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 Cutting Down

Cutting Down provides a practical and accessible treatment programme

based on Cognitive Behaviour Therapy (CBT) principles for young people
who self-harm.
This fully revised and updated second edition includes new tech-
niques from ‘third’ wave CBT, Acceptance Commitment Therapy (ACT)
and Dialectical Behaviour Therapy (DBT). This enriches the material and
brings the concepts up to date. Another key addition to this new edition
is the inclusion of strategies for young people who engage in suicidal
behaviour. The manual is evidence based and focuses on a flexible and
formulation driven model to direct treatment in around 15 sessions for
young people and six sessions for parents and caregivers. It provides a
clear structure for each session and an easy-to-follow outline on how the
therapist should deliver each session. The content of each session is sup-
ported by handouts and worksheets which can be used within sessions or
as homework between sessions.
Enhanced with online resources, the workbook will be useful for all
professionals working with young people who self-harm across a wide
range of settings from schools, primary care and voluntary sector, to
community mental health services and inpatient units.

Dr Lucy Taylor is a Consultant Clinical Psychologist working in inde-

pendent practice in Surrey. She has worked over 20 years in the NHS, includ-
ing jointly heading up the National & Specialist Child and Adolescent
Dialectical Behaviour Therapy (DBT) Service, Maudsley Hospital.

Dr Mima Simic is Consultant Child Adolescent Psychiatrist leading

the Maudsley Centre for Child and Adolescent Eating Disorders. She was
Consultant for the Community Adolescent Mental Health Team and National
& Specialist Child and Adolescent Dialectical Behaviour Therapy (DBT)
Service, Maudsley Hospital for nearly a decade. She has researched treatments
for self-harm in which she teaches and trains mental health professionals.

Ulrike Schmidt is Professor of Eating Disorders at King’s College

London and a Consultant Psychiatrist at the Maudsley Hospital. One key
focus of her research is on developing brief scalable psychological treat-
ments of value to the NHS, for people with eating disorders and other
common mental health problems, including self-harm.
Taylor & Francis
Taylor & Francis Group
http://taylorandfrancis.com
Cutting Down

■■ An Evidence-based CBT Workbook for Treating Young

People Who Self-harm

Second Edition

Lucy Taylor, Mima Simic and

Ulrike Schmidt
Cover image: © Getty Images
Second edition published 2023
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2023 Lucy Taylor, Mima Simic and Ulrike Schmidt
The right of Lucy Taylor, Mima Simic and Ulrike Schmidt to be
identified as authors of this work has been asserted in accordance with
sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other
means, now known or hereafter invented, including photocopying and
recording, or in any information storage or retrieval system, without
permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
First edition published by Routledge 2015
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record has been requested for this book
ISBN: 978-0-367-75580-5 (hbk)
ISBN: 978-0-367-75578-2 (pbk)
ISBN: 978-1-003-16304-6 (ebk)
DOI: 10.4324/9781003163046
Typeset in Stone Serif
by KnowledgeWorks Global Ltd.
Access the Support Material: www.routledge.com/9780367755805
Contents

ACKNOWLEDGEMENTS IX

Introduction1

Part One: What’s going on? Assessment,

psychoeducation, risk assessment and
safety planning  13

Session 1 Understanding self-harm

Module 1 What is self-harm and CBT for self-harm?15
Module 2 T he function of self-harm, introducing the virtual
characters and my timeline of self-harm  17
Module 3 Risk assessment protocol and safety plan19
Session handouts21
Session worksheets31

Session 2 Values, strengths and goals

Module 4 My strengths36
Module 5 Formulation – the start37
Module 6 Values, problems and goals39
Module 7 What is CBT?42
Module 8 Alternatives to self-harm43
Session handouts46
Session worksheets55

Session 3 Are you ready to make a change?

Module 9 Are you ready to make some changes?60
Module 10 Relationships65
Session handout68
Session worksheets69

v
C ontents

Part Two: Feelings, thoughts and behaviour75

Session 4 You and your feelings

Module 11 Getting to know your feelings79
Module 12 The function of emotions82
Session handout 85
Session worksheets86

Session 5 L inks between feelings, thoughts and

behaviours
Module 13 Emotions diary review and activity scheduling95
Module 14 The help triangle97
Module 15 Negative automatic thoughts (NATs)100
Session handouts103
Session worksheets107

Session 6 Dealing with thoughts

Module 16 T hought distortions, thought challenging
and thought records109
Module 17 Other strategies for dealing with thoughts113
Module 18 Self-critical thoughts116
Session handouts119
Session worksheets123

Session 7 Core beliefs and rules of living

Module 19 B  eyond the ‘help triangle’: core beliefs and
rules of living125
Session handout131

Session 8 Formulation of your journey

Module 20 Formulation133
Session handout138
Session worksheet139

Part Three: Coping strategies141

Session 9 The coping tree

Module 21 Review of formulation and the coping tree144
Module 22 Problem-solving146
Session handouts149
Session worksheet153

vi
 C ontents

Session 10 U
 nderstanding and managing fear
and distress
Module 23 Facing the situation157
Module 24 Psychoeducation: fight or flight160
Module 25 Cognitive strategies for anxiety162
Session handout 165
Session worksheets166

Session 11 Being mindful

Module 26 Being mindful: introduction to mindfulness171
Module 27 Urge surfing and riding the emotional wave177
Module 28 Self-soothing179
Session handouts181
Session worksheets184

Session 12 Managing emotions

Module 29 Managing your emotions188
Session handouts194

Session 13 Managing relationships

Module 30 Anger management199
Module 31 Assertiveness202
Session handout207
Session worksheets209

Session 14 Hopelessness
Module 32 Hopelessness217
Session handouts224
Session worksheet226

Part Four: On you go!227

Session 15 Ending therapy

Module 33 Reviewing goals 230
Module 34 Identifying triggers for self-harm and coping
strategies230
Module 35 Living in line with my values: revisiting
my values232
Module 36 Ending and my certificate233
Session handout236
Session worksheets238

v ii
C ontents

Part Five: Parent sessions241

Session 1 Psychoeducation 243

Session handouts 248

Session 2 Validation 249

Session handout 254
Session worksheet 259

Session 3 How to help 260

Session handout 266
Session worksheet 269

Session 4 Moving forward together 270

Session 5 Support with new skills 273

Session 6 Next steps 275

INDEX 277

v iii
 Acknowledgements

We would like to thank all those staff and young people who contributed
to the second edition of the manual. Our special gratitude to the group
of ‘wise minds’ who inspired us to develop the parent sessions – Professor
Dennis Ougrin, Dr Julian Baudinet, Dr Partha Banerjea and Dr Christy
Wellings. They all shared their expertise and insights from their ongo-
ing work with young people and families in their clinics. We offer our
thanks to assistant psychologist Megan Tongs, for her invaluable help
with editing the sessions, amending the worksheets and handouts and
giving feedback with the manuscript.
We would also like to acknowledge the specialists in the field to whom
we have referred throughout the book – in particular Marsha Linehan
and Russ Harris.
We offer special thanks to the young people who have worked hard
in both editions to illustrate the concepts and add their creativity and
input to the book.

ix
Taylor & Francis
Taylor & Francis Group
http://taylorandfrancis.com
 Introduction
Lucy Taylor, Mima Simic and Ulrike Schmidt

There has been a dramatic rise in self-harm over the last decade. Even
experienced therapists can find working with these young people dif-
ficult. Self-harm behaviours are widely defined as ‘causing deliberate
hurt to your own body’, i.e. it is something that a person does to him/
herself on purpose that injures or damages their body. (see NICE guide-
lines for information).1 We are including suicidal behaviours under the
umbrella term of self-harm, as the two often occur together and the bor-
der between them is fluid. There are specific exercises in the book that
work to elicit the function and intention of the behaviour, which can
guide the treatment plan. Based on Cognitive Behaviour Therapy (CBT),2
a highly effective method for working with emotional problems, Cutting
Down offers a practical and accessible programme for mental health
therapists from different professional backgrounds working with young
people who self-harm, or engage in suicidal behaviours. This manual is
aimed for a variety of presentations of self-harm including strategies for
young people with emerging borderline personality disorder, although
Dialectical Behaviour Therapy (DBT) is currently the best evidence-based
approach for this group of young people.3,4 The manual offers ideas taken
from the CBT, DBT, Acceptance and Commitment (ACT)5,6 and Radically
Open DBT (RO DBT)7 literature to work with self-destructive solutions to
intense emotions. Although the CBT elements of this book are rooted in
Beck’s Cognitive Model,8 it also draws on Gillian Butler’s work9 in aim-
ing to construct a ‘plausible account’ of the young person’s experiences.
Due to the nature of the young person’s problems, the book also takes
a trans-diagnostic approach within CBT: in other words, a form of CBT
that targets cognitive and behavioural processes common to a range of
underlying disorders and personality predispositions. It will allow you
to ‘move about’ the manual to target strategies from more traditional
CBT or draw on concepts from ACT, DBT and RO DBT, depending on the
young person, their story and thinking style.
The programme has been adapted since the first edition to com-
prise five parts, with the addition of a module for parents/carers. Note to

DOI: 10.4324/9781003163046-1 1
CUTTING DOWN

therapist: parent sessions will be used as a term throughout the manual,

but also includes carers. The parent module is designed to be offered
alongside the young person’s sessions and designed to be interwoven with
the work the young person is covering at the time. The parent sessions
start around young person’s session 4 in the manual. However, occasion-
ally therapists may need more time to encourage the young person or
parents/carers to join in the programme, and this is acceptable. There
are five parent/carer sessions, with an optional sixth but in line with the
flexibility of the book, their content and timing can be adjusted accord-
ing to the family you are working with.
Although, we know from research and experience that involving
parents/carers in the treatment plan is beneficial, if there is a lot of resist-
ance or animosity within the family, the therapist can use discretion and
flexibility as to how and when to involve others.

YOUNG PERSON SESSION PARTS

Part 1: What’s going on? Assessment, psychoeducation, risk assessment and safety planning
Part 2: Feelings, thoughts and behaviour
Part 3: Coping strategies
Part 4: On you go!

PART 5: PARENT SESSIONS

Understanding self-harm and behavioural reinforcements (coincides with the beginning of

young person part 2)
How to validate your child and self-validation
Working together to reduce SH (coincides with ending young person’s part 2)
Supporting your child with new skills (coincides with young person’s part 3)
Ending and forward planning (coincides with young people’s part 4)

As in the first edition, each of the four young person parts covers a spe-
cific stage of therapy, split into a total of 32 modules. Although designed
to be delivered over a course of 15 sessions, the programme is presented in
a way that allows the therapist to decide which combination of modules is
chosen and how long is spent on each, based on the clinical needs of the
person they are working with. Throughout the programme, virtual young
persons are used to illustrate the various exercises and strategies, including
their particular problems that led to self-harm (e.g., lack of assertiveness
or self-critical thoughts). Look to Handout 1.2: Real life stories –
virtual characters, for a snapshot of their stories. Part 1, What’s going
on? introduces self-harm and CBT and aims to help young people develop
insight into feelings, problems, goals and the concept of change. The sec-
ond edition focuses a little more on motivation for change to speak to
young people who feel very hopeless about life and are self-harming or

2
 INTRODUCTION

engaging in suicidal behaviours because they cannot begin to imagine

that things could ever change for the better. Part 2, Feelings, thoughts
and behaviour, looks at working on activities, managing depression or
low mood and identifying and managing negative thoughts. The second
edition has been adapted to include some strategies from different mod-
els that are described as ‘third wave’ CBT, e.g., ACT, DBT and Radically
Open Dialectical Behaviour Therapy (RO DBT). ACT originated by Steve
Hayes (see reference 5 for further reading) and, as Harris describes, aims
to ‘create a rich and meaningful life, while accepting the pain that life
inevitably brings’ (6). This therapy model teaches the young person addi-
tional ways to manage negative thoughts. The main components of ACT
include learning psychological skills to handle painful thoughts and feel-
ings effectively and to clarify what is important and meaningful to us, in
other words – our values; then to use that knowledge to set goals and act
in a direction that matters to us. DBT focuses interventions on teaching
clients who tend to get easily emotionally dysregulated, how to increase
skills in managing their distress, emotions and relationships while also
practicing mindfulness. RO DBT was developed for clients who inhibit
their emotional expression due to their persistent anxiety and harsh
self-judgements leading to difficulties in connecting with other people.
RO DBT promotes skills in changing client’s physiology to promote social
safety and more genuine emotional expression. All listed ‘third wave’ ther-
apies address issues of the client’s values as a part of their engagement and
motivation for change in treatment. Part 3, Coping strategies, introduces
modules on problem-solving, assertiveness, mindfulness and alternatives
to self-harm. Here we have added further ways to reduce distress, such
as basic emotional regulation strategies, and a section on hopelessness,
drawing on the radical openness model. Part 4, On you go!, finishes the
programme with a review of goals, identifying triggers and developing
a keeping well bag of skills to reinforce the programme. Downloadable
worksheets accompany the text.
This second edition includes a fifth part for parents and carers. The
sessions include relationship skills, supporting parents to validate their
young person, working together to help reduce self-harm and recognis-
ing how parents can contribute to recovery.

Who the programme is for and how to use it?

This book is designed for clinicians working with adolescents engaging in

self-harm and suicidal behaviours and their parents/caregivers, this unique
workbook is ideal for counsellors, counselling psychologists, clinical psy-
chologists, CBT therapists and child and adolescent mental health workers
and trainees, working in primary, secondary or tertiary care settings. The
authors recommend the programme to be used by professionals who have
some core CBT training. However, if this is not the case (and for general
good practice), it is important that anyone delivering the manual has reg-
ular supervision with a CBT trained professional. It is beyond the scope of

3
CUTTING DOWN

the book to explain therapy style questions and the basics behind the CBT
model. References are included for further reading.
The content was originally designed for one-to-one use, but the mate-
rials could translate to a group context as the skills are generic to common
maintenance factors in self-harm. The addition of suicidal behaviours in
edition 2 stemmed from the fact that some young people feel so depressed
or hopeless that they do not feel life can get any better.
From epidemiology studies, we know that at least a quarter of all ado-
lescents in the community engage in self-harm behaviour each year, with
indications from the literature that this has increased over time. The
need for effective treatments for young people who self-harm is evident.
The manual has already shown promising effectiveness. A pilot study
of using this book with adolescents seen in a community Child and
Adolescent Mental Health Service (CAMHS) setting, demonstrated sig-
nificant reductions in self-harm behaviour, low mood and anxiety after
eight to twelve sessions.10 Although the number of sessions was deemed
to be too low by the therapists, the positive results led to further devel-
opment of the manual and publication of this book. More recently, in
2019, the manual was used in another pilot study11 which compared the
Cutting Down manual with solution focused therapy and mentalisation
based therapy. The authors concluded that out of the treatments explored
in this study the manual-based CBT was the most promising treatment
for adolescents with self-harm referred to community mental health ser-
vices. A randomised controlled trial has been carried out in Germany,
which found that adolescents who were treated by clinicians using the
Cutting Down manual reduced the rate of non-suicidal self-harm faster,
compared to adolescents who had a significantly more intensive commu-
nity treatment (more sessions of mostly CBT).12 The authors suggested
that the Cutting Down manual could provide a brief, practical first line
treatment for adolescents in routine clinical care.
This book uses evidence-based strategies, in particular CBT, and is
based on a flexible and formulation driven model. Edition 2 also contains
a risk assessment and safety planning protocol and a parent package. It is
particularly suited to younger adolescents and young people with symp-
toms of depression and/or anxiety who might find it difficult to express
their feelings of vulnerability and suppress their emotions, referred to as
‘overcontrolled’ in RO DBT literature. The main aim of the book is to
help the young person understand the factors that serve to maintain their
problems and to teach them adaptive skills to address emotional difficul-
ties. Whilst the most common methods of self-harm in young people are
cutting and taking overdoses, this programme is designed to treat a broad
range of self-harm behaviours. Feedback from therapists and young peo-
ple who have used the manual has been positive and feedback from ther-
apists has led to the changes/extensions included in this second edition.
Therapists reported that they liked the ‘session-by-session’ structure and
have found the book particularly useful, as it addresses the majority of
problems traditionally associated with self-harm: for example, low mood,
anxiety, anger, lack of assertiveness and difficulties with problem-solving.

4
 INTRODUCTION

In other words, it has a trans-diagnostic approach which lends itself well

to individual formulations and tailored treatment. The young people
themselves reported that they liked the virtual young persons. They were
able to relate to some shared issues and found it useful to observe like-
minded young people ‘bringing’ their own problems to the session and
specific treatment strategies being illustrated. Sessions for parents/carers
were developed recognising the importance for parents of understanding
why a young person is self-harming, but also having in mind their crucial
role in supporting the young person to reduce self-harm and manage sui-
cidal urges. The aim of the new materials for parents/carers is also to help
parents to improve relationship with their child when negative familial
affect is maintaining the young person’s difficulties.
Essential elements for the development of the Cutting Down pro-
gramme have been identified through a comprehensive review of the
evidence based on treatment of self-harm and associated psychologi-
cal maintenance factors, such as depression, anxiety and hopelessness.
Another addition to this second edition is the discussion of values (taken
from the ACT model). This is to help the young person find meaning in
their life and work within a CBT framework, to move towards a value led
and meaningful life.
There are homework exercises for the young person to complete
between sessions.
Initial modules focus on psychoeducation and a comprehensive
cognitive behavioural assessment of the self-harm behaviour. Levels of
motivation for giving up/reducing self-harm are assessed using simple
‘motivational rulers’ adapted from Rollnick and Miller13 If motivation is
assessed to be low, further motivation work is offered as an option.

General issues to consider during therapy

The terms ‘feelings’ and ‘emotions’ are used interchangeably through the
book as meaning the same thing – technically, emotions. Young people
have reported to us that they often prefer the term feelings. However,
it is important to bear in mind that clinical experience has shown that
people can easily mix up thoughts and feelings. As it is very important
in CBT to become adept at recognising the difference between a thought
and a feeling, consideration of terminology and each young person’s
understanding of thoughts and feelings throughout the book is recom-
mended. A key aspect of the treatment throughout will be helping the
young person distinguish thoughts from emotions on a daily basis.

The therapeutic alliance

From discussions with young people in therapy, we know that some

aspects of building a therapeutic alliance are particularly difficult for
them, in particular, developing trust and making connections.

5
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