Treating Non-Suicidal Self-Injury Requires a Wide Lens

I wasn’t going to be a therapist. In fact, psychology wasn’t even on my radar in my young adulthood. I had bigger dreams, you see. I was going to be a filmmaker. I went to film school with big dreams of making movies that would shift the tectonic plates and inspire world peace. 

During one of my early film production classes, I found myself serving as first assistant director on a classmate’s film project. Most of us assumed that a first AD was second-in-command to the director.

In reality, “first AD” is actually a cruel misnomer for the on-set negotiator responsible for choreographing the vastly different personalities that make up any given film crew. My first day on set was spent mostly in the bathroom, consoling the lead actress who had been offended by an ill-fitting costume. By the end of that first day, I hadn’t come within ten feet of the camera.

Back in class, I shared the details of our shoot and lamented my missed opportunity to share in the creative movie-making process. I’ll never forget the amused expression on my instructor’s face. He noted that all film sets—all groups of humans, for that matter—need at least one person managing the group itself. 

Group dynamics are filled with complexity, intensity, pushing, and shoving. He warned us that as filmmakers, we couldn’t fool ourselves into thinking that we were simply storytellers. Film crews are their own kind of family, requiring their own kind of creative solutions to constant clashing and colliding. He finally responded to my exhaustion with an optimistic spin, “You know, first ADs are sort of the production crew’s therapist.”

From First AD to Therapist 

It was no surprise to anyone when I landed back in school. But this time, it was to become a therapist. Grad school was the first time I was exposed to the psychology greats, and I was hooked. The idea that I could use a relationship to fix a relationship sounded like a gift, and I threw myself into some serious psychodynamic training. 

My clients didn’t seem as fascinated by this as I was. They weren’t really interested in how unconscious patterns from their childhoods were recapitulating in current relationships. Nor did they see how the intricacies of our therapeutic relationship in that small room applied to their own lives. 

No matter how well I thought I was offering insight, remaining neutral, or simply reflecting my client’s process, we didn’t seem to be getting anywhere. My supervisors told me that therapy is a slow process, sometimes agonizingly slow, and that patience is essential. I took their words into the room with me, and hoped they were right. 

Working with the Non-Suicidal Self-Injury Population

But even years later, my clients didn’t seem to be getting much better. They had learned to express their feelings to me, but I wasn’t their family member or friend. Our relationship was filled with safety, security, even love, but their outside lives were still dysfunctional. Over the years, I found myself doubting the therapy process.

At the clinic where I interned, I became the go-to therapist for the self-injury population—more specifically, the non-suicidal self-injury population—and those cases were passed on to me automatically for a few years. My supervisor seemed to think I was a good fit for this group, and what I told him in supervision supported that idea. What I never told him at the time was that I was breaking some major rules. 

Once my self-injurers opened up to me, they often talked about the inauthenticity of the world around them and their lack of tolerance for phony human interactions. I abandoned my neutral psychodynamic stance and agreed that even therapy felt bogus sometimes. I spoke plainly to my clients about how much I grappled with the “rules” of therapy, especially when we wanted to bring other people into our sessions. Together we would criticize what we considered to be an unhelpful and contrived setting. 

Sure, we understood the self-harm. We could understand until we were blue in the face. But that understanding alone wasn’t doing anything. Problems were still problems, and they weren’t being solved.

Enter Family Systems

I couldn’t understand why I kept failing to effect change in my clients’ lives. I was doing all the interpreting I was supposed to be doing. I was even in my own intensive therapy to handle countertransference and personal judgments. I used dialectical behavior therapy (DBT) techniques from my training, but my cutters kept cutting. Even when they stopped, it was only a matter of time before they would start again, and we’d find ourselves back at square one. 

Since most of them were teens, I’d go out to the waiting room time after time only to meet their parents’ hopeful gaze with the weekly half-hearted smile and requisite, “See you next time.” Their faces would fall, my clients would shrug, and we’d continue what felt like a circular journey. I’d return to my notes and wistfully fantasize about talking more honestly with the entire family about what I thought was happening.

When I couldn’t stand it any longer, I decided to go back to basics. I pulled out a dusty copy of Families and Family Therapy by Salvador Minuchin—a book I was supposed to read seven years earlier, but instead skimmed so I could pass the quiz. This time, the words were like a cool glass of water, and my thirst was insatiable. I downed the book in a matter of hours. I devoured a few more books, and by 3AM that morning I had signed up for a long-distance training course in systems.

I was filling my hungry mind with ideas that finally made sense, and thus began a radical shift in my professional development. My practice started filling up with families—not individuals. My work became contextual, not internal. Most importantly, my cutters stopped cutting for good, because problems that had plagued their families for far too long were finally getting solved.

Lights, Camera… Therapy 

There is a “cut to the chase” attitude that appealed to me about family systems—a near-irreverence toward the slow, methodical passivity that characterizes so many traditional models. This kind of work is less about mere conversation and more about action. Early systems thinkers saw therapy as a task with an end to it, where families were expected to take action toward positive change. 

I’m now considered somewhat of a poster woman for family systems. At my institute for self-injury, we make family involvement a condition for treatment. Any families who aren’t willing to engage in our process are politely referred elsewhere—as a testament to our belief in the effectiveness of this kind of work for this kind of problem. 

We mix creative cocktails of structural, strategic, and experiential techniques to address what we believe to be at the heart of self-harm. We talk openly with our clients about what we think is going wrong. We capitalize on strengths we spot in the family, and insist that they’re capable of solving their own problems with a little push here and a little tug there.

This kind of work is so vastly different from how I was originally trained, and so much more effective. By helping families see that non-suicidal self-injury is simply the most visible problem—and that in reality, all members of the family are suffering—we get to the core issue with more grace and expediency. 

By refusing to agree that the self-injurer is the problem, we’re able to direct the conversation to fundamental problems within the family dynamic. When we address those problems instead, the self-injury is rendered unnecessary. The family gets to go home to reconnect under a new set of rules, with new understanding for one another, and a greater sense of belonging and love.

When you do family therapy, you have to be ready to jump between stages. You have to wear several hats at a time, and modify your plan as needed. To know the family dynamic, you have to perform it a few times yourself. Then you have to be able to hop over to the sidelines and coach the family from a distance. As my film school instructor taught me, families are hard. They need someone to choreograph the complex relationships that occur in any group. They require a nimble and agile First AD.