Rage and Client Self-Harm: An Interview with Angela Caldwell, LMFT

An interview with Angela Caldwell, LMFT on cutting and non-suicidal self-injury. Curt and Katie talk with Angela about the causes of self-harm, the mistakes therapists make in addressing self-harm as well as how to identify reasons behind this harmful coping mechanism and how to identify when suicidality is a risk. We also look at how rage within nice families can lead to self-injury.

It’s time to reimagine therapy and what it means to be a therapist. To support you as a whole person and a therapist, your hosts, Curt Widhalm and Katie Vernoy talk about how to approach the role of therapist in the modern age.

Transcript

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Interview with Angela Caldwell, LMFT

Angela Caldwell is a licensed Marriage and Family Therapist and Family Coach. She is the Founder and Director of the Self-Injury Institute, where her practice focuses on the treatment of self-injury from a family systems perspective, as well as the Caldwell Family Institute, where she offers out-of-the-box coaching for families that are looking for something other than therapy to help them reach their growth potential.

Angela is currently on the adjunct faculty for the MFT graduate program at California State University Northridge, where she teaches family systems theories and couples therapy. She has been teaching graduate students for over a decade at four different universities, and previously taught assessment for a large majority of her teaching career. She was selected by Antioch University to design a curriculum for a new Counselor Assessment class, and has offered consultation on assessments for the last eight years.

Angela has served in MFT leadership for much of her career, including holding executive offices in CAMFT and AAMFT. She has worked side by side with Ben Caldwell and other leaders on various advocacy efforts in California, most notably on the passage of SB 1172, which banned reparative therapy for minors in 2012.

In this episode we talk about how to best treat client self-harm:

“It is a mistake to make the goal of therapy, stop cutting…Because non suicidal self injury is more broadly understood as a form of coping, that’s akin to making the goal of treatment stop crying, as opposed to understanding what you’re crying about. So in this case, understand what you’re cutting about, addressing that, making that the goal of therapy, and then what you do is you render the self injury unnecessary.” – Angela Caldwell, LMFT

• Angela’s perspective on family systems and champions of families and dinner tables
• The mistakes in treatment planning and way of being related to self-injury
• What not to do when clients disclose self-harm
• The intrusive nature of liability-focused treatment planning and interventions in the room
• The need to render cutting irrelevant
• The role of the family treatment for addressing self-injury
• Non-suicidal self-injury versus suicidal self-injury (the difference is intent)
• “It’s important for therapists to be able to talk about suicide – to use the word suicide with the same emphasis that we use the word hamburger.” Angela Caldwell, LMFT
• It’s important to be direct in asking about intent
• “I’m cautious to link self-injury with suicide in such a short, abrupt way.” Angela Caldwell, LMFT
• Rage in families who are too nice leading to self-injury
• The profiles in non-suicidal self-injury: peer-based and rage-based
• Social media self-injury and mental illness competitions
• How rage is often misunderstood – looking at how rage and anger are very different
• Rage is animalistic and limbic

“We have a misunderstanding that rage is simply anger with the volume turned all the way up, rather than understanding that rage is actually a neurochemically different emotion. It’s a different secretion in our brains. Rage is limbic, as opposed to anger, which is cortical, and that’s a fancy way of saying: anger you’re still rational…Rage is animalistic, limbic, the blood vessels and heart kind of feels the same in those two emotions, but the brain functioning and the urge is different. The urge in anger is pro-social, is to approach. And the urge of rage is to destroy, tear apart, punch a hole in the wall. It’s destructive. Self injury is rage.” – Angela Caldwell, LMFT

• Self-injury is rage (when anger is not useful) when you do not want to be a burden
• Rage comes with tactile stimulus seeking, seeking destruction
• Discovery is mortifying
• The problem with group treatment for cutting
• The contagion factor – Barent Walsh
• Co-rumination – looking at adolescent female relationships
• Family Therapy as the most effective treatment for non-
• Rewrite the family constitution around anger and anger expression
• Family assertiveness training, teaching families how to disagree and hurt each other’s feelings
• Angela’s strategy to provoke fights within the families that she sees and conducts repair

Resources for Modern Therapists mentioned in this Podcast Episode:

We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!

Self-injury Institute (Now Caldwell Family Institute)

Barent Walsh, PhD

Relevant Episodes:

Preventing Client Suicide

When Clients Die

 

Meet the Hosts: Curt Widhalm & Katie Vernoy

Curt Widhalm, LMFT

Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, the CFO of the California Association of Marriage and Family Therapists, an Adjunct Professor at Pepperdine University, a former Subject Matter Expert for the California Board of Behavioral Sciences, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com.

Katie Vernoy, LMFT

Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant. As a helping professional for two decades, she’s navigated the ups and downs of our unique line of work. She’s run her own solo therapy practice, designed innovative clinical programs, built and managed large, thriving teams of service providers, and consulted hundreds of helping professionals on how to build meaningful AND sustainable practices. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more about Katie at: http://www.katievernoy.com.

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Modern Therapist’s Survival Guide Creative Credits:

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Music by Crystal Grooms Mangano https://groomsymusic.com/

 

Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):

Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements).

… 0:00
(Opening Advertisement)

Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide, where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.

Curt Widhalm 0:15
Welcome back, modern therapists. This is the Modern Therapist’s Survival Guide. I’m Curt Widhalm with Katie Vernoy, and occasionally we talk about some of the issues that our clients bring into sessions, things that we might not get really prepared for in our normal therapist trainings and our grad schools. Sometimes these very special topics are very much at the cutting edge of things that we learn about, and to get to the point of things today, we are joined by Therapy Reimagined speaker. All I’m seeing is shaking heads from Katie and our guest. Our guest is Angela Caldwell. She is here to talk to us about self injury, and it’s one of our Therapy Reimagined conference speakers. We’re very excited to have her back this year, and she’s here to share all of her wisdom and expertise on working with cutting and non suicidal self injury. Thank you very much for spending some time with us today.

Angela Caldwell 1:18
Thank you for having me and for all the puns.

Katie Vernoy 1:24
We’re so glad to have you. You’re a friend of the show, for sure, and you did an awesome job at our conference last year, and we’re so glad to feature you this year. The first question that we ask all of our guests is, who are you and what are you putting out into the world?

Angela Caldwell 1:38
Yeah, I love that you guys asked that question. It’s that is great, reflective, introspective question. So here’s my answer. I have changed across my, the span of my career so far. I came in, I think I came in like most therapists. I wanted to, I wanted to be a therapist, I wanted to help people. I wanted to, I wanted to have a specialty. I didn’t want to be a generalist, and so my specialization in self injury was how I started, and that’s how I built my reputation. It’s how I built my business. It’s how most other therapists, my friends, it’s how they know me, it’s how I get referrals, and it’s a population that is always dear to my heart. But I would say, over the past three years, there has been a shift in what I am interested in putting out into the world. And so I’ve gone backwards. I think, I think some therapists go from being generalists to specializing, and I feel myself going from specialization to generalized. Most people who know me know that I am absolutely a champion of family systems therapy, and that’s become, that’s become my joy and happiness now. And you know, past three to five years or so. Now I’m looking at my clientele, and there’s the percentage changed so it used to be mostly non suicidal, self injury, some garden variety family therapy, and now it’s mostly garden variety family therapy and some self injury. It doesn’t mean that I don’t still love that population, and it doesn’t mean I want to talk about it all day long with you guys today. But what I’m putting out in the world is I want to, I want to add my voice to the champions of families, the champions of dinner tables. I want to build dinner tables. I want families to get along. I want families to find their way back to each other. I don’t want to, I don’t want to, there’s, there’s a small movement. I don’t know you guys, tell me what you think. There’s a little movement. It feels like of therapists who are interested in severing family ties because they’re identifying family members as being toxic, and you have to remove the toxic people from your lives. I want to move against that Curt. I want to say, let’s not remove family members from families. Let’s, let’s patch families back up and sew them back together. So what did I just say? I think I’m selling dinner tables.

Curt Widhalm 4:01
Jumping right into it, when, when therapists are faced with clients who are engaging in self injury, what are some of the mistakes that a lot of therapists make early on? That if we’re going to use this as a learning place, like, how do therapists usually approach this in an incorrect way, so that way, we can help our listeners not make those same mistakes.

Angela Caldwell 4:25
So two mistakes come to mind right off the bat, and the first is in the treatment planning, and the second is in the way of being in the room. So the first mistake, I would say, is the goal. It is a mistake to make the goal of therapy, stop cutting.

Katie Vernoy 4:41
Okay.

Angela Caldwell 4:42
And then in the way of being it is a mistake, hold on to your hats and glasses to take it so seriously. So in the treatment planning side, it’s understandable. It’s understandable that a therapist, especially somebody who’s not as familiar with this, would want to, that seems like a reasonable goal. Somebody comes in and says, I’m cutting a lot, which is not usually how it happens. Somebody comes in and what they say is, my mom thinks I should be in therapy, or my boyfriend thinks I should be in therapy, and cutting is a problem, or burning is a problem, or carving is a problem. And so the therapist reasonably thinks, Okay, well then let’s help you stop cutting, or stop carving, or whatever it is. Because non suicidal self injury is more broadly understood as a form of coping, that’s akin to making the goal of treatment stop crying, as opposed to understanding what you’re crying about. So in this case, understand what you’re cutting about, addressing that, making that the goal of therapy, and then what you do is you render the self injury unnecessary. In the way of being again, understandably, a lot of therapists approach this with their own anxiety, and that makes them put a gravity to the topic, that that exacerbates the problem, and it makes a therapist, it’s hard, it’s a weird thing for me to say, but the elephant in the room would be the cutting and I want you to kind of let it be an elephant in the room. I always tell people in my therapy with self injurers, I’m hardly ever talking about self injury.

Katie Vernoy 6:09
That makes me feel so much better. Because I think it’s something where, you know, there’s, well, there’s a few things there. The first one is making a goal of not cutting is like…

Curt Widhalm 6:23
It’s symptom reduction.

Katie Vernoy 6:25
It’s symptom reduction, but it’s also removing something without putting something in its place. And I think that’s the thing that I find really hard with trying to change coping, whether it’s smoking or cutting or drinking or whatever, if there’s not a replacement, then you just have a person in pain with no mechanism to soothe themselves. And so to me, I think a lot of times, and I think about this when I was in community mental health, but that notion of like liability being the issue, and so we have to show that we are trying to get them to stop hurting themselves. It’s like, okay, and maybe that’s what the paperwork says. But like, are you cutting this week? Let me see your arms, like, whatever it is, like, it feels so intrusive and overwhelming, and from what you’re saying, potentially irrelevant. It’s, it’s the type of coping strategy. And I’m sure you’re gonna go into more detail, and I’m over simplifiing, but it’s the type of coping strategy. That’s not the treatment, the treatment is getting to, what, the what, what’s there. But the other part is like, don’t be so focused on I mean, they go hand in hand, right? Because if your, if your treatment goal is to do it, is to stop doing it, then you’re going to have to check it and talk about it all the time. Whereas, if the treatment goal is more around what…

Angela Caldwell 7:43
Rendering it unnecessary.

Katie Vernoy 7:45
Rendering it unnecessary, then, of course, you can relax into it, which, for me, it feels a lot better. So.

Angela Caldwell 7:51
I love what you just said. If I could record that speech, because the other thing you’re up against, it’s not, I think the greener therapists are concerned about liability. Once you get over that hurdle, the other thing you’re up against is parents, because this is a population that’s presenting usually around teenage hood, and if not the other teenage hood, early 20s, right? And there, there’s, there’s a family member that that is understandably very upset about the cutting, very upset about the burning, and they very much want that to be the focus of treatment. So you’re up again, you’ve got an opponent there, in a way, with a parent or a concerned loved one. And it’s that speech that you just gave is, is what I tell parents is, hey, listen, we can’t make that the focus, because if I take that away, I’m taking away the only oar that he or she has in the paddle boat, right, like, then, then she’s going to crash, right? That doesn’t assuage them completely. It buys you about a week. So but if you can give a version of that speech every week, actually, now that I think about it, a lot of my treatment is reassurance with parents.

Curt Widhalm 8:55
Which, you know, has that natural, I guess, extension into the family therapy work that you’re talking about at the beginning. But I imagine that part of this discussion too is really also differentiating between the non suicidal self injury and self injury that does come with suicide. And I know suicides being a big focus of a lot of the discussions around mental health right now, and a lot of the trainings focusing on it. It’s a topic that we visited several times here on this show already. How do you go about assessing the differences between suicidal and non suicidal self injury?

Angela Caldwell 9:33
it’s one word you are looking for intent, so non suicidal self injurers lack intent to kill themselves. As a matter of fact, you see the contrary. What you, what you’ll hear in your office are stories about how the other night, I cut so deep, and it really scared me, so I had to wake my mom up. In fact, that’s sometimes how they end up in therapy in the first place. One time I burned so bad and it wasn’t healing that I actually called 911. Well, listen to what you’re hearing in those. Sessions, what you’re hearing is, oh, God, I might die. Not I think it’s time for me to die, right? So you guys probably have suicide experts that come on here that can walk through a comprehensive suicide assessment. All good therapists know that you should be assessing for suicide with all of your clients all of the time. It’s just that you do it in the back of your mind. The relationship between non suicidal self injury and suicidal self injury is, this is such an annoying answer. I hate when people say this. And I’m going to say it both simple and complex. I told you the simple part just now, the intent. Sometimes my students or my associates will say, but how do you how can you assess for intent? And that, as my husband likes to say there is such thing as a stupid question. Ask, ask what the intent was. I have this thing that I say that it’s important for therapists to be able to talk about suicide, to use the word suicide with the same emphasis that we use the word hamburger. We should be able to create a space in the room where it’s safe to talk about this. You get to bring all of those thoughts to me. You get to tell me about your ideas. And you get to, you don’t have you’re not going to scare me. You can change your mind. You can think that you want to kill yourself one day and not think you want to kill yourself the next day. Okay, so the simple part is intent and ask. How do you assess for intent? You ask, like, outright ask, there’s a lot of cool stuff that comes with being direct, with coming out and saying, okay, so what was happening there? Were you trying to die? What you do in that magical sentence is build rapport, you establish trust, you show that client you’re not afraid to talk about this. You’re not going to hold it against them. You want to know all the information. You’re not going to freak out. Okay, the complex part: parents will ask you, and principals and psychiatrists will ask you some version of this question, “Is self injury a gateway drug to suicide,” right? So, and it’s you get why they’re asking that. This is a scary thing for loved ones to see. And the answer to that is, and I’ll tell therapists, it’s it’s a trickier thing to talk about with parents and loved ones, of course, but not because it’s self injury, because any emotional distress is a gateway to suicide, right? Because eating disorder can lead to suicide or substance abuse can lead to sue. It’s not that the action, in fact, that’s not even a correct sentence. The eating disorder isn’t leading to suicide. The self injury isn’t leading to suicide. All of those are ways to cope with something that is going unresolved, and if that thing continues to be unresolved, then yes, you are looking at a suicide risk. Of course you are. There’s a there’s a problem in the way that it’s being researched. Not the researchers fault, the way that we’re consuming the research on it, in terms of correlation. And you guys are familiar with the causation versus correlation problem?

Katie Vernoy 12:55
Yes.

Angela Caldwell 12:57
Anytime we establish a correlation in the literature, all of us, I’m even guilty of this, all of us want to jump to a causation. Of course, we do. We’re human beings. We are creatures that want to be able to explain and predict our environments. When you when you actually do a deep dive into the databases, what you will find is a strong correlation between non suicidal self injury and suicide attempts. A, we don’t want to mistake that for causation and B, slow down. Also do a deep dive into the correlation between substance abuse and suicide attempt, divorce and suicide attempt, grief and suicide attempt, right? There’s the problem with that discussion is the way that we take it in, not so much how it’s being researched, right? The researcher is doing a great job. But the way that we’re taking it in is, if she’s cutting she’s probably going to commit suicide. Okay, that’s a problematic statement for all the reasons I just described. The reason I can forgive people for making that mistake is because of what it is. Unlike an eating disorder, unlike general depression, unlike a divorce, self injury, a lot of times, in fact, most of the times happens on the arm, usually nearby the risk wrist, and usually with some kind of blade. So it sure looks a lot like what we see in suicide. So I can, I can, I can forgive and understand why people get freaked out about that idea. That was a big speech.

… 14:24
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Katie Vernoy 14:27
I was just, I was thinking about kind of this idea of correlation versus causation. And I think there’s, I think there’s a lot of folks who get, they tell themselves a story. And so one of the stories I think I’ve told myself in the past is that sometimes self injury is coping, and sometimes it’s practicing. And I think that story of it being practicing, I think, is what kind of flows in with this causation. How far off am I? Because is the question from your from your understanding of it.

Angela Caldwell 15:04
That, so we’ve got a couple of researchers that are, you know, taking the lead on that. That’s the question, I think they are trying to answer, and they don’t have an answer for that. The most important researcher we have here is a guy named Matthew Nock. I mean, if you look at what he’s been writing, he’s, he’s trying to answer that question. So the bad news, Katie is we don’t know. I will say that anecdotally, and so I’m looking at my years of practice, and I’m, how many is that? My very first case was my very was my very first? Like our number one of 3000 hours was self injury. So I’ve been doing this for 15 or 16 years. I have not seen practice. I have seen coping and I have seen cry for help. That’s what I’ve seen there. It’s not to say that I’ve never seen suicidal ideation, even suicidal gesture in my office. It’s just that it’s, I’m cautious, to link self injury with suicide, so in such a short, abrupt way.

Curt Widhalm 16:03
You talked about the need to address what’s going on underneath the self harm as being the key to treatment here, and in looking at that, what are kind of some of the times that we see self harm as an expression of a deeper symptomology. Like, get us to this, get us to this, nuts and bolts of like, why do people…

Angela Caldwell 16:27
Why are they doing it?

Curt Widhalm 16:28
Why if it’s not suicide? Why is it?

Angela Caldwell 16:31
Yeah, okay, so my favorite question. You know, it’s funny. I wanted to give this talk. I submitted an abstract to this conference once, and it got turned down because it wasn’t what they were looking… oh, wait a minute, that was you guys. It wasn’t what they were looking for at the time. But I actually wanted to give, and someday somebody will let me give a talk about one of the causations. Is that a word? One of the causes? I wanted to give a talk entitled ‘Rage in the family, the problem with really, really nice families.’

Katie Vernoy 17:02
So wait we turn that down? That sounds amazing.

Angela Caldwell 17:08
Katie, I’m going to send it to you next time. This is going to seem overly simplified, and I guess I’m sorry for that. I want you to go with me down an over simplified path. There are two things that are at the core of self injurers, or excuse me, non suicidal self injury, and that is, we, we talk about that in terms of profiles. There’s two profiles. One profile we call the rage based profile, and the other one we call the peer based profile. We used to call it the attention seeking, and that was frowned upon. We don’t want to use that. Therapists punched me in the face for using that term. So we change it to peer based self, non suicidal, self injury. So in the first case, Nah, let’s do the second one. It’s easier. In the second case, the peer based one, if you have ever heard, there’s this software called Facebook, and there’s another one called Instagram. I imagine you’re familiar.

Katie Vernoy 18:00
We’re familiar.

Angela Caldwell 18:03
And there’s like, YouTube insta talk, you know, there’s like, whatever. I’m new to the world wide web. So, okay, come on, any any therapist in the world is aware that we have an issue on social media, with younger, with kids, and then the younger, the older kids, right? The 20s, mid 20s. There is an epidemic in my little corner of the field, and there has been for years now of us getting calls from parents. My kids started cutting, or a best friend found out and called the principal, and the principal, and the principals send them, you know, sending them to us because they heard that their friend was cutting over Instagram or Facebook. And what’s happening is they’re taking pictures of their cuts or their burns or the words that they carved into their arm, and they’re posting them. They’re broadcasting them on social media, okay? This is different from when we grew up, us geezers, right? Because it was an unknown idea. It was no nobody knows what the prevalence was when we were, you know, we were coming up. It was certainly more surprising to people, because there wasn’t some avenue to be able to broadcast it to everybody. So when I first started this specialization, check this out, most of the people when they tell when I said, How did you learn about this? What? How did you start this? And most of them, it was an accident. So a great example of that is: I had somebody who was telling me the story of the very first time she cut herself accidentally, and she was doing dishes, and her mother was berating her and screaming these awful things in a drunken rage at her, and she was getting this big headache, and she was having a panic attack, and she the dish that she was washing broke, and it cut her hand, and her panic disappeared, and her headache disappeared, and that’s how she discovered self injury. So it was stories like that that I was hearing in the early days, and now the stories you hear. I saw it on Instagram. I saw it on Facebook, right? It, there’s a self injury has taken on a little bit of a social currency, because now I say, now you guys have to check me on that. Did we do this? Maybe, did all generations do this? I’m going to say now and then you can correct me. There’s a contest going on to be the most fucked up.

Curt Widhalm 20:21
You can cuss. It’s the internet.

Angela Caldwell 20:25
Sorry, mom. Okay, there’s a beauty pageant, but it’s not a beauty pageant. It’s like a mental illness pageant going on right now, and it’s been going on for 10 years, and they are, they’re one up like they’re one upping each other in trying to be the most mentally ill. About three years ago there we found that there’s a new one, because for a while they were all cutting and then out cutting themselves. Now, do you know that? Now they’re all hearing voices, now they’re all psychotic. Now they’re out psychoticing each other. But it’s it really is, things like someone will cut their arms and put a picture of it on Instagram, and then it starts a whole thread that now someone else cut both of their arms. Well, I cut my legs well. And it’s like a it’s like a contest. Okay, so the treatment plan for that, roll your eyes. Don’t discuss it. Let them do it. Those are the cutters that are going to do it, like, three or four times and give up on it and assess to see if there’s actually a real problem that you can help with. Like, is there actually some other Is there a family issue? Is there depression, anxiety? Is there something else I can actually treat here? I’m gonna say on your podcast, don’t even treat it. It’s gonna go away after the fourth time. Ignore it. Leave it alone. Okay.

Curt Widhalm 21:32
Can direct those legal inquiries to Angela…

Angela Caldwell 21:42
We can have another podcast where we talk about how mad that is at me for the things that I say. Don’t say that! Okay, so the harder one, the harder one is the rage based. When we discuss rage, we have to talk about the difference between rage and anger. There’s a misunderstanding in our culture, not all cultures, but in ours, we have a misunderstanding that rage is simply anger with the volume turned all the way up, rather than understanding that rage is actually a neurochemically different emotion. It’s a different secretion in our brains. Rage is limbic, as opposed to anger, which is cortical, and that’s a fancy way of saying: anger you’re still rational. If you think about when you become angry with someone, I joke with my clients about this, have you ever noticed there’s a gift that anger brings, anger brings the gift of clarity. All of a sudden, if things were hazy before, now you know exactly who fucked you when they did it, and what you need them to do right now, right? And I’m a new parent. My kids are three and four, and I’m very in touch with how rational and cortical anger can be, because all of a sudden you were gesticulating. Very clearly you are enunciate. Put that down, right? It’s like all of a sudden the clouds have cleared. You can see exactly what’s happening. I would make an argument that anger is actually quite rational. You can, you can be in a debate. Anger fuels Black Lives Matter and the civil rights movement and feminism. Right? Anger is very clear and very rational and very logical. Rage is being cut off on the 405, right? Rage is animalistic, limbic, the blood vessels and heart kind of feels the same in those two emotions, but the brain functioning and the urge is different. The urgent anger is pro social is to approach, right? And the urge and rage is to destroy, tear apart, punch a hole in the wall. It’s destructive, right? Okay, self injury is rage. That’s that. Self injury is destructive. Self injury is the result, believe it or not, it’s the same emotion in a self injury in a not peer based, in a rage based episode. The emotion happening there is the same emotion that we know from being cut off on the 405. It’s this, it’s this animalistic, I can’t believe it comes from a place of injustice, of feeling completely invisible, completely unheard. And it’s it occurs because in a given situation, your anger is not useful to you. So go back to my freeway example. If you’re on the freeway in your car and somebody cuts you off, this is not a time that your anger would be useful to you. You can’t say, Hey, listen, I was here first. You need to get behind me so that the other guy has an opportunity to say, oh, you know what, I’m sorry about. That it’s not useful. Well, when, when your brain, your cortex, is aware that you cannot use the chemicals that it just secreted for you in anger, it’s going to lose its mind, and that’s a whole nother podcast episode of what’s going on there. But it’s going to lose its mind, and it’s going to start seeking. So the research that we have for this, this argument that I’m making, argues that rage comes with a stimulus seeking drive. I want you to think about how other people. Might seek stimulus. Other people might, if you happen to be, I don’t know someone like Angela Caldwell, you might be punching things like your steering wheel or throwing your iPhone against the wall and having to pay another $600 for a replacement. But things like that, like like when you think about stimulus, like banging your fist on the on the desk. If you think about when you have those moments of rage, those are you’re seeking destruction. Imagine what happens if you have that natural human emotion that we all have. Everybody has it, but you’re being raised in a really, really, really nice family, a really, really nice family whose governing rule, principal cardinal rule, is, Thou shalt not burden another human being. Well, we have a problem now, right? Yes, because if I punch something, it’s going to burden another human being. If I, if I put a hole in the wall, somebody’s going to have to buy some drywall or some plaster, right? If I break my phone, someone’s gonna have to buy a phone. I can’t break my mom’s dish. Those are her special dishes. I can’t go outside and scream. It’ll upset the neighbors. If you take away all of the places to vent, I should say, to seek and obtain tactile stimulus, you’re leaving something someone with only one possible option, and that’s their own body. It’s tricky, because when they do that, when they go after their own body, they’re able to have the serotonin secretion afterwards that, yes, admit it, we all have when we punch the steering, steering. I mean, your hand hurts, but you feel better. They feel better. They’re all going to tell you after they cut, they feel better, so they have that, but they also have been able to do it. They’ve been able to vent the rage and to feel better without breaking any rules, without upsetting anybody, without causing a burden to anybody else. So when they’re discovered and they go to therapy, they are mortified. It’s the last place they want to be, because the whole point was to cut on my own body so that it doesn’t cause a burden to anybody else. And all they’ll talk to you about in those first two or three sessions is how much money this is costing their mom and and how they really don’t want, if they really find and I have clients all the time telling me that they really should give their space up to somebody who really needs therapy. They’re, they’re, they’re insisting that they don’t need this. They’re insisting that they are. I make a joke. It’s maybe not a nice joke. The F word of cutters that they are fine. They are absolutely fine.

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Curt Widhalm 27:32
I know when I was first getting trained, so the very popular idea was, you know, around this attention or this peer seeking sort of cutting that, oh, these people need the attention that comes along with Let’s send them to groups. You laugh. I know from my experience of working with a ton of teenagers, this is a bad idea. From your perspective, why doesn’t group therapy work for teens engaging in self harm?

Angela Caldwell 28:07
I don’t have the right to have my own perspective. I have my own experience with it. It’s it’s Barent Walsh, who is the king of something called the contagion factor. And then I’m going to ask everybody who encounters this to do a deep dive into the research on something called co-rumination. This is a fascinating corner of literature that examines adolescent relationships, particularly female-female relationships, and how, yes, it increases bonding, but in female sometimes it increases depression because of this thing called co-rumination. Come on, Katie, you know what I’m talking about.

Katie Vernoy 28:41
It’s like this visceral thing. I’m like, Oh my gosh.

Angela Caldwell 28:44
Right?

Katie Vernoy 28:45
Those friends that you’re just like, Uhg.

Angela Caldwell 28:48
Uh huh, right? And I was, I mean, I was a pretty emo kid, like, I definitely remember sitting with my other emo girlfriend and and sitting and talking about how bad life is. And then she talked about how bad life was, and so I talked about how bad life we just got deeper and deeper and deeper and deeper and affected mood, affected energy level, affected my outlook and my attitude, you know. So, okay, so Curt, that’s one part of it. Is co-rumination, which is a fascinating part of our field. And then, like I said, Barent Walsh, he’s a PhD who’s been in the self injury field for, I think, decades before I showed up and his he’s got a focus in his research on something called contagion factor, and that is the probably what you see. It’s what most of us see. When you put teenagers in a group together, they one up each other, they cut harder, they cut deeper than the last one, and you get an epidemic in a matter of days.

Curt Widhalm 29:40
But I think that there’s also when you misidentify a person who starts from that rage perspective, the bearer of the family secrets, as being somebody who needs the attention end of it. Is now you’re throwing them into this very mortifying situation of, I didn’t want attention from one person now I’m supposed to have the attention of eight.

Angela Caldwell 30:02
Right. I feel like there should be a, like, the opposite of a PET team. Like, there should be a team that, like, removes you from those from, like, the psych wards, you know, like, get her out of there.

Katie Vernoy 30:13
So, so those are the things that don’t work. Like, we don’t want to do group therapy. We don’t want to focus on it. We want to make sure that we understand that it’s not the goal for treatment to get rid of non suicidal self injury. What does effective treatment actually look like? We’re running short on time. I want to get to the very practical. This is the survival guide for therapist’s portion. Like, what should therapists do that’s effective treatment?

Angela Caldwell 30:40
All right, guys, here it is. It’s easy family therapy. Just do it. And can I? Can I get mad on your podcast?

Katie Vernoy 30:45
Yes you can get very mad.

Angela Caldwell 30:46
I am so sick of the question, okay, what if you don’t have access to the family? Oh, my God. You have access to the family, unless they are in the ground. You have access to the family. Therapists are so scared of that the family’s gonna say no. I got news for you. All families say no. Do you want to go to family therapy, Katie? Do you want to go to family therapy, Curt? Nobody wants to do family therapy!

Katie Vernoy 31:09
No.

Angela Caldwell 31:09
Wake up! There is no such thing as the family that goes, You know what? We have a funky family dance, and we all need to change, Angela, so tell us how to do it. There’s no such thing, guys. Therapists, stop asking me that question, What if I don’t have access to the family? You have access to the family. All right, okay, I feel better now. See, that was great.

Katie Vernoy 31:31
There we go. No, I think it was anger, because she seemed very rational.

Angela Caldwell 31:34
Damn it. You’re right. That was if you ignored me, I would start punching the computer. That would be rage. Okay: Family Therapy. What kind of family therapy doesn’t matter. I happen to practice strategic and structural. You can do experiential you can do Bowen, the type of family therapy doesn’t matter, as long as your treatment goal is to rewrite the family constitution around anger and anger expression. What family therapy looks like with these kinds of family is more like assertiveness training. This is a family that is that engages in what we call careful talk. So the sessions feel very stifled and very stilted. The family members won’t, won’t speak directly, or they, or they’ll they’ll carefully dance around what they’re trying to say. It’s the it’s the opposite of what you guys know about me. They’re very indirect in their communications. So your your family therapy treatment plan is designed around relaxing fears that you’re going to hurt people’s feelings, help them realize, of course, you’re going to hurt people’s feelings. This is a family. I don’t know how to be in a family without hurting my family members feelings, right? But that’s okay. You can do that. For me in structural family therapy that is unbalancing, and enactment after enactment after enactment to help them rehearse that, to go ahead and get your feelings hurt and watch how easy this is to repair. I was saying before it’s, it looks a lot like assertiveness training. This, I think, is kind of, it becomes a little bit of a fine art, because you can tell someone to be assertive. That’s not therapy. They can read that in a book. You can model assertiveness, Okay, moving a little bit more toward therapy, but that’s you being assertive. It’s one thing for them to be, to watch a therapist do it, right? It’s another thing to actually get them to be assertive. All right. So here it comes. You provoke a fight, a fight in the family, and you do it session after session after session, and you unbalance and unbalance and unbalance. And you you what happens with all humans? If you make them mad enough, they’re gonna shout. They’re gonna say what they’re actually thinking and feeling. They’re gonna shout at you first because you’re safe. They don’t want to upset their family members. They have to get in the car in an hour with that family member. They’re going to shout at you first. You ready? Shout back. Have an argument with them. Have an argument with them and let them see, and as you’re having the argument, it’s almost like kind of having two games on at the same time. Have the argument with them and simultaneously say, Hey, we’re having an argument. I still like you. Keep going, right. And like, reassure them that this argument is not going to break our relationship. And then session after session get provoke fight, so that they have arguments with each other and conduct the repair in session, show them that that fight was not detrimental to their relationship. In fact, highlight the places and it has to be genuine, don’t make shit up, right? Highlight the places where that fight actually made them understand each other better, and they’re probably going to like each other better now. It’s actually going to bring them closer. It’s actually going to increase their bonding. That’s it. It’s called fight therapy, called Fight Club.

Curt Widhalm 34:46
Thank you so much for sharing all of your wisdom with us today. Where can people find out more about you and your practice?

Angela Caldwell 34:53
Okay, Curt, I know you’re going to ask me that, but you’ve caught me at a funny transition. It’s an exciting transition. So everybody can find me at my website, which is selfinjuryinstitute.com and my phone number and emails on there. We are just about, I don’t know when you’re gonna air the podcast, but in like two weeks, we are launching the new website, which is the caldwellfamilyinstitute.com so that’s, that’s, that’s us moving kind of from a specific self injury world to broader family coaching.

Curt Widhalm 35:22
And we will include links to that in our show notes. You can find those at our website, mtsgpodcast.com. Also check out the conference website, therapyreimagined conference.com. Angela is one of our fabulous speakers. She’s going to be bringing all of this energy and entertainment and information to us. It’s a virtual conference, September, 24th, 25th and 26th. I am super excited for Angela’s presentation. Our friends over at SimplePractice are helping us put this on, taking care of CEs and check out the website for all of the information around that. And until next time, I’m Curt Widhalm with Katie Vernoy and Angela Caldwell.

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