This book has been re-issued in softcover under the title Working with Self-Harming Adolescents : A Collaborative, Strengths-Based Therapy Approach
Filling the gap in both the brief therapy and family therapy literature, Living on the Razor’s Edge breaks new ground by providing therapists with a practice-oriented guidebook for working with this rapidly growing and challenging treatment population. Matthew Selekman presents an innovative and flexible client-informed solution-brief family therapy model for self-harming adolescents that integrates the best elements of solution-focused, narrative, postmodern, strategic, cognitive, and expressive therapy approaches with Native American healing methods and rituals. Numerous connection-building therapeutic experiments and rituals are presented for helping foster closer and more meaningful relationships between parents and adolescents. Many of the therapeutic techniques and strategies presented in this volume are empirically supported by research on adolescent development, protective factors of resilient children and adolescents, and treatment outcome studies. The book is packed with case examples and interview transcripts of culturally diverse clients. Selekman also demonstrates how to do one-person family therapy with adolescents where conjoint family work proved to be futile due to serious parental or marital difficulties, a lack of family support, or to better meet the developmental needs of older adolescents.
Since adolescent self-harming problems can be quite complex and often attract the involvement of many helping professionals from larger systems, Selekman provides a highly practical and comprehensive multisystemic family assessment framework to guide therapists in determining at what systems levels to target interventions. Another exciting feature of this book is Selekman’s Stress-Busters’ Leadership group. This 8-session skill-building psychoeducational group was specifically designed to meet the unique needs of self-harming adolescents and can be implemented in any school or treatment setting.
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’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.
Foreword by Bill O’ Hanlon
1. The Multisystemic Family Assessment Framework:
A Kaleidoscopic Method of Inquiry
2. Improvisational Systemic Interviewing: Crafting and Selecting Meaningful Questions
3. Cognitive Skills and Mood-Management Training: Changing Self-Defeating Thoughts and Promoting Self-Soothing
4. Changing the Family Dance: Solution-Oriented Therapeutic Experiments and Strategies
5. Untangling Family-Helping-System Knots: Facilitating Transformative Dialogues
6. Going at it Alone: One-Person Family Therapy
7. Riding the Waves of Change: Goal-Maintenance and Solution- Enhancement Strategies
8. The Stress-Busters’ Leadership Group
About the Author
Matthew D. Selekman, MSW, has a private practice and provides family therapy training and consultation in Evanston, IL. He is a member of the training faculty for the Institute for the Study of Therapeutic Change in Evanston, IL.