Non-suicidal self-injury is a perplexing clinical problem, often seen in adolescent-age girls and boys, and associated with serious health consequences. Common types of self-harming behavior include cutting and burning skin, usually beyond as single incident. Helping Teens Who Cut is a book that takes a detailed look at the causes of adolescent self-injury and its treatment with a relatively new approach called dialectical behavior therapy (DBT). The book was written primarily for parents but is an equally valuable resource for mental health professionals.
Michael Hollander, a clinical psychologist, gives parents a lot to think about, starting with the basic question, "Why do some people intentionally hurt themselves?" His answer is that in most cases, teenagers perform self-injury "to control the extremely painful and frightening experience of overwhelming emotions and/or to escape from an awful feeling of being numb and empty." His is a convincing explanation supported with reference to emotional dysregulation theory, neurobiology, and social learning principles. He adds further to this interpretation by including many narrative case illustrations of actual adolescent patients who talk about their reasons for engaging in self-harm.
Hollander is a devoted DBT practitioner. The treatment he recommends is a type of cognitive-behavioral therapy developed in the early 1990s and applied subsequently to numerous psychological disorders. In essence, DBT considers the relationship between cognitive influences (what we "think about" our actions) and clinical problems, with an emphasis on teaching adaptive replacement behaviors. A DBT therapist helps an adolescent learn to modulate and change painful emotions that are associated with self-injury, relying heavily on mindfulness philosophy, distress tolerance, and interpersonal skills training. Hollander explains that the standard outpatient protocol for DBT is weekly individual and group sessions, 24/7 telephone access to the therapist, and committed family involvement lasting a minimum of 6 months. He not only describes the essential elements of DBT but gives several examples of how it is implemented. With considerable insight he covers matters of assessment, confidentiality, between session progress monitoring, possible impediments to successful treatment, and the role of adjunct therapies. Because he wrote the book for parents, his explanation of DBT also includes many suggestions for families participating in therapy and tips for staying the course with a daughter or son in need of comprehensive treatment.
Helping Teens Who Cut succeeds on many levels. Hollander writes clearly, with conviction, and obvious clinical expertise. It is a book that works best by reading it cover to cover, although I suspect many parents may skip from one chapter to another is search of information that resonates most convincingly. I liked the text summaries in each chapter as a way to highlight "take home" points for parents who may struggle with some of the theoretical discourse. To the author's credit, the book has two instructive appendices, one that describes different therapeutic settings available to children and adolescents, and a second that discusses internet web sites related to self-injury.
While I am persuaded by DBT, and how it is presented in this book, it must be acknowledged that there is sparse research on its effectiveness with adolescent self-injury. More studies are needed to document the contribution of DBT to short-term and lasting improvement. The book includes a brief report of pre-DBT and post-DBT behavior changes of 42 patients that were treated by Hollander and his colleagues, outcomes that are promising and should promote more experimentally sophisticated research. Many young people and their families will benefit from this fine book and the future it portends.
© 2009 James K. Luiselli
James K. Luiselli, Ed.D., ABPP, BCBA is a psychologist affiliated with May Institute and a private-practice clinician. Among his publications are 6 books and over 200 journal articles. He reviews books for The New England Psychologist.