Treatment for Deliberate Self-Harm: Integrating Emotion-Focused Therapy

This article proposes that Emotion-Focused Therapy (EFT) can be effectively utilized as a treatment modality for deliberate self-harm or integrated with existing treatment approaches. A brief literature review examines evidence suggesting that attachment and emotion regulation are important etiological variables associated with deliberate self-harm. EFT addresses these variables by emphasizing the importance of the therapeutic relationship and assisting clients in the regulation and transformation of negative, maladaptive emotions. The article describes the basic tenets of EFT, comparing and contrasting this approach with therapeutic models most commonly used in the treatment of deliberate self-harm. Finally, it is recommended that future outcome research utilize randomized clinical trials to evaluate the effectiveness of EFT and compare it with other treatment modalities.     

Emotional antecedents and consequences of deliberate self-harm and suicide attempts

Emotional experiences immediately prior to (emotional antecedents) and following (emotional consequences) deliberate self-harm and suicide attempts in female inmates (N = 63) were examined. Anger was the antecedent emotion reported by the largest proportion of individuals who had engaged in deliberate self-harm (45.16%), suicide attempts (40.9%), and ambivalent suicide attempts (30%). Relief and other positive emotional shifts were more common in deliberate self-harm (41.94%) (involving no intent to die) than in suicide attempts or ambivalent suicide attempts, particularly for persons with borderline personality disorder. These findings underscore the utility of discriminating between deliberate self-harm and suicidal behavior and highlight the potential role of anger in triggering such behaviors.     

Painful engagement in deliberate self-harm: The role of conditional goal setting

Conditional goal setting is the tendency for people to see attainment of their future personal goals as necessary for their well-being. It has been argued that this represents an unhealthy way of relating to one’s goals, as well as being particularly problematic when goals are perceived as unlikely. High conditional goal setting has been found to be related to depression and to hopelessness. The present study examined conditional goal setting in deliberate self-harm, where problematic thinking about the future is very prominent. A group of individuals attending hospital for a recent episode of deliberate self-harm (N = 25) were compared with controls attending hospital for minor injuries (N = 25) as well as a psychologically disordered but non-suicidal control group (N = 25). Participants generated goals and rated goal likelihood, the extent to which those goals were seen as necessary for their future well-being (conditional goal setting), and also the extent to which the goals were seen as sufficient for their future well-being (goal sufficiency). Deliberate self-harm patients showed a higher degree of both conditional goal setting and goal sufficiency than did both of the other groups, further confirming the idea of painful engagement with personal goals, rather than disengagement, as characterising deliberate self-harm.     

Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with borderline personality disorder

Borderline personality disorder (BPD) and deliberate self-harm are clinically important conditions for which additional economically and clinically feasible interventions are needed. Literature on both the emotion regulating and experientially avoidant function of self-harm and the role of emotional dysfunction in BPD provided the rationale for developing a group intervention targeting emotion dysregulation among self-harming women with BPD. This study provides preliminary data on the efficacy of this new, 14-week, emotion regulation group intervention, designed to teach self-harming women with BPD more adaptive ways of responding to their emotions so as to reduce the frequency of their self-harm behavior. Participants were matched on level of emotion dysregulation and lifetime frequency of self-harm and randomly assigned to receive this group in addition to their current outpatient therapy (N = 12), or to continue with their current outpatient therapy alone for 14 weeks (N = 10). Results indicate that the group intervention had positive effects on self-harm, emotion dysregulation, experiential avoidance, and BPD-specific symptoms, as well as symptoms of depression, anxiety, and stress. Participants in the group treatment condition evidenced significant changes over time on all measures, and reached normative levels of functioning on most. While these preliminary results are promising, the study's limitations require their replication in a larger-scale randomized controlled trial.     

Cross-national comparisons of the association between alcohol consumption and deliberate self-harm in adolescents

How differences in drinking patterns may affect the impact of alcohol consumption on deliberate self-harm among adolescents is explored in this international comparative study. Schools in Australia, Belgium, England, Hungary, Ireland, the Netherlands, and Norway (N = 30,532) were surveyed. In all countries the risk of deliberate self-harm was significantly elevated among adolescents who reported some or numerous episodes of intoxication, controlling for confounding factors. The results support the assumption that intoxication is significantly related to the association between alcohol consumption and deliberate self-harm in adolescents.     

The Indirect Effect of Early Experiences on Deliberate Self-Harm in Adolescence: Mediation by Negative Emotional States and Moderation by Daily Peer Hassles

The present study examines whether early experiences of threat, subordination and devaluation with family influence adolescents’ negative emotional states and subsequently deliberate self-harm; and if this effect is conditioned by daily peer hassles. The sample consisted of 441 adolescents (57.6 % female) with ages between 13 and 18 years old from middle and high schools. Participants completed self-report instruments measuring early memories of threat, subordination and devaluation, daily peer hassles, negative affect and deliberate self-harm behaviors. Results from conditional process analysis showed that adolescents who feel devalued and experience threat and submission within family tend to endorse high levels of negative affect, which in turn accounts for increased endorsements on deliberate self-harm. Moreover, the impact of negative affect on deliberate self-harm is amplified by the presence of moderate and high levels of daily peer hassles. This study suggests the relevance of assessing and intervening on type of emotional memories (i.e., threat, subordination and devaluation), daily disruptions with peers and negative emotional states with adolescents who self-injure. These findings may be useful in the development of preventive and intervention programs for reducing deliberate self-harm in adolescence.     

Deliberate self-harm in 14-year-old adolescents: how frequent is it, and how is it associated with psychopathology, relationship variables, and styles of emotional regulation?

Deliberate self-harm was studied in 14-year-old adolescents from four schools in southern Sweden with a test-retest design, using a nine-item version of the Deliberate Self-Harm Inventory. At Time 1, 40.2% of the adolescents indicated deliberate self-harm on at least one occasion compared with 36.5% at Time 2. Test-retest data showed high stability over periods of up to 2 months in duration. Cross-validation of the results from Time 1 to Time 2 showed robust correlations between deliberate self-harm and general psychopathology, a relative absence of positive feelings toward parents, and a ruminative style of emotional regulation. Further, rumination/negative thinking and a relative absence of positive feelings toward parents were predictors of self-harm independently of general psychopathology. In addition, deliberate self-harm correlated with symptoms of eating disorder and negative body esteem in girls.     

Predictors of Deliberate Self-Harm Behavior Among Emerging Adolescents: An Initial Test of a Self-Punitiveness Model

The current study examined the extent to which an expanded self-punitiveness model could be applied to deliberate self-harm (DSH) among students making the transition to university. Specific components of the self-punitiveness model included perfectionism, overgeneralization, self-criticism, and shame. A sample of 319 university students completed a measure of deliberate self-harm as well as two multidimensional perfectionism measures and measures of self-criticism, overgeneralization, and shame. Correlational analyses found few significant associations among deliberate self-harm and the self-punitiveness factors among men. In contrast, among women, deliberate self-harm was associated with dimensions of trait perfectionism such as parental criticism and socially prescribed perfectionism, as well as with overgeneralization, self-criticism, and both characterological shame and bodily shame with the strongest associations found with shame. Supplementary analyses found a strong link between overgeneralization and shame and an association between self-criticism and shame among women. The results support the contention that particularly among young women making the transition to university, deliberate self-harm behavior is a reflection of a self-punitive personality orientation with multiple facets and a sense of shame associated with an overgeneralized sense of failing to meet social expectations.     

Deliberate self-harm in 15-year-old adolescents: a pilot study with a modified version of the Deliberate Self-Harm Inventory

The purpose of the present study was to investigate the rate of deliberate self-harm in 15-year-old Swedish adolescents, gender differences in this behavior, and possible associations with self-esteem and mindfulness. For this purpose, we developed a simplified version of Gratz's (2001) Deliberate Self-Harm Inventory (DSHI), and carried out a pilot study with 123 adolescents from three different schools in southern Sweden. The results showed that 65.9% of the adolescents reported having engaged in some kind of deliberate self-harm at least once; 41.5% reported at least one kind of self-harm more than once; and 13.8% reported at least one kind of deliberate self-harm behavior "many times". Although there were no overall gender differences in self-harm, the girls reported significantly more of cutting wrists, arms and other body areas than the boys. High rates of deliberate self-harm were associated with low self-esteem and low mindfulness.     

Deliberate self-harm in adolescence: a challenge for schools

Acts of deliberate self-harm (DSH) by adolescents are thought to be on the increase. Many of those who self-harm are of school age and it is to be expected that schools (and their teachers) will be aware of the problem and will respond appropriately as part of their pastoral-care provision. However, a recent survey of research in pastoral care and personal-social education undertaken by the author found virtually no reference to DSH. It appears that empirical evidence about schools' experience of, and responses to, DSH does not exist. This paper reports some of the findings of a Nuffield Foundation-funded study undertaken in England in 2003/2004. A variety of self-harming behaviours, from cutting to unnecessary risk-taking, were reported by the 34 teachers and other professionals interviewed in schools, pupil referral units and support agencies such as child and adolescent mental health services (CAMHS). The findings indicate that teachers' awareness of DSH is patchy and that their reactions are often those of shock, panic and anxiety. The implications of the findings for those in education are considered in the context of a discussion of the literature. The contested status of the concept of deliberate self-harm, the need for a cautious raising of awareness, and the importance of supervision for front-line workers in schools are amongst the issues considered.     

Adolescents' deliberate self-harm, interpersonal stress, and the moderating effects of self-regulation: a two-wave longitudinal analysis

The predictive effects of peer victimization and harsh parenting on deliberate self-harm were examined. As derived from the experiential avoidance model, the study also tested whether these links were moderated by individual self-regulation approaches. Data were collected at two points in time from 880 junior high school students (mean age = 13.72) in Sweden. Analyses using structural equation modeling revealed that Peer Victimization was predictive of self-harm. Although Harsh Parenting was not predictive of self-harm, this link was moderated by adolescents' gender. No moderating effect of self-regulation was revealed. The study concludes that the high prevalence of deliberate self-harm recently found in community samples of adolescents cannot be prevented without attending to environmental psychosocial factors.     

Self-cutting: patient characteristics compared with self-poisoners

A large ( n = 14,892) consecutive sample of deliberate self-harm (attempted suicide) patients who presented to a general hospital in the United Kingdom during a 23-year study period was examined (over two consecutive time periods) in order to compare the characteristics of those who used self-cutting ( n = 428) and those who self-poisoned ( n = 11,065). Patients who used different methods on other occasions, or were not assessed by the psychiatric service, were excluded. In the first time period (January 1976-June 1988), the self-cutters were distinguished from the self-poisoners by more often being male, single, not employed, and having a history of previous deliberate self-harm. In the second time period (July 1988-December 1998) the self-cutters were again distinguished by more often being male and having a history of previous deliberate self-harm, but also by being more likely to live alone, misuse alcohol, and have low suicidal intent scores. The finding of an excess of males among the self-cutters is contrary to the impression in the literature that self-cutting presentations to general hospitals more often involve females. It also indicates that the treatment needs of those who deliberately cut themselves are likely to differ from those of self-poisoners.     

Measurement of Deliberate Self-Harm: Preliminary Data on the Deliberate Self-Harm Inventory

Deliberate self-harm has recently begun to receive more systematic attention from clinical researchers. However, there remains a general lack of consensus as to how to define and measure this important clinical construct. There is still no standardized, empirically validated measure of deliberate self-harm, making it more difficult for research in this area to advance. The present paper provides an integrative, conceptual definition of deliberate self-harm as well as preliminary psychometric data on a newly developed measure of self-harm, the Deliberate Self-Harm Inventory (DSHI). One hundred and fifty participants from undergraduate psychology courses completed research packets consisting of the DSHI and other measures, and 93 of these participants completed the DSHI again after an interval of 2–4 weeks (M = 3.3 weeks). Preliminary findings indicate that the DSHI has high internal consistency; adequate construct, convergent, and discriminant validity; and adequate test-retest reliability.     

Clinical trials for rapid changes in suicidal ideation: Lessons from ketamine

Rapid‐acting treatments for suicidal thoughts are critically needed. Consequently, there is a burgeoning literature exploring psychotherapeutic, pharmacologic, or device‐based brief interventions for suicidal thoughts characterized by a rapid onset of action. Not only do these innovative treatments have potentially important clinical benefits to patient populations, they also highlight a number of methodological considerations for suicide research. First, while most clinical trials related to suicide risk focus on suicide attempts, new clinical trials that use suicidal thoughts as the primary outcome require a number of slight modifications to their clinical trial design. Second, the rapid onset of these new interventions permits an experimental therapeutics approach to suicide research, in which psychological and neurobiological markers are embedded into clinical trials to better understand the underlying pathophysiology of suicidal thoughts. The following review discusses these methodological innovations in light of recent research using the N‐methyl‐D‐aspartate (NMDA) receptor antagonist ketamine, which has been associated with rapid effects on suicidal thoughts. We hope that “lessons learned” from the ketamine literature will provide a blueprint for all researchers evaluating rapid‐acting treatments for suicidal thoughts, whether pharmacologic or psychotherapeutic.     

Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients

This study examines the efficacy of a short-term individual therapy, Manual Assisted Cognitive Treatment (MACT), which was developed to treat parasuicidal (suicidal or self-harming) patients. In this trial, MACT was modified to focus on deliberate self-harm (DSH) in patients with borderline personality disorder (BPD). Thirty BPD patients who were engaged in DSH while in ongoing treatments, i.e., treatment-as-usual (TAU), were randomly assigned to receive MACT (N = 15) or not. DSH and level of suicide ideation were assessed at the baseline, at completion of the MACT intervention, and six months later. Results indicated that MACT was associated with significantly less frequent DSH upon completion of the intervention and with significantly decreased DSH frequency and severity at the six months follow-up. Moreover, MACT's contribution to reducing DSH frequency and severity was greater than the contribution by the amount of concurrent treatments. In contrast, MACT did not affect the level of suicide ideation and time-to-repeat of DSH. In conclusion, MACT seems to be a promising intervention for DSH in patients with BPD. More definitive studies are needed.     

Cancer-related fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients

Cancer-related fatigue (CRF) is a significant clinical problem for more than 10 million adults diagnosed with cancer each year worldwide. No "gold standard" treatment presently exists for CRF. To provide a guide for future research to improve the treatment of CRF, the authors conducted the most comprehensive combined systematic and meta-analytic review of the literature to date on non-pharmacological (psychosocial and exercise) interventions to ameliorate CRF and associated symptoms (vigor/vitality) in adults with cancer, based on 119 randomized controlled trials (RCTs) and non-RCT studies. Meta-analyses conducted on 57 RCTs indicated that exercise and psychological interventions provided reductions in CRF, with no significant differences between these 2 major types of interventions considered as a whole. Specifically, multimodal exercise and walking programs, restorative approaches, supportive-expressive, and cognitive-behavioral psychosocial interventions show promising potential for ameliorating CRF. The results also suggest that vigor and vitality are distinct phenomena from CRF with regard to responsiveness to intervention. With improved methodological approaches, further research in this area may soon provide clinicians with effective strategies for reducing CRF and enhancing the lives of millions of cancer patients and survivors.     

Vers une prise en charge des troubles cognitifs des patients atteints de cancer

Cancer and its treatments can have deleterious effects on cognitive function and a negative impact on the patient's quality of life. This work proposed a review of the different studies that have been implemented to deal with or prevent cognitive impairment in patients suffering from cancer. Two dissociated but complementary approaches emerge in patients support: a pharmacological approach and a psychological approach, in the form of cognitive rehabilitation. Despite a growing interest of researchers in this issue, we note that many practical and methodological problems persist; results remain therefore difficult to generalize. We hope that our reflections on the support of cognitive disorders in oncology will help the development of new research in this field considered very important by patients.     

Enhancing the Conceptualization and Measurement of Implicit and Explicit Affective Evaluations: A Case Study in Disordered Eating

Affective evaluations (i.e., evaluations of affectively evocative stimuli) play important roles in many behaviors, including clinically relevant behaviors like disordered eating. Understanding automatic and controlled affective evaluations can enhance prediction and treatment of more deliberate versus more impulsive clinical behaviors, respectively. However, methodological and theoretical shortcomings cloud the implicit affective evaluation literature, particularly as applied in clinical psychology. This article aims to improve the clinical science of implicit and explicit affective evaluation by capitalizing on theoretical and methodological advancements drawn from implicit social cognition. We recommend three key enhancements to the affective evaluation literature: improve the structural comparability between indirect and direct measures, assess evaluations on both valence and arousal dimensions of affect, and carefully characterize and select stimuli. Additional improvements to analytic approaches (e.g., mixed effects modeling and process dissociation) are also recommended. Such efforts will advance our theoretical understanding of the relative contributions of automatic and controlled processes to clinically relevant affective evaluation, thereby informing assessment and improving intervention. Applying advanced methodologies of implicit cognition to clinical phenomena will also reiterate and reinforce the use of these advances in social psychology.     

Functional MRI of Language in Aphasia: A Review of the Literature and the Methodological Challenges

Animal analogue studies show that damaged adult brains reorganize to accommodate compromised functions. In the human arena, functional magnetic resonance imaging (fMRI) and other functional neuroimaging techniques have been used to study reorganization of language substrates in aphasia. The resulting controversy regarding whether the right or the left hemisphere supports language recovery and treatment progress must be reframed. A more appropriate question is when left-hemisphere mechanisms and when right-hemisphere mechanisms support recovery of language functions. Small lesions generally lead to good recoveries supported by left-hemisphere mechanisms. However, when too much language eloquent cortex is damaged, right-hemisphere structures may provide the better substrate for recovery of language. Some studies suggest that recovery is particularly supported by homologues of damaged left-hemisphere structures. Evidence also suggests that under some circumstances, activity in both the left and right hemispheres can interfere with recovery of function. Further research will be needed to address these issues. However, daunting methodological problems must be managed to maximize the yield of future fMRI research in aphasia, especially in the area of language production. In this review, we cover six challenges for imaging language functions in aphasia with fMRI, with an emphasis on language production: (1) selection of a baseline task, (2) structure of language production trials, (3) mitigation of motion-related artifacts, (4) the use of stimulus onset versus response onset in fMRI analyses, (5) use of trials with correct responses and errors in analyses, and (6) reliability and stability of fMRI images across sessions. However, this list of methodological challenges is not exhaustive. Once methodology is advanced, knowledge from conceptually driven fMRI studies can be used to develop theoretically driven, mechanism-based treatments that will result in more effective therapy and to identify the best patient candidates for specific treatments. While the promise of fMRI in the study of aphasia is great, there is much work to be done before this technique will be a useful clinical tool.     

Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk?

In response to high suicide rates among veterans, the Department of Veterans Affairs (VA) has mandated that veterans at risk for suicide be given Safety Plans (SP). Research on the efficacy of SPs, however, is unclear and no prior study has examined the degree to which more personally relevant (i.e., higher quality) SPs may be associated with better outcomes or evaluate which components of SPs may be most effective at reducing suicidal behavior. The goal of the present study was to examine whether more personally relevant (i.e., higher quality) SPs reduce future suicide-related outcomes (psychiatric hospitalization, self-harm, and suicide attempts), and to determine which components of a SP may be most effective at reducing these outcomes. Participants were 68 individuals enrolled in a longitudinal national registry of returning military veterans receiving care from the VA, and who had at least one suicide-related event in the VA Suicide Prevention Applications Network. Data were collected between December 2009 and September 2016 and were analyzed between March 2016 and February 2017. Scores of SP quality were used to predict suicide-related outcomes. SP quality was low. Higher SP quality scores predicted a decreased likelihood of future suicide behavior reports (note entered into veteran’s chart after a report of any self-harm behavior, including a suicide attempt). Higher scores on Step 3 (people and places that serve as distractions) predicted a decreased likelihood of future suicide behavior reports. More personally relevant SPs may reduce future suicide-related outcomes among veterans. Low SP quality scores highlight the need for training around SP implementation in the VA.