Some teens suffering with emotion dysregulation problems engage in extreme behaviors involving suicidality, self-injury behaviors, restrictive eating, bingeing, lying, stealing, or experimenting with substances or sexual activity. The purpose of this appendix is to give you a general idea of what to do about these types of problematic situations.
In all these cases, asking for professional guidance is your best course of action. Keep in mind that all these problems are beyond the scope of the ACT parenting tools you have learned in this book; they require help from a mental health provider who works with emotion dysregulation problems. A specialist will come up with recommendations and a plan for you to handle your teen’s extreme behaviors; this is not something you can address on your own at home. These types of problematic behaviors require a thorough assessment, close monitoring, and specialized parenting responses.
Your teen’s struggles, whether they involve problematic eating behaviors, alcohol, lying, or suicidal threats, are driven and activated by different sources. However, the uncomfortable, painful emotions your teen is going through and the thoughts or images associated with them are a very common source for all these behaviors. Because your teen suffers with emotional sensitivity, he experiences his emotions at a more intense level than you and I do, as if he had an open wound; he feels anything and everything intensely, and a triggering situation is like salt added to the wound. Therefore, when his emotional switch goes on, he experiences sadness, anxiety, frustration, or another emotion at a maximum level. Then, from that place of emotional sensitivity, he uses a broad range of avoidance strategies, such as thinking about suicide, engaging in self-harm behaviors, overeating or restrictive eating, or smoking marijuana, to name a few emotional avoidance strategies whose purpose is to reduce or turn down the emotional experience. Here is the outcome: your teen’s responses work in the short term, but they’re not sustainable in the long term, as you may already imagine.
From an ACT point of view, all of your teen’s ineffective behaviors are driven by experiential avoidance. Let’s briefly go over each one of these problems.
According to Ross and Heath (2002), in a typical high school in the United States, 14 percent of teens report self-injury at a given time; 12 percent of college students experience self-injurious behaviors. As you can see, parasuicidal behaviors happen often, and many teens struggling with emotional sensitivity struggle with not only parasuicidal but also suicidal behaviors.
Let’s start by distinguishing between these two behaviors. Suicidal behavior refers specifically to a teen’s action with the ultimate goal of ending life and a clear intention to die. Parasuicidal, self-injury, or self-harm behaviors, on the other hand, are actions to harm the body in a nonfatal way in response to painful emotional struggles, and they take different forms, such as cutting, burning, picking, or even head banging. Basically, the distinction between these two behaviors is based on the intention or purpose of the behavior on the teen’s part.
This distinction is extremely important, since you may be confused at times about your teen’s behavior and don’t know how to respond to it. Sarah’s daughter, Luciana, has been cutting her wrists for the last three months and wears long-sleeve shirts, so no one can see her scars; Sarah only noticed them during breakfast time when Luciana was wearing her PJs. Sarah’s mind quickly had the thought Luciana is killing herself slowly. She just wants to die. Is she trying to punish me? How come I didn’t see this before? I should have known how serious her depression was. Although it’s natural that Sarah’s mind comes up with all those thoughts, and it may appear that Luciana wants to die, the purpose of cutting is very different from wanting to die.
Most teenagers who engage in self-injury behaviors do so as a way to avoid their psychological struggles. In Luciana’s case, she started cutting after learning that her girlfriend’s family decided to move to a different state. Upon learning of this, she felt a wave of loneliness and fear, feelings that in her own words “are bigger than her”; she has been cutting whenever she thinks of her friend moving away and imagines what it will be like to spend the weekends alone or have lunch by herself at school.
The above scenario is just one situation that shows why a teen cuts or engages in self-harm behaviors; there could be many other reasons for a teen to cut, such as struggling with school, having fears about being misperceived by friends, memories of traumatic events, feelings of guilt, and so on. Each teen has a different driver of cutting behavior, but here are the two common denominators: your teen is in severe pain and is using an avoidance strategy.
Self-injury behaviors are quick avoidance strategies. It’s quite likely that when your teen experiences a very uncomfortable experience, such as a memory, thought, or emotion that is simply intolerable, he doesn’t know another way how to handle it—except making the pain go away by using any of these self-harm responses—even though the emotional discomfort he goes through may simply get bigger in the future.
Now if your teen has attempted suicide, clearly with the purpose of ending his life, it’s advisable to remove any means that he could use again for attempting suicide until you discuss this with a professional. This means removing any knives, pills, razors, or anything else your teen could use to hurt himself, from his room, the bathrooms, and the household as a whole. As soon as you find a therapist specialized in emotion dysregulation problems, then that provider will offer you specific guidance about how to respond to any other suicide attempt.
“If I cannot go out with my boyfriend this weekend, I’ll shave my head, and cut my wrists” is an example of a threat. When teens make different types of threats to their parents, it can be very challenging and painful for them. There is no easy response in that moment; if you respond to those threats, you may be augmenting an ineffective behavior, and if you don’t respond to those threats, you may still be augmenting other experiences your teen is goes through, such as feelings of loneliness or abandonment. It’s a catch-22 for you.
For instance, a client of mine used to make threats to her mother with the purpose of spending time with her. Every time this teen made a threat, her mother sat next to her and comforted her with caring words. Her mother encouraged and praised her and even talked about other matters. As you can see, the mother’s behavior was augmenting her daughter’s behavior of making threats; this realization only came out after conducting an assessment in a therapy session.
There is no single correct response, because teens make threats with different purposes, intentionally or not. Sometimes your teen makes a threat to get a specific response from you, such as leaving him alone, or when he’s trying to avoid doing something or avoid a situation, and without realizing it, your parenting behavior may be reinforcing your teen’s behavior. The purpose of your teen’s behaviors cannot be assumed as a rule every time he makes a threat, and that’s why the guidance of a mental health professional is necessary to give you insight into how to respond.
Teens suffering with emotion dysregulation problems may also be struggling with restrictive eating, bingeing, purging, anorexia, or bulimia. These behaviors may have started with what seems to be a natural concern of your teen with his body image and shape; however, these behaviors can easily become emotion management strategies and ultimately a disorder that can be fatal for your teen. Low food consumption and ongoing weight loss as it’s seen in anorexia can lead to death.
Teens are usually secretive with these behaviors and their attempts to manage them, because these behaviors are usually associated with high levels of shame. It’s a very common reaction for parents I work with to nag their teens about their eating patterns, which is understandable but not helpful.
If you’re concerned about your teen’s eating patterns, here is what you can do: pay attention to specific cues, such as loss of weight, how often your teen refuses to eat during meal times, fasts, or excessively exercises. Making an appointment with a pediatrician is recommended as a starting point. Get a blood test and a general medical checkup to make sure your teen is safe.
Avoid nagging your teen about his eating behaviors.
Moving forward, you will need the support of a team, including a mental health provider and a nutritionist, so you can receive appropriate coaching from specialists about how to handle these behaviors.
Experimentation with substances is common during adolescence. You may have also heard terms like substance dependence or substance abuse; regardless of the term, it’s important to keep in mind two things. First, experimentation with substances, regardless of the substance, could unfold as an emotion avoidance strategy. For instance, Remy smoked weed as a one-time thing at a party because he was curious about it. Later on, he got fearful about being seen as a fat kid by his classmates, to the point that even wearing baggy clothes to hide his body didn’t reduce his fear. He started smoking weed to manage his fears, and he quickly started to rely on it as an emotion avoidance strategy.
Second, using substances as an emotion management strategy could take on a life of its own. Teens struggling with emotional sensitivity feel everything, everywhere, any time, and because their struggle is extremely aversive for them, they will quickly do anything they can to reduce, suppress, or eliminate it. Unfortunately, the combination of drug consumption, withdrawal reactions, and vulnerability to intense emotions could lead them to organize their life around using more and more drugs. In situations like this, a detoxification program may be needed.
Some common interventions involve testing your teen, monitoring the friends he hangs out with, searching his room for substances and removing them, limiting his access to money, or setting a behavioral plan with specific consequences based on the amount and frequency of the substances he uses. The effectiveness of any of these interventions will vary from teen to teen, and therefore it’s important to consult with a therapist to come up with a specific plan to address this problem.
Even though you hear “good advice” from friends or relatives, this is not the time to experiment with your parental responses; without knowing it, you can make an extreme situation worse. Parenting is one thing, but parenting a teen with emotion dysregulation is a different story; everyone knows how to run, but running a marathon requires a different set of skills.
The trouble with listening to the advice of friends or relatives is that they do not always take into consideration the context in which a problematic behavior occurs, the driver of your teen’s problematic behavior, or the interaction between you and your teen presents itself. For instance, the advice of “making sure your teen apologizes to you for his behavior” seems very benign and appropriate; however, in context, what if when you get frustrated, you go into dictatorship mode and demand an apology because that was the advice given to you? Would you say that’s helpful advice? Does it help your relationship to show your teen that when you’re frustrated, you demand a specific response from others? How is your teen learning to handle frustration based on that interaction?
A mental health professional trained in emotion dysregulation problems will come up with specific recommendations that are consistent with the appropriate help your teen needs to receive.
Up to this point, you have read how ACT understands these complex problematic behaviors for your teen and how important it is to have specialized help from a mental health professional.
It is not easy for you, the parent, or for anyone in your shoes, to handle these types of situations, and naturally you may experience all types of reactions. Even though you have been open to learning all the ACT skills in this book, as well as additional ones, these particular problematic behaviors can be very hard to deal with and are an invitation to pause and check the impact of them on yourself.
Taking a breather and learning to take care of yourself in these moments is very important, since it gives you an opportunity to fuel, recharge, and to start again. Every moment is a new moment to start again.