Working with self-harming teens often seems like riding a runaway roller coaster, which keeps threatening to go off the rails altogether. Just as things get smooth and predictable, a crisis sends you hurtling downhill again. Then, after you work slowly and thoughtfully to get back on an even keel, another crisis sends you careening off in new directions. As much as anything, this kind of therapy requires us to recognize that successful interventions will probably not be simple, can't be narrowly focused, and shouldn't depend on a single treatment modality. To succeed, you have to be highly flexible and able to turn on a dime, as the circumstances demand.
Fifteen-year-old Rachel and her mother, Joan, were referred to me by Libby, the high-school social worker, for an emergency family assessment. The immediate reason was that Rachel and two of her friends had pulled up their shirts during geography class to reveal diamond-shaped cuts on their abdomens. Libby was concerned that Rachel appeared depressed, regularly disrupted classes, and was getting poor grades. She suspected Rachel was drinking excessively and using drugs. Libby described Rachel's peer group as very negative: they, too, were cutting themselves regularly, bingeing and purging, and showed signs of substance abuse. In addition, she thought Rachel's boyfriend, Sabir--the group's apparent ringleader--was "disturbed." Life at home was difficult for Rachel. She'd told Libby she couldn't stand her stepfather.…
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