Non-Suicidal Self-Injury

Wellness Perspectives on Behaviors, Symptoms, and Diagnosis

Kelly L. Wester, Heather C. Trepal

• Publisher: Routledge
• Year: 2016
• Print ISBN:
  9781138780354
• eBook ISBN:
  9781317673514
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Grounded in a wellness, strengths-based, and developmental perspective, Non-Suicidal Self-Injury is the ideal guide for counselors and other clinicians seeking to understand self-injurious behaviors without pathologizing them. The book covers topics not previously discussed in other works, including working with families, supervising counselors working with clients who self-injure, DSM-5 criteria regarding the NSSI diagnosis, NSSI as a protective factor for preventing suicidal behavior, and advocacy efforts around NSSI. In each chapter clinicians will also find concrete tools, including questions to ask, psychoeducational handouts for clients and their families, treatment handouts or treatment plans for counselors, and more. Non-Suicidal Self-Injury also includes real-life voices of individuals who self-injure as well as case vignettes to provide examples of how theoretical models or treatments discussed in this book immediately apply to practice.

Section III
Treatment Considerations

seven
Evidence-Based Treatments

While non-suicidal self-injury (NSSI) is growing in prevalence among teens and young adults, very little is known about treating self-injury specifically. Various evidence-based treatments have been implemented and found to work in decreasing NSSI; however, changes in NSSI have been a secondary benefit to a treatment originally developed to treat another pervasive disorder, such as Borderline Personality Disorder or depression. Additionally, most researchers have conducted these studies with individuals diagnosed with Borderline Personality Disorder, potentially complicating what treatments may look like in populations without this diagnosis or symptomology. To complicate matters further, while the majority of the treatments listed in this chapter have been found to effectively reduce NSSI, there is conflicting evidence. For example, most dialectical behavioral treatments (DBT) have been found to reduce NSSI and other suicidal behaviors; however, usually not more than treatment as usual. What this means is that DBT decreases or extinguishes NSSI behaviors, yet other treatments as usual (i.e., individual therapy, medication) have also decreased NSSI at similar rates, indicating there is truly no significant difference between how you might typically work with a client and the implementation of a manualized treatment in working with clients who self-injure.

There are many possible reasons for this lack of difference: (a) most of these studies have been conducted with individuals with more severe and pervasive diagnoses such as Borderline Personality Disorder, (b) most of the treatments have been conducted with smaller sample sizes, thus the results may not hold up consistently across different populations or reveal a true difference in a study due to the small number of people who received the treatment, (c) individuals who self-injure look very different, some with and some without severe diagnoses, thus one treatment may not work for every person, (d) high dropout rates for the majority of the treatments tested (ranging from 20% to over 50% of clients drop out prior to the end of treatment), and (e) researchers have not controlled for the reasons why an individual self-injures prior to treatment (e.g., social, emotion regulation, family conflict). Therefore, it is important that you take into consideration the whole context of the person, more specifically the client’s diagnosis or comorbidity of symptoms as well as the reasons or functions of his/her self-injury. Going back to Chapter 2 on the theories of NSSI, as an example, it is imperative to understand if self-injury serves as an emotion regulation tool, or whether its purpose is socially reinforced. Additionally, it would be important to understand if your client’s NSSI had an addictive quality for them, as this could impact treatment decisions.

Historically, the standard treatment for NSSI has been hospitalization, but this has been found to be an expensive option that has not demonstrated reliable effectiveness (Linehan, 2000). Hospitalization may have historically been selected as a treatment method given the misunderstanding and representation of NSSI as a form of suicidal behavior. While NSSI and suicide are related, they remain distinct behaviors. Due to the purpose of NSSI to maintain life and functioning, a brief hospitalization stay along with medication has shown little to no assistance in decreasing NSSI specifically.

As mentioned, very little research has been conducted on effective treatments of NSSI, with even less being conducted on NSSI alone outside of exploring other mental health disorders and symptoms. Yet, we can take information from each of the studies conducted with various disorders and glean not only potential manualized treatments, but also forms of treatment that appear to consistently be working in both inpatient and outpatient settings. We can still learn from all of these treatments and determine the treatment that is best fit for the student or client we are working with. This chapter will provide information on manualized, evidencebased treatments, and the following chapter will provide additional suggestions, interventions, and treatment recommendations.

The most commonly supported treatments have been versions of Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT). Both of these therapies aim to increase problem solving skills among clients. Each of these, along with other forms of treatment with empirical evidence, is discussed in this chapter.

Cognitive Behavioral Therapy (CBT)

General CBT

Most CBT programs aim to reduce NSSI behaviors by exploring possible cognitive distortions and enhancing one’s ability to cope adaptively through problem solving methods rather than avoidance. When explored alone, CBT has indeed decreased self-harm behaviors; however, rarely did CBT decrease self-harm more than treatment as usual (e.g., Donaldson et al., 2005; Taylor et al., 2011). CBT seems most effective when paired with another form of treatment. Specifically, Slee, Spinhoven, Garnefski, and Arensman (2008) paired a 12-session CBT model with treatment as usual (TAU) for 15- to 35-year-olds who self-injured. This means that the CBT provided was in addition to the TAU for these clients, which included anything from individual therapy to medication. Slee and colleagues found that clients in the CBT+TAU group decreased in both self-harm behaviors (defined as self-injury with and without intention to die as well as self-poisoning, so behaviors beyond that of just NSSI), as well as increased their ability to regulate emotions. These changes were maintained at a 9-month follow up of clients.

The central feature of Slee and colleagues’ intervention was to identify and modify the cognitions or emotions that were maintaining the desire and need to self-harm. The first step in their treatment was to assess and explore the most recent self-harm event to help understand and specify the emotional, cognitive, and behavioral factors related to self-harm. Once this concrete event was explored in detail, the goal then was to modify dysfunctional cognitions, implement emotion regulation strategies such as mindfulness and acceptance of emotions, followed by implementing problem solving techniques. Figure 7.1 contains an example of the order in which Slee and colleagues implemented their CBT protocol. The figure does not contain the exact interventions they implemented but provides examples.

Figure 7.1. Example of cutting down or CBT process for working with NSSI.

What is unclear in the study conducted by Slee and colleagues was whether it was the addition of CBT specifically that enhanced emotion regulation strategies of clients, leading to a decrease in self-harm behaviors, or whether it was that the clients in this CBT treatment group received double the therapy (i.e., medication + CBT; or TAU individual sessions + CBT session) weekly for a minimum of 10 weeks. Regardless, there seem to be components of CBT that work to alter cognitions around self-harm, thus decreasing the behaviors.

Manual-Assisted CBT

Manual-assisted cognitive behavioral therapy (MACT) has been used to treat self-injurious behavior. Evans and colleagues (1999) found both lower rates of engagement in self-injury as well as an increase in time delay from desire to engagement in self-injury among clients who received MACT versus TAU. MACT is designed to be a short-term treatment program of 6 sessions that includes teaching skills to manage emotions and negative thinking while increasing problem solving skills among clients. Clients were provided each chapter of the manual for each session in which they could read the content as well as work through various worksheets. See Table 7.1 for an example of the 6 sessions of MACT discussed by Evans and colleagues (1999).

Table 7.1. Manual-Assisted Cognitive Theory (MACT)

1	Explore and analyze most recent episode of self-harm, including response from others and whether others know about self-harm
	Discuss/list advantages and disadvantages of self-harm
2	Provide problem solving techniques
3	Train and assist clients in self-monitoring thoughts and feelings
4	Distress coping strategies
5	Education regarding dangers of substance use and abuse
6	Revisit attempts or episodes of self-harm
	Skill deficits identified
	Coping strategies for future identified

* Table description adapted from Evans and colleagues (1999)

Taylor and colleagues developed (2015) another CBT manualized treatment specific to adolescents. They developed an 8- to 12-week CBT protocol for youth that incorporates aspects of acceptance of emotions and motivational interviewing strategies to increase willingness and motivation to participate in therapy. In their one study of the treatment (Taylor et al., 2011) they found that self-harm behaviors (including NSSI and suicidal behaviors) decreased among the 25 youth by treatment completion, with reductions in self-harm maintained at a 3-month follow up. They did not compare this treatment to a control group or treatment as usual; therefore, the effectiveness of this treatment above therapy as usual is unknown. Their program contains four modules:

1. Getting Started, wh...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Introduction
• SECTION I—Non-Suicidal Self-Injury: Basic Information and Considerations
• SECTION II—Assessment and Diagnostic Considerations
• SECTION III—Treatment Considerations
• SECTION IV—Education and Advocacy
• Index