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Article Excerpt
Mental health counselors are facing increased demand to treat both adolescents and adults who present with repetitive non-suicidal self-injurious behaviors', yet there are few empirically supported treatments or general treatment guidelines available. 1 will review the research on problem-solving and dialectical behavior therapy, two cognitive-behavioral treatments that have the most empirical support for reducing self-injurious behavior. I conclude by providing specific treatment recommendations drawn from the literature that can be of use to mental health counselors working with individuals who self-injure.
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There is growing interest within the field to find effective outpatient treatment strategies for reducing non-suicidal self-injurious behaviors (NSSI). Self-injurious behavior, for the purpose of this paper, refers to acts that damage body tissue (e.g., cutting, burning) and occur without suicidal intent. Researchers are documenting increases in the prevalence of self-injurious behavior in adult populations (Hawton et al., 1997), and it is believed a similar increase is occurring within adolescent groups. Prevalence rates of NSSI have ranged from 4.3 to 35% (Briere & Gil, 1998; Gratz, 2001), and Favazza (1998) estimated that anywhere from 400 to 1,400 per 100,000 persons engage in NSSI behaviors per year. Self-injury has typically been identified as a behavior resistant to treatment efforts (Zila & Kiselica, 2001), and presents many challenges to a therapist since acts of NSSI can lead to severe injuries and accidental death. In addition, individuals who engage in non-suicidal self-injury are at heightened risk for suicide, further complicating the treatment. The standard treatment approach has been hospitalization, but this is an expensive option that has not reliably demonstrated effectiveness (Linehan, 2000) for suicidal or non-suicidal self-injury Additionally, individuals engaged in non-suicidal self-injury are unlikely to be admitted because they do not express intent to die. Consequently, hospitalization is used less frequently and many mental health counselors are left trying to treat this difficult behavior on an outpatient basis with little guidance regarding the best treatment approach.
Unfortunately, there is little empirical data offering treatment guidelines for NSSI. Few large-scale treatment studies include self-injuring or suicidal individuals because of ethical and legal risks (Linehan, 2000). Even fewer studies specifically target NSSI behaviors as the main focus for treatment (MacLeod et al., 1992; Miller & Glinski, 2000); however, NSSI is sometimes included as a target behavior along with suicide ideation and attempts in the treatment studies that do exist, so these studies can provide some guidance.
Given that non-suicidal self-injury is primarily conceptualized as a tool for emotion regulation (Linehan, 1993; Nock & Prinstein, 2004) maintained through positive and negative reinforcements, treatments utilizing cognitive-behavioral strategies show the greatest promise for successfully reducing the behavior. Cognitive-behavioral interventions have demonstrated effectiveness at reducing repetitive suicidal behaviors (Evans, 2000), implying potential success for the treatment to generalize to non-suicidal self-injury My goal for this paper is to highlight studies of interventions that show some success in treating NSSI, identify what may be the effective mechanisms of change in these studies, and conclude with a set of recommendations for how to approach the treatment of this behavior. Due to the limited number of treatment studies specific to non-suicidal self-injury, my review of empirically supported treatments will at times include studies that examined changes in both non-suicidal self-injury and suicidal behavior.
COGNITIVE BEHAVIORAL THERAPIES FOR NON-SUICIDAL SELF-INJURIOUS BEHAVIOR
In reviewing the literature, only two types of treatments falling within the cognitive-behavioral domain that focus specifically on NSSI were identified: Problem-Solving Therapy (PST; D'Zurilla & Goldfried, 1971) and Dialectical Behavior Therapy (DBT; Linehan, 1993). These treatments share common features such as being time-limited, structured therapies with an emphasis on immediately targeting NSSI and remedying skill deficits. Each treatment's effectiveness with reducing NSSI will be reviewed and where possible, suggestions of potential mechanisms of change will be identified.
Problem-Solving Therapy (PST)
The major assumption underlying the use of PST is that dysfunctional coping behaviors result from a cognitive or behavioral breakdown in the problem-solving process (D'Zurilla & Nezu, 2001). The goal of therapy is to help clients identify and resolve the problems they encounter in their lives, as well as to teach clients general coping and problem-solving skills that they can utilize in the future to deal more effectively with the problems they encounter. This is usually done by teaching the different steps in problem solving including problem identification and goal setting (often by utilizing a behavioral analysis of the problem), brainstorming and assessing potential solutions, selecting and implementing a solution, and evaluating the success of the chosen solution. Teaching these steps is viewed as important to reducing NSSI because researchers have consistently found that individuals who engage in self-injury often exhibit poor problem-solving skills (Evans, Williams, O'Loughlin, & Howells, 1992; Pollock & Williams, 1998; Speckens & Hawton, 2005) and tend to have rigid thinking styles (Kernberg, 1994). As in many other treatments, PST also stresses the importance of forming a strong therapeutic relationship with the client so that the teaching and practice of skills is a collaborative process.
Research on the efficacy of PST in reducing self-injurious behaviors has found mixed support, making it difficult to draw specific conclusions. Early studies examined the effectiveness of PST compared to crisis-based social work interventions or treatment as usual. Some of the early studies found that PST was effective in significantly reducing acts of self-poisoning as well as reducing suicidal ideation compared to crisis-interventions and treatment as usual (Gibbons, Butler, Urwin, & Gibbons, 1978; Patsiokas & Clum, 1985). However studies by Hawton et al. (1987) and Liberman and Eckman (1981) failed to find evidence that PST was more effective than treatments as usual. Ali these studies were limited by small sample sizes, exclusion of individuals deemed to be at high risk for suicide, and confounding access to social work/case management services in addition to psychotherapy. More recent studies of PST have demonstrated short-term success at reducing suicidal behaviors compared to treatment as usual (e.g., McLeavey, Daly, Ludgate, & Murray, 1994; Lerner & Clum, 1990), but the differential improvements have not been maintained at long-term follow-up points as long as 24 months (e.g., Rudd et al., 1996; Salkovskis, Atha, & Storer, 1990). These studies often included NSSI in their definition of suicidal behavior, making it difficult to determine whether PST has a unique treatment effect on just NSSI.
In a meta-analysis of 20 studies that used randomized clinical trials for assessing the efficacy of different treatments for "parasuicide" (including NSSI and suicide attempts), Hawton and colleagues (1998) found that many of the types of treatment reviewed in the meta-analysis (e.g., intensive therapy, in-patient therapy, medication) either failed to produce reductions in self-injurious behaviors, or failed to demonstrate significant reductions of the behavior compared to controls. Problem-solving therapy appeared to produce the greatest reductions in parasuicide among participants compared to standard care controls; however, the reductions found were not statistically significant. The authors subsequently concluded that there is no consensus as to what treatment strategies are best, but of the studies reviewed, problem-solving therapy showed the most promise. A follow-up meta-analysis of problem-solving therapy used to treat "deliberate self-harm" (greater emphasis on NSSI) found that PST significantly reduced comorbid depressive symptoms, hopelessness, and problem levels among participants, however results regarding PST effectiveness on reducing acts of NSSI were inconclusive (Townsend et. al., 2001). Possible reasons for the inconclusive results include the small sample of studies (only 6) and the small participant samples within each study. Furthermore, due to the difference in outcome variables measured, most of the analyses included only 3 or 4 of the original 6 studies. Therefore, it seems premature to...
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