Non-Suicidal Self-Injury and Its Treatment

Self-Injury

Non-suicidal self-injury is the direct and deliberate destruction of one’s own body tissue without the intent to die (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007). Unfortunately, self-injury is a pervasive and dangerous problem among adolescents. The average age of onset for self-injury is 12 years old, however, it has been reported in children as young as 6 years old (Nock & Prinstein, 2004). Even though self-injury often starts in childhood/adolescence, it often persists into adulthood as well.

The most common forms of self-harm include cutting, poisoning and drug overdose (Greydanus & Shek, 2009).  Less common methods of self-harm are hitting, biting, shooting, burning, hanging, pinching, scratching and jumping from high places (Vajani, Annest, Crosby et al., 2007).

The majority of adolescents who engage in self-injury also meet the criteria for a mental disorder including depression, eating disorders, schizophrenia and substance use disorders as well as borderline, avoidant, and paranoid personality disorders (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Unfortunately, the diagnosis of mental disorders is not very helpful in explaining self-injurious behavior, as many adolescents with the same diagnoses do not self-harm. Some research suggests that identifying the purpose the self-injury serves for the individual is key to understanding why the individual engages in it. Self-injury is theorized to be a four-function model with two dichotomous dimensions – positive or negative reinforcement for the behaviors, and intrapersonal or interpersonal functions (Nock & Prinstein, 2005). 

 

    Positive Reinforcement Negative Reinforcement

Intrapersonal “to feel something, to get a rush” “to get rid of bad feelings,  to distract myself from  bad thoughts”

Interpersonal “to get attention” "to get other to leave me   alone"

"to let others know how bad I am         "to get out of having to  feeling"   do something"

Of course, there are multiple factors (psychological, biological, environmental) that help explain the development and maintenance of self-injurious behaviors. Research reveals, however, that self-harm in adolescents reflects underlying hopelessness and low self-esteem as well as represents ways to deal with unacceptable inner feelings and affect the behavior of others (friends and family members) (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007). The act of self-injury sometimes happens after a gradual rise in tension once the individual reaches a personal threshold – this is known as the “spring-path” mechanism. The “switch path” mechanism, on the other hand, refers to an uncontrollable urge/impulse being switched on in the individual who then engages in self-harm. The act of self-harm thus provides release from an unmanageable inner state of mind as well as unrelenting inner tension and pain (Madge, Hewitt, Hawton, et al., 2008). 

While non-suicidal self-harm does not usually result in active suicide attempts, over time, the risk of suicide does increase after a self-harm episode. The risk increases 1.7% after 5 years, 2.4% after 10 years and 3% after 15 years (Greydanus & Calles, 2007). Approximately 5% of patients who go to the ER after self-harm will commit suicide within 9 years (Skegg, 2005).

Treatment

According to research, behavior therapy approaches seem to be most effective in reducing self-injury. A 2002 study (Kahng, Iwata & Lewin, 2002) found an 80% reduction in self-harm in a program that emphasized careful behavioral assessment to identify the function of self-injury for the individual followed by reinforcement-based interventions.

Dialectical Behavior Therapy (DBT) has also proven effective for both suicidal and non-suicidal self-injury (Linehan at al., 2006). DBT has also been adapted for use with adolescents and is effective in both outpatient and inpatient settings (Katz, Cox, Gunasekara, & Miller, 2004).

In a DBT program, a clinician helps the client to identify the antecedents and consequences of their self-harm so they can better understand the functions of those behaviors and identify ways to modify them. Once client and therapist understand the functions of self-injurious behaviors, they develop other alternative and incompatible behaviors to replace them. The clinician also focuses on modifying the client’s environment to support behavior change and in the case of adolescents, this means working with the family throughout treatment. This can mean learning new ways to interact within the family as well as learning parent management skills.

Although behavior modification is a crucial element of DBT, it also places strong emphasis on acceptance, namely finding the balance between change and acceptance. Since self-injury is most often motivated by an inability to tolerate one’s negative thoughts or feelings, learning to accept and tolerate one’s current experience and circumstances can be very helpful.

In a comprehensive DBT program clients take part in individual and group skills sessions. In individual therapy the goals are to (in order of importance) (1) decrease life-threatening behaviors, (2) decrease therapy-interfering behaviors, (3) decrease quality-of-life interfering behaviors, and (4) increase behavioral skills. In group skills training clients learn mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance skills. In adolescent programs specifically, there is an extra module called “walking the middle path”, which involves learning family-focused skills including validation of self and others, the use of behavioral principles and three common adolescent-family dilemmas (Miller et al., 2007). As in all comprehensive DBT programs, clients also benefit from phone coaching sessions outside of regular therapy sessions, which can be invaluable in learning to manage crises and practice new skills in the real world.

Self-Injury References

Lloyd-Richardson EE, Perrine N, Dierker L, Kelley ML. Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychol Med. 2007;37:1183-1192.

Greydanus DE, Shek D. Deliberate self-harm and suicide in adolescents. Keio J Med. 2009; 58:144-151

Vajani M, Annest JL, Crosby AE, et al. Nonfatal and fatal self-harm injuries among children aged 10-14 years—United States and Oregon, 2001-2003. Suicide Life Threat Behav. 2007; 37:493-506.

Madge N, Hewitt A, Hawton K, et al. Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. J Child Psychol Psychiatry. 2008; 49:667-677.

Greydanus DE, Calles JL Jr. Suicide in children and adolescents. Prim Care Clin Office Pract. 2007;34:259-274.

Skegg K. Self-harm. Lancet. 2005;366:1471-1483.

Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72, 885–890.

Nock, M. K., Joiner, T. E., Gordon, K., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Nonsuicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65–72.

Nock, M. K., & Prinstein, M. J. (2005). Contextual features and behavioral functions of self-mutilation among adolescents. Journal of Abnormal Psychology, 114, 140–146.

Kahng, S., Iwata, B. A., & Lewin, A. B. (2002). Behavioral treatment of self-injury, 1964–2000. American Journal on Mental Retardation, 3, 212–221.

Katz, L. Y., Cox, B. J., Gunasekara, S., & Miller, A. L. (2004). Feasibility of dialectical behavior therapy for suicidal adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 276–282.

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757–766.

Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. New York: Guilford Press.