Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen. 

Cutting and other forms of self-harm are on the rise with teens as they self-injure to help cope with their emotional distress, anxiety and depression and the topic of self-harm is really a difficult one. It’s so hard to think of our teens injuring themselves intentionally. Today, we welcome Jennifer Leydecker back to our voices of compassion podcast to discuss Non-Suicidal Self-Injury or NSSI and what that looks like. Jen is a licensed marriage and family therapist and clinical program manager at CHC and works with teens every day. Welcome, Jen.

We’re so glad that Jennifer Leydecker is here with us today. She works with teens in our Intensive Outpatient Program and this topic of self-harm is one that she knows well because of the teens that she works with. So thank you for being with us today, Jen. 

Jennifer Leydecker, LMFT: I’m excited in some ways to talk about this topic because it is one that sometimes comes as a surprise to parents, and so I think this is a really important podcast for us to have and really relevant to the teens that I work with and have worked with for a long time in terms of self-harm and suicidal behaviors.

Cindy Lopez: Self-harm, or self-injury is part of this bigger category of what is called NSSI: Non-Suicidal Self-Injury. So let’s talk about that, what are we talking about when we talk about self-harm or self-injury?

Jennifer Leydecker, LMFT: So non-suicidal self injury is self-harm that’s done in the context and not related to a suicide attempt or a suicidal behavior. And so for a lot of the teens that I work with self-harm does look like a form of like cutting or scratching, but it can also be things like pinching their skin, other teens will pick to the point of like making themselves bleed or hair-pulling there’s kind of a overlap a little bit sometimes between self-harm and trichotillomania, and then also things like punching themselves or inflicting bruises on their body in different ways. So we’ve had self-harm present itself in a number of ways. Cutting is generally the most frequent for us as well.

Cindy Lopez: So Jen, you just mentioned trichotillomania, what is that?

Jennifer Leydecker, LMFT: That is a disorder generally related to anxiety where they’re pulling on their hair as a function of their anxiety. So it’s not related to generally the self-harming behaviors in that way, but we do have teens that pull hair as the function as the way to do self-harm, and I’ll probably talk about this a lot for us we look at the function of the behavior, especially coming from the DBT lens and so those two things are different sometimes for us.

Cindy Lopez: And DBT we’ll definitely be talking more about that, that’s dialectical behavioral therapy and that’s a very effective intervention for kids who are experiencing self-harm. So Jen, who self-injures, can you generalize that?

Jennifer Leydecker, LMFT: I think the most recent information that I was reading is that over kind of the lifespan about 15% of the population has engaged in self-harming behaviors. So we have younger children, pre-adolescents that engage in self-harm and then you have adolescents, which I think is why a lot of us associate self-harm with and then there are adults that engage in self-harming behaviors as well in terms of using them as coping strategies, or a way to kind of regulate their emotions.

Cindy Lopez: And I think you said this before that many adults who are self-harming now were as a teen. So as you said, coping mechanism for them. So that continues, they haven’t figured out a different way to cope yet.

Jennifer Leydecker, LMFT: Yeah, so sometimes the behavior will occur and start in adolescence and they continue that through into adult.

Cindy Lopez: Hm.

Jennifer Leydecker, LMFT: Without intervention or sometimes we use the term willingness a lot in DBT, without willingness and commitment to stopping that behavior.

Cindy Lopez: I can imagine as a professional working with these kids, like it’s really difficult to see them and hear them talk about why they’re doing it. What do you hear from students from teens about why they harm themselves in this way, and is it intentional?

Jennifer Leydecker, LMFT: It is intentional in that they are doing it to either regulate themselves when their emotions are really overwhelming. They’re feeling too much, and so it’s used in a way to kind of ground them in the moment. It also is a way for them to feel better when their emotions are too much and so there is kind of this like euphoria that can happen after and then there’s also the piece where the teens who are really numb and they’re not experiencing emotions, they’re not enjoying anything so that when the depression can be really significant, they use the self-harm as a way to experience some feeling. So it doesn’t always bring on an emotion, but it’s just feeling something in those moments where they feel really numb.

I think the other piece for some is that it can be done in a way that is kind of really quickly and so it’s done impulsively. They will kind of will just engage in the behavior in those moments where they feel out of control, and they’re able to use that to kind of gain control of a situation. Other teens will use it as a form of punishment and kind of look at it as a way to address feelings of shame or guilt that they’re experiencing for not meeting their expectations or the expectations of others.

There’s many different functions that we’ve heard from our teens, and a lot of times it really is an expression of all of that emotional pain and just coming out in different ways and so they engage in self harm to address that.

Cindy Lopez: Yeah and it’s interesting because as we’ve talked about this too, you’ve talked about it as a communicative behavior. It’s how they express how much pain they’re in, but it’s often very private, right? So that communication part of the behavior how does that happen when they’re trying to be really private about it or maybe that’s not the case with everyone.

Jennifer Leydecker, LMFT: Yeah I would say it’s definitely a mix in terms of the teens that we have worked with in RISE, our Intensive Outpatient Program, and so some of the teens, the self-harming behavior is really private. They’ve engaged in it for months, if not years before reporting it or someone noticing and identifying it as self harm and then referring them to us and other times the teens do use it as a communicative behavior. So it’s a representation to them of how much pain they are in, and they can show people that with the wounds on their skin and sometimes that’s done in ways that I think sometimes we hear the term like attention seeking  from parents or other peers like they’re showing their cuts and it’s really attention seeking so it’s posted on social media or things like that, and so we really look at it in that moment sometimes as it’s a cry for help, it’s an expression of this is what I’m experiencing and I just need somebody else to know and so for us, we come from a non-judgemental stance, and so it’s kind of like what are they needing in that moment and it sounds like they’re needing help, so how do we step in, and we support them with what they’re managing, which is a lot of emotion.

Cindy Lopez: We’ve also talked about how cutting can be a contagious behavior, right? So, can you talk about that contagion piece of this behavior?

Jennifer Leydecker, LMFT: Yeah it definitely is something that our teens experience through social media, or even the regular media shows and movies and things like that, that they’re watching. And so for some of our teens that are really struggling, they see that and think that works for them in terms of being able to manage their emotions or to cope with a really big events that they’re experiencing as a teenager and the kind of life altering moments that some of them go through at this time, and so, they’ll start the behavior. We have had teens who have tried self-harm and haven’t found that it worked for them, or it wasn’t something that was effective and it just hurt. So they didn’t continue that behavior and there are teens who have seen that it’s worked for their friends and then they start engaging in that behavior as well. So it’s something that we think about in terms of the group of teens that we put together at RISE in terms of our clients and then there’s a lot of research around the contagiousness of the self-harming behaviors.

Cindy Lopez: Yeah so for our listeners, Jen has mentioned RISE a couple of times, so RISE is our Intensive Outpatient Program at CHC, and we do that in partnership with Stanford. So, Jen, do you want to talk a little bit about that program? What does that involve?

Jennifer Leydecker, LMFT: So RISE our Intensive Outpatient Program, the teens are with us four days a week for three hours a day and we’re a comprehensive dialectical behavioral therapy based program. So we, use DBT, which is very skills-based and is the only evidence-based treatment for self-harming and suicidal adolescents. We use that as our treatment modality, and RISE has been open for almost four and a half years at this point, 5 years in May, um, and so we we’ve worked with a lot of teens that are engaging in self-harming and suicidal behaviors over that time.

Cindy Lopez: And so to our listeners, if you have a child or you know someone who you were thinking might be a good candidate for the RISE program, please reach out. You can find out more at chconline.org, connect with our care team, and they can help you with that.

So if I’m a parent and you know, I see stuff in the media, I hear about self-harming, I’m not necessarily seeing it in my child, as a parent what can I do to either prevent this from happening or become more aware of what’s happening with my own child?

Jennifer Leydecker, LMFT: I think in the way that we’ve talked about before in this podcast, and I know other providers at CHC have talked about in their podcasts as well is really being observant, and for us, it’s in a nonjudgmental way. And if you notice changes in your teen, coming with compassion and curiosity and asking them questions about how things are going. Sometimes just an organic conversation from like watching a show and noticing something and just kind of opening the door, wow that’s an interesting behavior or you know, I hear that self-harm comes up or I know some of the high schools will sometimes do different things around mental health and self-harm and suicidality and so kind of opening that door for the conversation to happen, and parents are going to have an emotional response to that because it’s about a child hurting and potentially their child hurting. And so kind of taking that deep breath before asking the question so that it’s a curious question. There isn’t that piece where the teen who might be experiencing that or might engage in that behavior, feel judged at the way that the question is asked, and I think that’s the piece that sometimes when parents ask or have made comments, the teen is very observant. Even as a parent, I think sometimes my daughter who’s nine doesn’t always pay attention and then she’ll say something later, I was like, oh, you were actually listening during that time and so really kind of knowing your teen is paying attention to you, even if they feel like they’re cooler than you. They’re keying in and so they’re paying attention to the way that you respond to different things, and so noticing that and allowing kind of that neutral question around that behavior to come out is really important.

Cindy Lopez: So can you give an example for parents of how to ask that question? What would that question be?

Jennifer Leydecker, LMFT: So seeing things on the media, like watching a show, there’ve been a couple of shows that have come out over the last couple of years that kind of addressed or showed self-harm very directly and explicitly and so you can start with, like, well, that’s something I didn’t realize teenagers engaged in. What do you think of that, right. So opening the door or just kind of asking, I’ve heard that they talk about this at school like you do know anybody that engages in that behavior or is it something that you’ve come across and that you might get an honest response. It just depends or it might just kind of open the door a little bit and so a couple of weeks later, they might come to you and start talking so it just plants a seed sometimes in that you’re engaging in open conversation and that can be really important for the teens.

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Cindy Lopez: So, we’ve talked about in the past building skills around emotional regulation in a healthy way, are we talking DBT kinds of skills?

Jennifer Leydecker, LMFT: We are talking DBT kinds of skills, and I think for us in DBT sometimes we are experiencing such a big emotion that putting together a coping plan and problem solving the emotion our brain is not working that way in the moment, right, so our amygdala has taken over. We are in full blown emotion mind and so the thing that we talk about with the teens, or we call them our crisis survival skills in DBT. So our distress tolerance skills are really integral because it’s the idea of tolerating that emotion to the point where you don’t make the situation worse. So it doesn’t fix the emotion all the time, it doesn’t make it better, sometimes it will decrease the emotion or it’ll decrease the distress in the moment and then you use the cognitive skills of emotion regulation that we have, but it’s really about making it through those really hard moments where emotions are driving the bus that you don’t crash.

You just kind of coast through that straight away and you make it to the end and those are simple things like just watching TV, watching your favorite show. We had a group of teens come through and where like Friends, which I grew up watching Friends, and so now to hear them talking about it, as their like go-to coping strategy or The Office was another one that a lot of our teens would watch and so it’s kind of distracting with other emotions like that. Horror movies also come up a lot. I am not a horror movie person, but that’s something that other people use, or just kind of leaving the situation sometimes can be really helpful in creating that space. Self-soothing is another DBT skill that a lot of our teens use and especially if they have pets, their pets are definitely both a distraction and something that is  soothing to them to cuddle up or just pet their animal, is really a key piece.

So we talk a lot about those types of things, and then I think the other piece that we sometimes kind of forget about are just our mindfulness skills. So the idea of just sometimes stopping and taking a couple deep breaths can really create that distance between the emotion and what’s prompting the emotion. And so, we’ll pull those in for some of our teens to where just taking some deep breaths, sometimes using other strategies that are really effective. Sometimes exercising through the stress is helpful. So some of our active teens will go for a run or they’ll do some jumping jacks. Those types of things can be really helpful.

Cindy Lopez: So when we talk about DBT, we talk about it as a very effective intervention for teens who are self-harming, but what makes DBT so effective?

Jennifer Leydecker, LMFT: Oh there’s so many things, but I think I go back to, especially with adolescents, in so many ways there’s this idea of feeling judged or feeling invalidated, and so as a therapist in DBT we come from a nonjudgmental stance as often as we possibly can, and we also balance our big dialectic that we talk about balancing all the time is change and acceptance and part of that acceptance is validation and so sitting with a teen and validating their emotion and their experience while recognizing the behavior isn’t something that we want them to continue, but just the experience that they had that prompted that self-harming behavior can be really important to them because they haven’t experienced that level of validation before.

The other piece, I think in terms of like the change side is we talk about what are the targets that we’re looking at, and we hone in on those self-harming behaviors and we have a skill for problem solving that we look at called a behavior chain analysis and this is something that we do in individual therapy quite often with our teens, and we essentially dissect an event of self-harm down to the second, and really look at all of the different components that contributed to that and then on the other side of that, we look at all of the ways that we can insert a skill or just any moment where we could have gone a different direction, and we go through that, and we practice those skills, and so I think it’s both of those things are really important in terms of really targeting that behavior and addressing it, and the other thing for us and in DBT is they have to want to stop and for some of our teens, that’s a really difficult place. It’s very scary when we ask them to stop self-harming because it’s been theirs and it’s worked, and so we talked through commitment and willingness to stop multiple times with them. Sometimes it’s every individual session at the beginning, and then they’re also able to call us, which I think for some of our teens is really helpful in that moment to reach out to someone that’s able to give them the support that they’re needing.

Cindy Lopez: So if I’m a parent and wondering about my own child, my teen, if there’s some self-harming behavior going on, what would I be observing in my child,, and how do parents find out if they can’t see it?

Jennifer Leydecker, LMFT: So self-harming behavior it’s a behavior related to emotional distress so that presents itself as depression, anxiety, in relation to trauma and so there going to be other pieces of the puzzle that are presenting itself maybe more so than the self-harm is. If it’s more depressive symptoms, then there might be kind of that piece of there’s a lot of difficulty with motivation, there’s a lot of sadness or irritability. If there’s a lot of anxiety it presents itself in different ways like panic attacks or just moments of being really dysregulated and not being able to calm themselves down and sometimes with trauma symptoms those things look the same too, and so I think in a lot of ways it’s working with a provider finding a therapist for your teen, if you’re noticing that they’re struggling.

I think the other piece sometimes is it’s hard to differentiate in some ways like what’s kind of that typical adolescent behavior where there’s that pushback, especially like, I think of our seniors that are just finishing up all of their college applications. That’s a big momentous moment for them, and so sometimes it gets really stressful and then you also have finals and all of these pieces of the puzzle, and so stress makes sense in that moment, but if you’re seeing kind of that prolonged response to that type of stress, then reaching out and trying to find a provider. I think one of the things that I have always found really helpful is that CHC we have the free consultations talking with a psychologist or a therapist, and I think that’s a really great resource for those parents who are kind of on the fence and trying to figure out like, I’m not really sure which direction to go, but I think that can be a really helpful resource in talking just with a mental health provider and getting some clarity from somebody that works with teens frequently.

Cindy Lopez: Yeah, thank you for bringing that up. To our listeners you can find out more about that too again by reaching out chconline.org and our care team, and it is a free 30-minute consultation. So you just come and talk about what’s going on and what your concerns are and then that mental health provider will give you some advice and some guidance regarding next steps. So, do teens with this self-harming behavior do they talk about it with their friends?

Jennifer Leydecker, LMFT: Sometimes, it depends. Sometimes the peers will know. We do have a lot of our teens that they come in and as we start kind of unpacking with them their experience, they’re also a primary support for another friend that’s very similar to them and just may not have the same sort of access to parents that understand and want to look into mental health, or they aren’t comfortable going to their parents and asking for support and so I think sometimes there is open discussion about self-harm, and they’re trying to actively be the therapist for one another and then other times teens will engage in self-harming behavior and not tell anyone, and I think a lot of times, the emotion that’s driving those pieces is there’s a lot of shame about the emotion or about that behavior and so that sometimes the pediatrician or a parent happens upon seeing the self-harming wounds and then it gets the ball rolling in terms of getting them access to treatment.

Cindy Lopez: So Jen, as we think about DBT, it’s a good, effective intervention for teens themselves. Can parents actually learn DBT skills and does that help?

Jennifer Leydecker, LMFT: Yes, so our Intensive Outpatient Program, and then a lot of the others in the area and then also the comprehensive DBT programs, which are just at a general outpatient level, the parents are part of that in terms of participating in the skills groups and learning the skills with their teens. And there’s also research that has shown if you have a teen who’s not willing to participate in therapy, where you set them up with a therapist, you take them in and they sit and stare at the person for forty-five minutes and aren’t willing to do the work, the parents can actually learn the DBT skills themselves, and that can help shift and reduce the behaviors that the teen is engaging in. It reduces the distress in the home when the parent begins using the skills as well, and so that’s a really important factor to consider if you’re finding that your teen might be unwilling for treatment and you’re recognizing that the families needing support. There are parents of DBT groups in the community that can do the same work. There’s also parent workbooks that are available online that teach the DBT skills as well.

Cindy Lopez: That’s a great cause I think that that’s empowering for parents if they feel helpless and their teen, isn’t talking to them or they don’t want to participate in any kind of therapy, it feels like, yeah, there is something I can do, and it’s pretty effective.

Jennifer Leydecker, LMFT: It is, and in RISE what we hear consistently from our parents is I wish I was taught this as a teenager and oh my god, it has made work so much easier some days because I can use my mindfulness skills and I can kind of ground myself or in our interpersonal effectiveness skills they’re able to advocate for themselves in a way that they haven’t previously felt that they needed to, or they have this really strong increase in their self-respect and will really hold limits with people. So yes, the parents show up for their teens and they walk away with a lot of skills that are relevant across all areas of their life.

Cindy Lopez: That’s great. So if I’m a parent, if I’m a friend of another teen, and I know something’s going on, or I suspect something’s going on in terms of self-harming behavior. What should I do?

Jennifer Leydecker, LMFT: So a lot of the schools in the area they have wellness teams, and a lot of resources around support and so reaching out to the counseling staff at the schools and talking with them about that you have this friend. When I worked at a school, I had peers who brought their friends to me to support them in getting the support from me that they were needing in that moment and accessing it that way. Other times, you have the friend who was really knowing that this teen is struggling and they tell their parent, and then that parent would reach out to the counseling staff, or they would reach out parent to parent directly and really try to support the teen in a way that they’re recognizing the whole system needs that support, and so we’ve had families who have gone through a lot of the different avenues, but really a great resource is the counselors onsite at the high schools and the middle schools in the area.

Cindy Lopez: Jen, so grateful to you for taking the time today, to chat with us about this topic, and it’s so important, but difficult to talk about. As we wrap this up, what do you really want our listeners to hear from you today?

Jennifer Leydecker, LMFT: The big piece with self-harm or the non-suicidal self-injury is that it is a significant behavior, and I think as a parent when you learn about that it’s very scary and recognizing that and talking that through before coming to your teen with that emotion. I think as we’ve talked about it, sometimes it’s very hidden and it has gone on for an extended amount of time, and we feel sometimes blindsided by learning that your teen is engaging in self-harm, and so  it’s coming to them in a supportive way, having some compassion, because they are experiencing some level of distress in in those moments that they’re engaging in self-harm and so recognizing that they’re struggling, validating that and seeing that the behavior represents something and going from there versus I think sometimes because we don’t understand the behavior, it’s one that I think still it has a lot of different stigma and connotation in the community that sometimes it’s met with anger or like, well just stop, why can’t you just stop? And so that judgment behind it, doesn’t totally get at the behavior and so finding support, I think is the really big piece for our teens and for our parents.

Cindy Lopez: You also use the term compassionate curiosity before and that’s a lot of what you’re saying, listen, observe, do it without judgment, just, be curious and compassionate about what they’re experiencing, 

Jennifer Leydecker, LMFT: Yeah, it’s really important.

Cindy Lopez: Jen, thank you so much for joining us today.

Jennifer Leydecker, LMFT: Thank you.

Cindy Lopez: And to our listeners thank you as well for joining us. Again, you can find out more about all of this, our RISE Intensive Outpatient Program, our DBT skills groups, we even have parent support groups that are free that you can access as well. You can find all about that [email protected].

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