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Dialectical Behavior Therapy for Non-Suicidal Self Injury in

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Gina Mattei

on 17 March 2014

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Transcript of Dialectical Behavior Therapy for Non-Suicidal Self Injury in

Dialectical Behavior Therapy for Non-Suicidal Self Injury in Adolescents
Gina Mattei & Jim Rossi
Non-Suicidal Self Injury
Direct and deliberate destruction of one's own body tissue in the absensce of letahl intent - a behavior seemingly at odds with health and longevity
" (1)
(1) Nock, 2010, pg. 340
Prevalence rates have been difficult to attain given the shifting criteria from study to study.

Estimates have been obtained from the following studies:

Briere & Gil, 1998
Gluerry & Prinstein, 2010
Sornberger, Heath, Toste, & McLouth, 2012
What is NSSI?
NSSI in the DSM-V
Functions of NSSI
Prevalence of NSSI
7% of Pre-Adolescents
12-40% of Adolescents
17-35% of College Students
Onset: 12-14 years
Risk factors:
Poor emotional regulation
Psychiatric disorders
Childhood trauma
Hilt et. al, 2008 - NSSI related to
Hard Drug Use
Poor parental relationship quality
Describe selves as overweight & have binged
Prevalence of NSSI Functions
(2) Lloyd-Richardson, 2010
Utilized EMA to track 30 12-19 year olds from a community sample that had self-harmed in the last two weeks
NSSI urges
NSSI behaviors
Suicide ideation
Suicide attempts
Most commonly used as intrapersonal negative reinforcement
What use do NSSI behaviors serve?
(1) Nock, Prinstein and Sterba, 2010; (2) Lloyd-Richardson, 2010
Automatic Reinforcement:
To escape acute negative affective states (anxiety, anger, and sadness)
To escape cognitions (bad thoughts, rumination)
To punish selves
To feel relaxed
Social Reinforcement:
To avoid life stressors (school work, parents, punishment for something, being with others)
To get attention (positive or negative, just be noticed, let others know your pain)
To get control of a situation
Topography and Related Ideations of NSSI
Affective states that produce the behavior seem more acute than those that do not
NSSI is MORE likely to occur when adolescents are sober, alone, and distressed
Effective alternative behaviors were ACTIVE (ie. Exercise, playing video games, calling a friend etc.) not PASSIVE (watching TV, watching a movie, looking at pictures, etc.)

Emotion Regulation and NSSI
The theory of emotion dysregulation is rooted in biosocial theory, a diathesis stress model of NSSI

What is the role of pain sensitivity and emotion regulation?

Franklin et al. (2010):
Experimental proxy for NSSI (cold pressor test (CPT) and an audio startle task) in the presence of a stressful stimuli (having to prepare a one minute speech to be evaluated by one’s peers)
All groups showed equal levels of pain sensitivity, but the NSSI group had a higher threshold for pain tolerance

NSSI was associated with decreased PPI (frontal lobe processing) at baseline
The NSSI group experienced increased PPI AFTER receiving the CPT

So, Why Use DBT?
Focus on mindfulness and non-judgmental acceptance of one’s current cognitive and affective state, which precede NSSI behavior
View of self-harm behavior as an effective but maladaptive coping mechanism, not as a symbol of laziness, disobedience of manipulation (data supports this!)
Intensive and is especially designed for high risk populations (originally conceptualized as a treatment for Borderline Personality Disorder)

* NSSI itself does not necessarily indicate current suicidality...

BUT... it is HIGHLY predictive of future suicidality and often comorbid with ideation

DBT is...
NSSI Ideation
Angry at self
Angry at others

NSSI Behaviors
Individual Therapy

DBT Skills Training

Working with Parents and Caregivers

Consultation Team
Individual Therapy
"Pre-Treatment Phase"

Assessment by detailed history (adolescent and caretakers)

Orienting adolescent and caretakers to the organization and philosophy of DBT (psychoeducation)

Gain commitment to treatment (monitored/ maintained throughout)

Gain commitment not to self harm directly (even if just until next meeting)

Building Adolescent's sense of mastery and ability

Validating without approving!

Individual Therapy
Goal Setting - Priority Targets
Develop treatment goals in collaboration, with emphasis on goals which are most relevant
Priority 1
Life threatening behaviors (Suicide attempts, Self Harm, risky behaviors)
Priority 2
Client Treatment Interfering Behaviors (missing/canceling, late to sessions, not contacting clinician when in crisis, not doing homework/daily log, no response or destruction in session)
Priorty 3
Quality of Life Interfering Behaviors (substance use, eating disorder, fighting with parents/peers, school troubles, withdrawing, financial problems)
Individual Therapy
* Daily Logs
Thoughts, urges, and behaviors related to priority targets
NSSI or Suicidal ideation
Self-Harm behaviors
Sadness, rejection, anger, anxious, worthlessness
Skills that the adolescent used on a daily basis
Emotions and how strong they were on any given day
More detail to follow....
Chain Analysis Exercise
Individual Therapy
Change Strategies for NSSI
Cognitive Restructuring
Behavior analysis
Individual Therapy
Usually conducted by phone
Available 24 hours a day

Adolescents call when they feel as though they are going to self harm or they are having suicidal ideations

Skills Training
Interpersonal Dysregulation
Behavioral Dysregulation
Emotional Dysregulation
Cognitive Dysregulation
Core Mindfulness Skills
Interpersonal Effectiveness Skills
Distress Tolerance Skills
Emotion-Regulation Skills
Walking the Middle Path Skills
Skills Training
Skills Training

Managing their affect safely

Relating skillfully to those around him

Having self-awareness and awareness about others

Managing difficult situations without resorting to behavior that make the situation worse or that lead to shame or guilt

Think in ways that can include alternatives

Structure within the skills can be taught, discussed, and analyzed

Modeling, observing, and practicing with others

Peer group reinforcement of the skills - sharing ways they found the skills helpful, social support, accountability to others

Minimizing stigma
Group Guidelines:

no self-harm
stay on topic
Working With Parents & Caregivers

Done the best they could
Okay to be scared, worried, frustrated, mourning....

Anger at the adolescent
Overwhelming feeling of worry
Frustration that their child impacts their own life plans
Feeling that the NSSI is their fault
Grieving their dreams for their child
Working With Parents & Caregivers
Keep adolescent safe
Reducing access to self-harm means

Increase validation of adolescent with no judgement

Encourage and support with distracting and self-soothing techniques

Encourage adolescent to speak with practitioner

Avoid being overly intrusive while still being alert to self-harm

Minimize reactivity or attention to self-harming behaviors

Spend more time with adolescent when using safe and adaptive behaviors (positive reinforcement)
Working With Parents & Caregivers
Parent Coaching
Do DBT therapy validation and skill building with the parent in relation to their experiences with their child

Works best when the practitioner is not the same for the parent and the adolescent

Coach is really just there for the parent when they need them

Can be short term or long term

Working With Parents & Caregivers

Settle the parents need to know what happens in adolescent's therapy sessions

Provide opportunity for parents to share specific concerns

Help the parent develop effective ways of responding to the adolescent at home

Help the adolescent advocate for him/herself around a specific issue

Give the family time to problem solve together
Working With Parents & Caregivers
Middle Path
Distress tolerance skills
Emotion Regulation
Interpersonal Effectiveness
Slow down before reacting
More balance in responses, finding middle ground on disagreements
Accepting what can't change, remember to care for self, evaluate impact of behavior
Acting opposite of initial reaction
Less reactive, more validating, understanding antecedents, building positive experiences together
Consultation Teams
Provide accountability for DBT philosophies and interventions

Peer reinforcement for implementing challenging tasks of DBT

Non-judgemental and validating source of support

Organized and Structured environment

Develop awareness of thoughts and feelings

Enhancing practitioner learning

Efficacy Studies
Qualitative review of three studies that examined DBT and NSSI in adolescents (Katz et al., 2004; Rathus & Miller, 2002; Trupin et al., 2007)

All studies compared DBT that was attenuated for adolescents to Treatment as Usual conditions

DBT worked successfully in all three studies to reduce symptoms of psychopathology and was most effective at reducing NSSI and suicide ideation

Efficacy Studies
Results are promising, but should be interpreted with caution

“The data in all three studies are of considerably poor quality.”
(Quinn, 2009 pg. 165)
Confounding variables due to treatment setting
treatment integrity
symptom matched controls.

A call for significant improvements in research methodology and RCT’s to evaluate the relative efficacy of DBT

Efficacy Studies
Exhaustive quanatative review of 18 empirical studies (none of which were RCT’s) examining the use of DBT in adolescent samples

Found that DBT was most effective in reducing adolescent:
Externalizing behaviors
NSSI (Pre-Post d’s = .7 - .9)
Need for hospitalization
Suicide ideation (Pre-Post d’s = .7 - 2.2)
Suicide attempts
Treatment retention and adherence

Caution: Still no RCT’s in adolescents to date.

Efficacy Studies
While there has yet to be established RCT’s or a relevant meta-analysis on DBT in adolescents, results are promising in that DBT seems to cause a significant reduction in NSSI, suicide ideation, depression, aggression, etc.

Furthermore, the TRUE conclusion is that DBT is effective, we just do not know if it produces better effects than currently established EST’s.

There is an immense need for further research and better research design to validate DBT’s effectiveness in adolescent populations going forward.

Use of alternate behaviors
1. Assess for risk of suicide
2. Take actions to keep the adolescent safe if needed (contact parents)
3. Guide the adolescent through using alternate means of coping
4. Gain a commitment to safety if necessary
5. Re-contact the adolescent to follow up at a later time
* During the Call

no abusive or threatening language or actions
Skills Training
Clearer thinking, self awareness, non-judgemental life experience
Interpersonal Effectiveness
Assertiveness, how to have needs met, respect others, adjusting standards, increase self-respect, negotiating
Distress Tolerance Skills
Getting through the moment (briefly getting mind off of the circumstance to move through the moment), accepting life in the moment (awareness and relaxation, flexibility in perspective)
Skills Training
Emotion Regulation Skills
Walking the Middle Path Skills
Countering all-or-nothing thinking and absolute thinking
Recognizing emotions,
Primary vs. Secondary emotions,
The purpose of emotions,
How to reduce emotional suffering,
Reducing vulnerability to emotion dysregulation,
Opposite action skills
Chain Analysis Exercise

Part 2
* Instructed not to call if they have already self-harmed !!
Provide validation to parents about their feelings:
But.... Need to work on accepting they child they do have!
Parent Goals
Benefits of Groups *
Strategic Family Meetings *
Quinn (2009)
Qinn (2009) ctd.
MacPherson, Cheavens & Fristad (2013)
Efficacy Conclusions
Nock, Prinstein & Sterba, 2010
Harvey & Rathbone (2013)
Individual Therapy
Chaining Analysis (Functional Analysis)

Examine each behavior or situation and its Antecedents and Consequences

Making note of...

Separate from Individual Therapy
Now considered a separate condition in the DSM-5 under a category of disorders that require future research:

Non-suicidal self-injury
Suicidal behavioral disorder

No reimbursement due to status?
May change in future editions?
Validation is...
Validation is not...
Listening - no judgement
Being Mindful
Being Reflective - cognitions and emotions
Encouraging client
Being Genuine
Agreeing with everything
Saying you understand when you don't
Telling the client they are right
Telling the client how they should feel or behave
Being unrealistic about the client's abilities
Full transcript