Generally speaking, non-suicidal self-injury (NSSI) is conceptualized as a private behavior. Many cutters would even describe it as isolating and secretive and go to great lengths to hide the cuts and scars. These statements are true until you put several cutters together in a group to talk about self-harm.
If we follow the logic that self-injury often results from feeling unseen and unheard, thereby filling the self-injurer with rage, then putting that person in a group setting results in disaster. Do you often feel seen and heard in a group? (We’re not talking to you rare self-confident extroverts out there.)
It’s hard enough for a cutter to open up in individual and family therapy. To be expected to open up and share authentically in a group setting—usually in front of perfect strangers—is simply unrealistic. When we do get members talking, which takes some skillful work on the part of the therapist, the focus turns to the one member who is sharing. At that moment, the first domino falls: The “sharer” obtains needed attention, and other self-harmers are asked to listen and respect (not unreasonable). As they listen and respect, they continue to feel unseen and unheard, and eventually they learn that the way to obtain visibility is to self-harm and share about it (also not unreasonable). They cut, and because they’re smart, they cut bigger and deeper than the first sharer to ensure that they are seen. Others in the group are then asked to listen and respect, and, as they do so, they feel unseen and unheard. They solve the problem in the exact same way, and before we know it, there is an epidemic of self-harm.*
The goal of treatment for NSSI is to render the self-harm unnecessary. Group therapy tends to create an environment of necessity, where cutting is now necessary to solve the invisibility problem. Members feel compelled to “one up” each other, and in the process of talking about it, inadvertently share tips and tricks with one another—only perpetuating the problem. Our advice for therapists? Stop recommending groups! Focus on the self-harmer, and what is likely a problematic family environment, and you’ll find yourself getting a heck of a lot further.
*We are aware of groups for self-injurers that seem to be more successful when there are strict rules—and consequences!—that restrict any kind of sharing about the self-harm itself.
-April Kujawa is a Fellow and Intake Coordinator at the Kahn Institute for Self-Injury