Efforts to stem a rise in the number of adolescents found to be engaging in self injury, especially cutting

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1 Schools Face the Teen Cutting Problem Efforts to stem a rise in the number of adolescents found to be engaging in self injury, especially cutting By DANA WECHSLER LINDEN Schools around the country have begun offering new classes and mental-health programs to help stem a sharp rise in the number of adolescents found to be engaging in self injury, especially cutting. School officials, from high school to elementary levels, are working with adolescent psychologists to train their mental-health staff and teachers to counsel at-risk teens and to educate all students in dealing with stressful emotions. A growing number of the programs are based on a treatment called dialectical behavior therapy, or DBT, which aims to help people regulate their emotions and teach skills for avoiding selfinjury when the urge arises. What is believed to be the first randomized, controlled study of DBT in self-injuring adolescents was published in October and showed the treatment significantly lowered the frequency of self-injury in 77 teens compared with other common therapies. One of the key mechanisms of action [in DBT] seems to be to give them replacement behaviors, says Alec Miller, clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine in New York and one of the authors of the DBT study, published in the Journal of the American Academy of Child & Adolescent Psychiatry. Dr. Miller, who with a colleague wrote a manual adapting DBT for adolescents, has consulted with a number of schools introducing DBT programs. TEEN CUTTING: MYTHS AND FACTS Myth: Cutting is a kind of suicide attempt. Fact: Cutting usually isn t intended to be life-ending. It is a coping mechanism used by young people who are stressed, overwhelmed or in emotional pain. It helps them manage their emotions and feel temporary relief. Myth: Self-injury is something girls do, not boys. Page 1 of 5

2 Fact: Therapists and school officials often see more self-injuring girls than boys, but it may be that girls are more willing to ask for help. In many research samples of self-injuring people, there is a small, or no, difference in the proportion of males versus females. Girls are more likely to cut; boys are more likely to hit or burn. Myth: Self-harm is a problem among teens but not younger children. Fact: In a sample of 665 youth surveyed for a 2012 paper in Pediatrics, 7.6% of third graders, 4% of sixth graders, and 12.7% of ninth graders reported engaging in non-suicidal self-injury. Self-harming behaviors included cutting, hitting and scratching. Myth: Self-injury is a problem among social misfits and struggling students. Fact: People who self-harm include excellent students and those who struggle; youth who have a hard time fitting in, as well as leaders with a wide circle of friends; and those from advantaged and disadvantaged backgrounds. Myth: People who cut are looking for attention. Fact: Most people who do it say cutting, while painful, makes them feel relief temporarily. Young people often do it secretly: In one study, nearly a quarter of adolescents who reported self-injuring said they were sure nobody knew or suspected. Some say the physical pain distracts them from emotional pain, or that it makes them feel more alive. Sources: Dr. Stephen Lewis, University of Guelph; Dr. Janis Whitlock, Cornell University; Self-Injury Outreach & Support; Pediatrics. School mental-health staff in Ardsley, N.Y., this year led weekly individual and group therapy sessions using DBT with about 40 selected students, from elementary through high school. Other school districts in Westchester County, where Ardsley is located, have begun similar programs. In Battle Ground, Wash., Maple Grove School is testing a class for all students in 6th to 8th grades called DBT Steps-A, which aims to help prevent teens from engaging in self harm. And Stamford, Conn. s three high schools, with about 4,700 students, plan in January to begin offering DBT classes for credit to students considered at risk. The schools social-work staff evaluate five to 10 teens a day for self-injury, both new and ongoing cases, says Joseph O Callaghan, department head for social work for the school district. People are asking the question, Why are we having so many kids with so much trouble? he says. Adolescent psychologists say there has been a sharp rise in recent years in the number of teens found to be engaging in self injury, mostly cutting, which usually involves using a sharp object such as a razor blade to inflict small cuts on the arms or elsewhere. The teens, both girls and boys, come from a variety of Page 2 of 5

3 socioeconomic backgrounds and include good students and struggling ones. Many have obvious emotional challenges while others appear outwardly to be thriving, says Dr. Stephen Lewis, associate professor of psychology and self-injury researcher at University of Guelph in Ontario. Social media posts that feature cutting sometimes draw curious adolescents who want to try it, in what psychologists call a social-contagion effect. More teens also appear to be admitting to the behavior, or telling adults about friends who do it, because cutting has lost some of the social stigma it once had. Experts say young people engage in non-suicidal self-injury as a way of dealing with stress, anxiety, shame and other negative emotions the physical pain gives them temporary relief from emotional pain. A widely discussed theory is that because many teens are connected to their peers through social media all evening, they never get a break from social pressures and other stressors of the school day. Without a chance to decompress at the end of the day, many teens don t adequately learn to regulate their emotions, an essential developmental skill, psychologists say. Cutting has become the unfortunate coping strategy of our youth in the 21st century, says Dr. Miller, of Albert Einstein College. In the past, teens often blew off steam in less self-destructive ways, such as talking with friends and family or unwinding in front of the TV, he says. Jennifer Curt was a successful student at her New Canaan, Conn., high school, keeping up a 4.0 gradepoint average while competing on sports teams and socializing with a wide circle of friends. At night when she got home, though, she would feel overwhelmed and depressed. One night after her parents went to bed, she went into her bathroom, pulled apart her razor and made a small cut in her left arm, deep enough to bleed a little but not too much. The pain, I didn t like at first, Ms. Curt recalls. But she found she felt mentally tougher each time she prepared to cut herself. And afterward, the pain distracted me from all of my feelings, and everything else, until I fell asleep. Soon she was cutting herself secretly every few nights, she says, feeling increasingly out of control and finding it impossible to stop. Ms. Curt, who after treatment hasn t cut herself in 3½ years, says she had to learn things other people seem to be born with how to deal with feelings as they arise. In the fall, she will be a junior at George Page 3 of 5

4 Washington University, in Washington, D.C., where she is active in a group called Students for Recovery to help others with addictions and mental health disorders. DBT EXPLAINED Dialectical behavior therapy, or DBT, has been used for borderline personality disorder, PTSD and other conditions. A recent randomized, controlled study found DBT helped to reduce the frequency of self-injury among teens. Here are some major components of DBT: Mindfulness: A central element of DBT, around which the other components revolve. Mindfulness is the practice of being fully aware and present in this moment. Emotion regulation: Recognizing and understanding negative emotions and learning how to change them. The aim is to be less vulnerable to negative emotions when they occur. Distress tolerance: How to tolerate emotional pain when it can t be changed. Distresstolerance skills are used to get through a crisis. Interpersonal effectiveness: Learning to ask for what you want, and say no to what you don t want, while maintaining your self-respect and good relationships with others. Sources: The Linehan Institute--Behavioral Tech; Dr. Blaise Aguirre, McLean Hospital. Most teens who engage in cutting do it just once or twice with no intention to commit suicide. Others who do it for longer usually outgrow it in their 20s. Still, the practice is dangerous. There is a possibility of infection, permanent scarring or a serious accident. And research, including a 2013 study published in the Journal of Adolescent Health, has found an association between cutting and an increased risk for suicide. There has been little data collected until recently on self-injury that wasn t suicidal in intent. Dr. Jennifer Muehlenkamp, an associate professor of psychology at the University of Wisconsin, Eau Claire, published a study in 2012 on the prevalence of non-suicidal self-injury in teens. Based on recent research, she calculated updated figures for The Wall Street Journal and found that 9% of U.S. adolescents reported self-injuring in the previous year, and nearly 20% said they had tried it at some point in the past. Some experts describe DBT as blending the strengths of traditional talk therapy, with its focus on helping patients understand and accept themselves, and cognitive behavioral therapy, which emphasizes changing Page 4 of 5

5 negative thinking. DBT also teaches skills to help reduce the intensity of emotions or to distract from the urge to do self-harm. Holding ice cubes, for example, is often recommended. Mairead Brown, who graduated last month from high school in Kenmore, Wash., was cutting herself in 9th and 10th grades. She wrote her college application essay about her DBT skills group, she says, because it s been the most influential experience of my life. I use the skills every day. If I reach the distress point, I say, oh, I know how to deal with this. Ms. Brown says the worst part about cutting was disappointing the people who loved her, which is why she sought help from a therapist. DBT group sessions at the Ardsley, N.Y., high school start with a mindfulness activity, says Dawn Catucci, the school s psychologist. For example, the students might spend a few minutes quietly focusing on the taste, smell and texture of a snack and then describe what they observed. They also practice how not to judge others, and themselves, so harshly. Richard Jones, school counselor at Maple Grove, the kindergarten-to-8th-grade school in Battle Ground, Wash., says he became interested in DBT after seven students in the district committed suicide a few years ago. The town s schools put in place a suicide-prevention program. He also contacted a psychologist at the University of Washington who was developing DBT Steps-A, for preventing cutting and other harmful behavior. The pilot curriculum, in use for two years at Maple Grove, is designed as 50-minute lesson plans to be taught as a graded class by general education teachers to train students in emotion regulation skills. Cutting is a way teens cope with their stress, and the DBT program helps students look at their own decision-making process, says Mr. Jones. I do not want to send them off to high school without skills for dealing with emotional distress, he says. Page 5 of 5