Treatments for NSSI

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Collaboration and Motivation are Key

"Treatment" and "recovery" can mean different things to different people. In general, "treatment" refers to physical (e.g., wound care) and psychological (e.g., DBT) interventions that help people who are self-injuring. Generally, the goal of psychological treatments is to reduce NSSI by targeting the thoughts, emotions, and behaviors that underlie an individual's self-injury.

 

Until recently, few treatments were developed specifically for self-injury. Although there is currently no “gold-standard” treatment for self-injury, several treatments show promise in helping people decrease or stop these behaviors (Calvo et al., 2022; Turner et al., 2014), although the efficacy of treatments is still unclear (Fox et al., 2020).

Dialectical Behavior Therapy (DBT)

DBT is a psychotherapeutic treatment designed to treat Borderline Personality Disorder (BPD), of which NSSI is a common behaviour (Linehan, 1993). It was modified by Miller et al. (2007) to reduce NSSI and suicidality among adolescents, and has shown efficacy to reduce NSSI in multiple studies (Fleischhaker et al., 2011; Pistorello et al., 2012, Stanley et al., 2007). 

 

DBT is an intensive treatment lasting 6 months to 2 years and involves weekly individual therapy, group-based skills training, and between-session coaching. DBT integrates behavioral strategies (e.g., behavior analysis, problem-solving strategies, skills training in emotion regulation and interpersonal effectiveness, contingency management) with mindfulness (e.g., nonjudgmental, present-focused attention), and dialectical strategies (e.g., balancing acceptance and change) to reduce self-injury by:

  • Improving emotion regulation 

  • Increasing behavioral control

  • Strengthening positive identity 

  • Improving interpersonal skills

 

It is important to note that some research shows that DBT is not superior to other treatments in reducing self-injury (e.g., Katz et al., 2004, Nock et al., 2007). 

Emotion Regulation Group Therapy (ERGT)

ERGT was developed as an alternative to DBT, offering a briefer treatment period including 14 weeks of group-based psychotherapy. Unlike DBT, which is intended to treat NSSI in combination with other challenges facing people living with BPD, ERGT focuses solely on NSSI. It integrates components of DBT and Acceptance and Commitment Therapy (ACT).

 

ERGT treats NSSI in several ways:

  • Increasing awareness, understanding, and acceptance of emotions. By learning more about emotions and how to recognise them, individuals are better equipped to cope with emotional experiences. ERGT also helps individuals develop greater tolerance of uncomfortable emotional experiences.

  • Improving emotional control. Individuals learn how to better control the intensity and duration of their emotions.

  • Facilitating behavioral control. Individuals learn how to enact goal-directed behaviors and inhibit impulsive behaviors in response to negative emotions.​

 

ERGT was designed as an adjunctive treatment, meaning it is best used in conjunction with, rather than instead of, other types of treatment (such as individual psychotherapy). Several well-designed studies have shown that ERGT is effective in reducing self-injury in adult women living with BPD. A recent feasibility study also suggests that ERGT may be effective in adolescent girls engaging in NSSI. Importantly, research on ERGT has been limited to studies on women; more research is needed to determine whether ERGT is equally effective for men.

ERGT was also recently adapted to an individual setting for adolescents (ERIT-A; Bjureberg et al., 2017). An open trial investigating the online delivery of ERIT-A showed a reduction in NSSI, which was strengthened at 3-month follow up, and maintained at 6-month follow-up (Bjureberg et al., 2018). 

Treatment for Self-Injurious Behaviors (T-SIB)

T-SIB is a brief, nine-session intervention conducted weekly on an individual basis. Designed for young adults engaging in NSSI, T-SIB uses motivational enhancement strategies, functional analysis, and skills training for problem-solving, distress tolerance, cognitive distortions, and interpersonal communication to address self-injury. An initial pilot study of T-SIB found decreased self-injury over the course of treatment; however, further research is needed to see if T-SIB will be effective in other groups of people and to compare T-SIB to other treatments that address self-injury.

 

References

Bjureberg, J., Sahlin, H., Hellner, C., Hedman-Lagerlöf, E., Gratz, K. L., Bjärehed, J., Jokinen, J., Tull, M. T., & Ljótsson, B. (2017). Emotion regulation individual therapy for adolescents with nonsuicidal self-injury disorder: A feasibility study. BMC Psychiatry17, Article 411. https://doi.org/10.1186/s12888-017-1527-4

Bjureberg, J., Sahlin, H., Hedman-Lagerlöf, E., Gratz, K. L., Tull, M. T., Jokinen, J., Hellner, C., & Ljótsson, B. (2018). Extending research on Emotion Regulation Individual Therapy for Adolescents (ERITA) with nonsuicidal self-injury disorder: Open pilot trial and mediation analysis of a novel online version. BMC Psychiatry18, Article 326. https://doi.org/10.1186/s12888-018-1885-6

Calvo, N., Sara García-González, S., Perez-Galbarro, C., Regales-Peco, C., Lugo-Marin, J., Ramos-Quiroga, J.- A., & Ferrer, M. (2022). Psychotherapeutic interventions specifically developed for NSSI in adolescence: A systematic review. European Neuropsychopharmacology58, 86-98. https://doi.org/10.1016/j.euroneuro.2022.02.009

Fleischhaker, C., Böhme, R., Sixt, B., Brück, C., Schneider, C., & Schulz, E. (2011). Dialectical  behavioral therapy for adolescents (DBT-A): A clinical trial for patients with suicidal and self-injurious behavior and borderline symptoms with a one-year follow-up. Child and Adolescent Psychiatry and Mental Health5, Article 3. https://doi.org/10.1186/1753-2000-5-3

Fox, K. R., Huang, X., Guzmán, E. M., Funsch, K. M., Cha, C. B., Ribeiro, J. D., & Franklin, J. C. (2020). Interventions for suicide and self-injury: A meta-analysis of randomized controlled trials across nearly 50 years of research. Psychological Bulletin, 146, 1117–1145. https://doi.org/10.1037/bul0000305

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 Psychiatry43, 276–282. https://doi.org/10.1097/00004583-200403000-00008

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford.

Miller, A. L., Rathaus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. Guilford.

Nock, M. K., Teper, R., & Hollander, M. (2007). Psychological treatment of self-injury among adolescents. Journal of Clinical Psychology63, 1081-1089. https://doi.org/10.1002/jclp.20415

Pistorello, J., Fruzzetti, A. E., MacLane, C., Gallop, R., & Iverson, K. M. (2012). Dialectical behavior therapy (DBT) applied to college students: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 80, 982–994. https://doi.org/10.1037/a0029096

Stanley, B., Brodsky, B., Nelson, J. D., & Dulit, R. (2007). Brief dialectical behavior therapy (DBT-B) for suicidal behavior and non-suicidal self-injury. Archives of Suicide Research11, 337-341. https://doi.org/10.1080/13811110701542069

Turner, B. J., Austin, S. B., & Chapman, A. L. (2014). Treating nonsuicidal self-injury: A systematic review of psychological and pharmacological interventions. The Canadian Journal of Psychiatry59, 576-585. https://doi.org/10.1177%2F070674371405901103