; Greenberg, 1999).

Ritalin, the number one medication prescribed for attention deficit disorder, has now become a popular street drug of abuse. Young entrepreneurs are now selling their prescriptions as a form of speed to teenagers and adults alike. Low cost and accessibility make it an enticing purchase for youth seeking a “quick rush” or wishing to get out of a melancholic state of mind. Some of my clients have reported that peers at school are even dealing Prozac and Zoloft.

Integrative Solution-Oriented Family Therapy Practice

Over the past decade, a number of solution-focused brief therapy practitioners both in this country and abroad have recognized the limitations of being too formulaic or rigidly adhered to one particular model (Beyebach & Morejon, 1999; Chang & Phillips, 1993; Geyerhofer, personal communication, 2000; Lamarre & Gregoire, 1999; S. D. Miller, Hubble, & Duncan, 1995; Nylund & Corsiglia, 1994; Selekman, 1993, 1997, 1999). Some of the major pitfalls of practicing within the box of a particular model are: (1) It greatly limits what therapists can see and hear; (2) therapists are limited to a set of therapy model assumptions, strategies, and techniques; and (3) therapists rob themselves of the opportunity to allow their creativity to run wild in crafting questions and therapeutic experiments.

For me, solution-oriented clinical practice gives me permission to be improvisational, integrative, and to tap my imagination powers and test out whatever I think might work in any given moment in any given session. This is not to say that what we do in the therapeutic process should not be purposeful or in line with the client’s treatment goals, but rather that there are unlimited ways to empower clients to succeed in achieving their goals. Being therapeutically flexible, adopting a kaleidoscopic view of clients’ unique problem stories and interactions, and giving ourselves the freedom to traverse therapy model boundaries will help us to stay fresh and grow professionally. It also will help to liberate our clients from their oppressive problem stories more efficiently and effectively. Therapeutic flexibility is a must. Often these families are grappling with multiple issues and require therapeutic intervention on the individual adolescent, family, peer-group, school, and other larger systems levels. Each family member also may be at a different stage of readiness to change (Prochaska, 1999), to do something about their problem situations, or to address what the referring agent and other helpers want them to work on. I have added four important guidelines to the basic solution-oriented brief family therapy model (Selekman, 1993, 1997) to help to build in more therapeutic flexibility and to better meet the unique needs of self-harming adolescents and their families.

1. Bring forth client expertise: Integrate what works in treatment. After conducting a scholarly review of 40 years of treatment outcome studies, Miller and his colleagues have identified four important variables that clients identified as the key to their success in treatment (Duncan & Miller, 2000; Hubble, Duncan, & Miller, 1999; S. D. Miller et al., 1995). Clinicians should concentrate their therapeutic efforts in maximizing these four common factors in their clinical work with families.

• Clients’ extratherapeutic factors. These factors include the clients’ strengths and resources, theories of change, protective factors contributing to their resiliency, spiritual involvement, supportive elements in their environments, chance events, and client-generated pretreatment changes. Forty percent of what accounts for outcome variance has to do with what the clients bring to therapy and the therapist’s expertise in capitalizing on the client’s expertise.

• Therapeutic relationship factors. These factors include therapists’ caring, warmth, empathy, acceptance, validation, humor, and encouragement of positive risk-taking. Structuring skills (Alexander & Parsons, 1982; Henggeler & Alexander, 1999) include the therapist’s ability to convey confidence and competence and to take charge in family sessions when things get out of hand. This skill in particular has been identified by clients as being an important contributing factor of successful family treatment outcome for antisocial, violent, and substance-abusing adolescents. Thirty percent of what accounts for outcome variance has to do with these therapist-client relationship factors.

• Placebo, hope, and expectancy. This category of factors consists of the client’s faith that the therapist’s abilities and treatment procedures will be of benefit. Frank and Frank (1991) found that in successful therapies both the therapists and the clients believed in the healing powers of the treatment procedures provided. Several researchers in the field of psychiatry have demonstrated that antidepressants are no more effective than an active placebo, particularly if the placebo mimics the side effects of the real drug being tested (Greenberg, 1999; Greenberg, Bornstein, Zborowski, Fisher, & Greenberg, 1994; Kirsch & Sapirstein, 1998). In other words, if clients truly believe that a particular medication will help them because the prescribing psychiatrist has instilled optimism about the effectiveness of the medication, the placebo being administered will produce favorable results. Placebo, hope, and expectancy account for fifteen percent of outcome variance (Lambert, 1992).

• Model/technique factors. The last contributing factor to the client’s success in treatment is the therapist’s technical skills. All therapeutic models strive to create a safe climate for clients to take action. Technically skilled therapists are often quite accurate in matching therapeutically whatever they do with the clients’ problem views, theories of change, goals, and stages of readiness to change (Duncan & Miller, 2000; Hubble, Duncan, & Miller, 1999; Prochaska, 1999; Prochaska, Norcross, & DiClemente, 1994; Reimers, Walker, Cooper, & DeRaad, 1992). According to Lambert (1992), model/technique factors account for 15% of outcome variance.

By inviting self-harming adolescents and their families to share their expertise, unique needs, expectations, and goals, as well as to take the lead in guiding therapeutic activity, therapists can improve their chances of succeeding in treatment. To maximize treatment success, therapists should check in with their clients at the end of every session to find out what they found most useful, not helpful, or wish for them to address or change about their approach in future sessions.

2. Make room for client storytelling. One of the major criticisms of the solution-focused brief therapy approach (De Shazer, 1985, 1988, 1991) is that clients are not given enough room to share their problems stories and address affect-laden or unresolved conflict material that may surface during the course of therapy. This can occur because the solution-focused therapist avoids “problem talk” and actively tries to coauthor solution-determined stories (De Shazer, 1991; Nylund & Corsiglia, 1994; Selekman, 1997). Spence (1987) refers to this therapeutic strategy as the “singular solution.” He argues that therapists who operate from a singular-solution framework ignore or downplay client statements that don’t fit with their therapeutic framework. Spence contends that making use of all clients’ raw data (problem-saturated or not) opens the door for a multiplicity of therapeutic possibilities. P. Minuchin, Colapinto, and Minuchin (1998) argue that the solution-focused approach deliberately avoids the open exploration of family conflicts and that “families will often founder over their inability to face and deal with disagreements” (pp. 208–209) unless the therapist helps them to find more adaptive ways of resolving their differences.

The late and brilliant family therapy pioneer Harry Goolishian had the following to say about the limitations of the solution-focused brief therapy approach:

The ideas are not wrong but perhaps too sharply focused in one direction with reference to the development of new meaning. If we were to point to one danger in solution-focused approaches it would be the risk of trying so hard to produce a brief change-oriented experience that one can lose sight of, or contact with, the story of the client. This is particularly so with families which have been recycled through the mental health system. They have a long story to tell. (Goolishian, personal communication, March 7, 1988)

These important words of wisdom have stuck with me for years and

have greatly contributed to my becoming a much more flexible solution-oriented practitioner. I now find myself spending more time in the beginning of initial family sessions carefully listening to families’ problem-saturated stories and validating their experiences. Throughout the course of therapy, whenever a family member begins to have a strong affective nonverbal or verbal response to important material being discussed, or when he or she discloses affective-laden material, I avoid being a narrative editor and give him or her plenty of room to share the meaningful story.

Because many self-harming adolescents often feel invalidated and emotionally disconnected from their families (Conterio & Lader, 1998; D. Miller, 1994; Strong, 1998) it is crucial that therapists avoid inadvertently contributing further to this feeling by failing to support or bring out their “voices” in family sessions. Three powerful forces contribute to the development and maintenance of invalidating family interactions and the silencing of self-harming women—the mismanagement of anger, strong patriarchal cultural proscriptions for how women should think and act, and family secrets. The mismanagement of anger is one of the most common family characteristics of families with self-harming women (Conterio & Lader, 1998; D. Miller, 1994; Walsh & Rosen, 1988). Often the fathers in these families wield all of the power and have made it very clear to their wives and daughters that it is not okay to challenge or question their authority in any way. In some cultures, such as with Middle Eastern families, this unspoken rule is enforced by the oldest son in the family, who is next in command when the father is away (Abudabbeh, 1996). Self-harming women have learned that it is much safer to keep a lid on their anger by cutting or burning themselves than to risk being verbally ridiculed or harshly disciplined. In a similar fashion to bulimia, cutting in particular can serve as a way to purge one’s anger and frustration and to rapidly release tension. In some cases, the traditional fathers in these families may not resort to verbal or physical aggression but instead are conflict avoidant and use extended periods of silence, an equally powerful weapon. Problems and conflicts are never resolved when family members’ anger and

frustration has to be swept under the carpet. Therefore, family members are forced to come up with other ways to manage their anger and frustration with fathers who will not tolerate or listen to their concerns or frustrations with him. The use of parental silence can be quite effective at squelching the “voice” of an adolescent woman who is seeking validation, support, and more autonomy. When an individual is feeling a strong sense of hopelessness, a lack of power, and relatively little control in his or her family, cutting or burning, like substance abuse and eating disorders, can give the person a false sense of being in control.

In family therapy sessions, the therapist has to be very active in disrupting the invalidating family interactions occurring in the room by using reframing, externalization of the problem (White & Epston, 1990), and curiosity. One effective way that I disrupt invalidating patterns of interactions in families with self-harming women is to change how the self-harming behavior is viewed. For example, I was working with Debbie, a Caucasian 13-year-old who was cutting herself, experimenting with speed, and had a highly conflictual relationship with her father. Her father, who was a very tall, burly

businessman, apparently had no problem giving commands to family members and putting them in their place if they dared to challenge him or question his decision-making abilities. For the first time in one of our family sessions, Debbie took a big risk and began to confront her father about how he “never would listen” to her when she spoke to him. When the father began to reprimand her in the session, I turned to him and said, “That was absolutely beautiful the way your daughter stood up for herself! Do you think Debbie inherited your gene for assertiveness?!” Although initially he was puzzled by my comment, he soon began to smile and appeared proud that he could have given his daughter a “genetically important life trait.” The father’s style of communicating with Debbie began to change after he reframed her behavior as a positive “trait” that she had inherited from him. In future sessions, the father totally abandoned his blaming style of interacting with his daughter, began to make better eye contact with her, and would listen to her in our sessions. Once Debbie found it increasingly safe to assert herself with her father and effectively elicit

more support from him in and out of our family therapy sessions, her cutting and substance abuse behaviors stopped.

As can be seen in Debbie’s case, two of the most important therapeutic tasks to accomplish in family therapy with self-harming adolescents are: (1) to actively challenge and disrupt the invalidating family interactions that are often connected to traditional patriarchal socialization practices and (2) to create a safe therapeutic climate that gives the self-harming adolescent permission to externalize her anger or any other unpleasant thoughts or feelings she may be experiencing in particular family relationships or in any other social contexts. Replacing impulsive action with “words” is one of the main keys to successful treatment with self-harming adolescents.

In some cultures, young women have very little say when it comes to asserting their personal wishes (such as their desire to date), participating in other social activities outside the family, and deciding how to dress. Some of the adolescents I have worked with are in intense conflict with their parents over these issues, especially as they become increasingly immersed in the American teenage cultural world. The parents, on the other hand, cling to the traditional beliefs, customs, and expectations for their children that clash with the teenage world they often view as sinful. The self-harming behavior often exhibited by these young women is an attempt to cope simultaneously with the stress of acculturating and the strong family pull to conform to the traditional patriarchal proscriptions for women’s behavior. In very religious families the guilt for “sinning” can be so intense that the self-harming behavior becomes an act of repentance and self-punishment (Conterio & Lader, 1998; D. Miller, 1994).

The challenge for therapists in these clinical situations is to support the parents but at the same time build a solid alliance with the adolescent. The first step is to validate both parties’ positions. Secondly, the therapist should normalize for the family how most immigrant families struggle with similar issues and how this transition period of adjusting to the American culture creates a lot of family stress and conflict. Finally, the therapist needs to serve as an intergenerational negotiator (Selekman, 1993) and help the parents and their adolescents learn problem-solving and negotiation skills, as well as how to compromise. With some families, I have been able to unite the parents and adolescents against the “negative effects of the

transition period” which is wreaking havoc on their family relationships.

Besides externalizing the negative effects of this transition period for immigrant families, I sometimes externalize societal and intergenerational rigid gender socialization practices as the real enemy that is getting the best of family members (Philpot, Brooks, Lusterman, & Nutt, 1997; White, 1989). The therapist has to help family members see that these rigid gender socialization practices brainwash them to think that there is a “right way” to view and relate to the other gender. Therefore, it is not the other gender that is the enemy, but it is “the inflexibility of gender messages that do not allow for growth” (Philpot et al., 1997, p. 163) that has to be challenged and addressed in family therapy.

Another family dynamic that sometimes exists in families of self-harming adolescents is the presence of family secrets (Conterio & Lader, 1998; D. Miller, 1994). Family secrets may involve parental substance abuse or mental health difficulties, parental extramarital affairs, family violence, sex abuse, patterns of family cutoffs, being in a cross-generational coalition with a parent or grandparent, a family

history riddled with suicides and unresolved losses, or undisclosed adoptions. The parents and older siblings of the self-harming adolescent may collude to prevent these unspeakable and anxiety-provoking family secrets from leaking out. In some cases, the self-harming adolescent may be harboring such secrets as having been physically or sexually abused by a family member, a relative, or an adult outside the home, or possibly discovering a family member engaging in illegal or other troublesome behaviors of which other family members are not aware. Often the adolescent is either threatened not to disclose the secret or, out of loyalty to her family, decides to keep a lid on what is happening to her or what she knows about that is occurring secretively behind the scenes. Over time, the secret-keeping process can take its toll psychologically and physically on the self-harming adolescent, for instance, by intensifying depressed

feelings and anxiety, which in turn increase the likelihood of self-harming behaviors. Self-harming behavior can also be a metaphor for family secrets, such as family cutoffs or feeling cut in two due to being caught in the family web of divided loyalties.

In clinical situations where family secrets appear to be surfacing, I use curiosity and ask the family open-ended, conversational questions (Andersen, 1991, 1995, 1998; Anderson & Goolishian, 1988; Selekman, 1993, 1997) to explore with them if there are any significant untold family stories that may be contributing to what is keeping the treatment situation stuck. I ask the family the following types of questions:

• “It is clear to me that all of you have been working hard to improve your situation. However, it feels like we have run into a brick wall at this point in our work together. Is there anything we have not talked about that you think might be keeping us stuck?”

• “Are there any issues or concerns that you are surprised that I have not asked you about?”

• “Before we started working together, was there one thing that any of you told yourselves that you would not talk about with me or in the company of your family in our sessions?”

These types of questions can help pave the way for the disclosure of family secrets that may have been contributing to the development and maintenance of the self-harming behavior of the adolescent.

3. Integrate cognitive-behavioral therapy ideas and self-soothing strategies. With some self-harming adolescent case situations, disrupting invalidating family interactions and altering constraining family beliefs fails to have an impact on the adolescent’s self-harming behavior. This may be because the self-harming adolescent still is being pushed around by automatic self-defeating thoughts (Beck, Rush, & Emery, 1979), such as irrational “I” statements or catastrophizing (Ellis, 1974; Seligman, 1995). She also may be experiencing grave difficulties coping with overwhelming emotions and high levels of stress in her family and in other social contexts. Her capacity to identify and verbalize her different feelings, as well as soothe herself when overwhelmed by these emotions, may be deficit areas that require therapeutic attention.

Prior to teaching the adolescent effective tools for challenging her irrational self-defeating thoughts and useful self-soothing strategies to employ when plagued by emotional distress and other stressful situations, I first explore with her in great detail any past or present successes she has had in which she effectively coped with oppressive emotional states and negative thoughts that had been pushing her around. For example, Eloise, a Jewish 17-year-old who cut up and down her legs “50 times” with a razor blade following her boyfriend’s breaking up with her, used “journaling” as an effective coping strategy to get back on track with her life. After learning about Eloise’s use of journaling as a helpful coping strategy, I decided to capitalize on this important client extratherapeutic factor (Hubble et al., 1999) by having Eloise bring in her three-volume set of journals so we could incorporate them into our therapeutic work together. What was most fascinating about Eloise’s style of journaling was her deliberate use of different color print to capture her shifting emotional states from the relationship breakup to “feeling happier” and “more self-confident.” Immediately after the relationship breakup, Eloise began using black print and gradually moved into blue, green, red, and brown print in the first two volumes of her journals as she started to cope better with the loss. She began painting and exercising again and stopped isolating herself from the family. Her third volume of the journal began in orange print and finished in yellow print, which Eloise claimed represented “the sun and feeling happier.” By making maximum use of Eloise’s unique coping strategy in individual and family therapy, I was able to help further empower her to get back on track with her life.

Although Eloise found her journaling to be of great help to her, she still reported being plagued by self-defeating thoughts. Knowing that she was an avid fan of detective stories and murder mysteries, I had her pretend to be a super sleuth detective over a 2-week period and search for evidence to support her thoughts. By the end of her 2-week investigation, she came up empty handed and was successfully able to erase her self-defeating thoughts.

Besides teaching adolescents how to challenge and disrupt their self-defeating irrational thought processes, it is critical to increase their repertoire of self-soothing strategies and techniques. This includes teaching them how to visualize, meditate, use relaxation training, and journal, as well as helping them to access their inner resources and unique talents when experiencing emotional distress.

4. Facilitate connection-building. One of the major gaps in the solution-focused brief therapy model (De Shazer, 1985, 1988, 1991) is the lack of importance placed on the therapist’s use of self as the catalyst for helping to build meaningful connections among the adolescent and more distant family members, as well as in strained and conflictual peer relationship situations and in relationships with concerned and involved helping professionals from larger systems, particularly when clients identify these areas as playing a role in their problem situations. The leading proponents of the solution-focused brief therapy model would argue that a therapist engaging in such activity would be creating too much complexity for herself/himself and the clients and that if you do the model “right,” such therapist activity is totally unnecessary (Berg, 1994; De Shazer, 1988, 1991), because change will occur across the various social contexts the client interfaces in the form of a “ripple effect”(De Shazer, 1985). However, in my clinical practice, particularly with more complex and chronic case situations, I have found the standard solution-focused therapeutic strategies and techniques to fall short in helping create possibilities. For one, some of the solution-focused questions may block the self-harming client from telling her story by keeping the interview too sharply focused on the “positives” both in the present and in the past. In some cases, a “ripple effect” does not occur when the self-harming adolescent reduces or stops her problematic behavior, and the parents remain emotionally disconnected from her. Sometimes the reverse happens: The parents abandon their past unhelpful patterns of interaction with the adolescent but the child remains symptomatic and emotionally disconnected from her parents. Finally, I have also experienced case situations where the self-harming adolescent has made some important changes but those changes have failed to have an impact on her strained peer relationships or on her relationships with more pessimistic professionals from larger systems.

Many self-harming adolescents grapple with the establishment and maintenance of meaningful connections with one or both parents, other family members, peers, teachers, and other adults in their communities. In some cases, one or both parents have not been emotionally available to connect with and soothe them when they are overwhelmed by stress or painful thoughts and feelings. Similar to substance abuse, cutting or burning becomes a substitute comforter or a “friend” to help adolescents to cope. The self-harming adolescent may interpret the parent’s disengagement from her as a sign of rejection. All children and adolescents need to feel a sense of place or belonging in their families. This concept can be extended to every social context that the adolescent interfaces with outside the family as well. In Native American culture, children are considered “sacred beings.” The Maori Indian culture views their children as “gifts of the gods.” In both of these cultural groups there is much love, care, and attention given to children in their immediate and extended families and by the entire community (Brokenleg, 1998).

According to Bronfenbrenner (1979):

The capacity of a dyad to serve as an effective context for human development is crucially dependent on the presence and participation of third parties, such as spouses, relatives, friends, teachers, clergy, and neighbors. If such third parties are absent, or if they play a disruptive rather than supportive role, the developmental process breaks down. (p. 5)

Bronfenbrenner also contends that an adolescent’s ability to establish and maintain meaningful connections across multiple social contexts can also greatly enhance his or her psychological and physical levels of functioning.

Some self-harming adolescents report feeling alienated and lack meaningful connections with their teachers. This is in line with a recent Search Institute survey of 100,000 students from 6th through 12th grades, which found that only one in four students reported that they went to a school where adults and other students cared about them (Applebome, 1999). I honestly believe that if every child or adolescent had a meaningful connection with at least one teacher in their schools for emotional support and guidance, there would be far fewer extreme behavioral difficulties such as youth violence and self-harming behaviors occurring in our schools. Some good empirical evidence supports this belief. In his longitudinal research, Anthony (1984, 1987) found that the primary protective factor that at-risk inner-city children identified as helping them to overcome adversity while growing up was their inspirational others. The inspirational others were older siblings, extended family members, teachers, coaches, clergy, adult friends of the family, and community leaders. I have found it useful in clinical work with adolescents in general to involve their inspirational others in the family treatment process. These people can not only provide added support for the adolescent in other social contexts in which she is struggling outside the family, but they also may have some valuable words of wisdom and offer creative problem-solving ideas.

Self-harming adolescent case situations are notorious for attracting an army of concerned helping professionals well before an initial family therapy session. Often the school principal, dean, social worker, or teachers are worried that the adolescent is “suicidal” and may need to be psychiatrically hospitalized. The family physician may be the first helper to observe the adolescent’s cuts or burn marks and will more than likely refer the client to a psychiatrist colleague for an evaluation. This visit may result in the adolescent’s being diagnosed as clinically depressed, having a borderline personality disorder or obsessive-compulsive disorder, and being placed on medication and admitted into a psychiatric hospital. The self-harming adolescent’s voice is often lost in these dialogues about what the concerned professionals think is “wrong” with her and how to treat her. This is why it is best to mobilize as many of the involved helping professionals constituting the problem system as possible to share their concerns, expectations, ideal outcome pictures, and treatment plan ideas with the family and treating therapist as early as possible in the treatment process, if not in the very first family session (Anderson & Goolishian, 1988). This allows everyone to know where everyone else is coming from, both the adolescent and the family to have an active voice in their own treatment, and the involved helping professionals to have ample opportunity to notice changes occurring with the adolescent and her family, which can lead to shifts in their original ways of viewing the client’s problem situation.

Overview of the Book

Chapter 1 presents a multisystemic family assessment framework that takes into consideration the complex interplay between individual, family, peer-group, larger-system, gender, cultural, and community factors in the development and maintenance of adolescent self-harming behavior. This multisystemic assessment process informs therapists of which systems levels they should target interventions to.

Chapter 2 describes guidelines for crafting and selecting

therapeutic questions that grow out of the interviewing process to help foster therapist-family member cooperative relationships, to elicit their expertise, to challenge constraining family beliefs, and to help empower families to achieve their goals. The therapist’s use of spontaneous reflections, curiosity, and imagination is also discussed in this chapter.

Chapters 3 and 4 will present a wide range of therapeutic techniques and strategies for the self-harming adolescent and her family to experiment with both in and out of therapy sessions. Case

examples are provided throughout both chapters.

In Chapter 5, I discuss a variety of ways to help disentangle larger- system-knot situations that often occur with self-harming cases. Guidelines for how to foster cooperative and successful collaborative relationships with involved helping professionals from larger systems and the concerned members of families’ social networks will be covered.

The one-person family therapy approach is described in chapter 6. I discuss how this is a viable therapeutic option with older adolescents wishing to address their family or individual issues alone, in case situations where conjoint family therapy proves to be counterproductive or the parents are reluctant to participate in family therapy, and when one or both parents’ undisclosed individual or marital issues greatly contribute to the maintenance of the adolescent’s self-harming behavior.

Chapter 7 presents a variety of individual and family solution-enhancement strategies to minimize the likelihood of client slips. Several goal-maintenance techniques are discussed.

The eight-session stress-busters leadership group, specifically designed for self-harming adolescents, is presented in chapter 8. This skill-building group combines solution-focused, narrative, and cognitive-behavioral therapy ideas with experiential, art-therapy, and meditation techniques.

Chapter 9 summarizes the major themes of the book and offers some implications for future clinical work and research with self-harming adolescents and their families.

About the Author –

Matthew D. Selekman, MSW, LCSW, is a family therapist in private practice and the co-director of Partners for Collaborative Solutions, an international family therapy training and consulting practice. He is the author of Pathways to Change: Brief Therapy with Difficult Adolescents (Second Edition), Solution-Focused Therapy with Children: Harnessing Family Strengths for Systemic Change, and Family Therapy Approaches with Adolescent Substance Abusers.

ISBN: 0-393-70499-8