Research roundup: Self-injurious behavior, part 1

This month’s roundup features part one in a two-part series on self-injurious behavior

By Practice Research and Policy staff

October 27, 2011—Treating someone who self-injures can be complicated and stressful for the psychologist as well as the person in treatment. Better understanding of factors related to the occurrence of self-injurious behavior may facilitate more efficient and appropriate assessment and treatment.

Glenn, C.R. & Klonsky, E.D. (in press). Prospective prediction of nonsuicidal self-injury: A 1-year longitudinal study in young adults. Behavior Therapy, available online 12 June 2011. doi: 10.1016/j.beth.2011.04.005

Summary

Eighty one (81) predominantly female, Caucasian, 19-year-old college students completed a series of self-report measures and brief interviews discussing their past experiences with self-injury. The participants were asked to meet for follow-up one year later. Fifty one (51) of the original 81 participants completed a follow-up session allowing for correlates of non-suicidal self-injury (NSSI) to be assessed cross-sectionally and longitudinally over a one-year period. Despite relating to NSSI in cross-sectional analysis, correlates such as depression, anxiety, impulsivity, alcohol abuse, bulimia and associations with and functions of NSSI were all insignificant predictors of future NSSI in longitudinal analysis. The only significant predictors of future NSSI were participant reports of past NSSI, perceived likelihood of future NSSI and borderline personality disorder features. Participants who stopped self-injuring two years prior to the study were less likely to start self-injuring during the study when compared to participants who stopped self-injuring one year before the start of the study.

Practical Implications

Assessing for these predictors may help identify clients presently at risk for engaging in self-injurious behavior. More importantly, discussing with clients predictors for future self-injurious behavior may be very important during the later stages of treatment in order to identify and plan for healthy responses to future potential triggers. Developing a focused relapse prevention plan and strategy for re-engaging with care should self-injurious behavior resume may be necessary as the study suggests those most recently stopping self-injury are more likely to engage in such behavior in the future, whereas those who have had no instances for two years are less likely to resume self-injuring. This is helpful information to share with clients as well, as they can then be aware of what risks exist for them and how to best monitor their future behavior. Longitudinal data, as well as information from cross-sectional studies, is essential for clinicians to best understand the risks and predictors of NSSI.

Borges, G., Azrael, D., Almeida, J., Johnson, R.M., Molnar, B.E., Hemenway, D., Miller, M. (2011). Immigration, suicidal ideation and deliberate self-injury in the Boston Youth Survey 2006. Suicide and Life-Threatening Behavior, 41(2), 193-202. doi: 10.1111/j.1943-278X.2010.00016.x

Summary

One thousand and four (1004) surveys from students in 18 Boston public schools were analyzed to gain a better understanding of deliberate self-injury and suicide ideation risk. The Boston Youth Survey (BYS) covered a range of topics from health behaviors and the use of school and community resources to developmental strengths and risk factors. Nativity and time spent in the United States, birth place of the participant’s parents and the participant, the main language spoken at home and discrimination based on ancestry/nativity were key independent variables in this study. Researchers also collected information about race, ethnicity, age, gender, academic grade level, number of parents living at home with the student, hours spent working outside of school and single item responses to questions assessing deliberate self-injury and suicide ideation. Students who worked more than 20 hours per week were found to be more likely to participate in deliberate self-injurious behaviors than their peers who did not have jobs. Additionally, students who were born in the United States and were discriminated against because of their nativity were significantly more likely to engage in self-injury and suicide ideation.

Practical Implications

The authors expected to find self-injury and suicide ideation occurring more often among students who were immigrants themselves rather than those who were native born. Given that discrimination based on family background was correlated with self-injurious behavior and suicide risk, it may be that immigrants have some protection from these negative experiences, whether because of closer connection to the immigrant culture or some other protective factor. Native-born students not of the dominant culture may experience more discrimination and lack adequate, healthy coping responses. Helping teens find alternative means to address challenging situations and strong emotions is essential to reducing the incidence of self-injurious behavior.

Adrian, M., Zeman, J., Erdley, C., Lisa, L., & Sim, L. (2011). Emotional dysregulation and interpersonal difficulties as risk factors for nonsuicidal self-injury in adolescent girls. Journal of Abnormal Child Psychology, 39, 389-400. doi: 10.1007/s10802-010-9465-3

Summary

Non-suicidal self-injury (NSSI) and risk factors for NSSI were assessed from a sample of 99 predominantly Caucasian, middle-class adolescent girls admitted to a psychiatric hospital. Youth completed self-report measures of emotion processing, interpersonal relationships, social experiences and nonsuicidal self-injury. The authors found multiple connections between emotion regulation and family and peer interpersonal conflict. Emotional dysregulation and NSSI were facilitated through “unsupportive social contexts” such as family and peer discord. Family relational problems directly affected emotional dysregulation. Consistent with existing literature, adolescent girls admitted to a psychiatric hospital showed more negative affect and conflict and less positive affect and family cohesiveness than their non-psychiatric peers. Family relational problems, which result in a higher likelihood of peer conflict as well, often interfere with healthy development. Familial relational problems can result in emotion dysregulation, which increases the likelihood of NSSI. Ultimately, adolescents who did not have the opportunity to learn how to identify and express negative emotions in a supportive environment often developed unhealthy coping skills, such as NSSI.

Practical Implications

A thorough assessment of a client’s social and interpersonal environment may reveal risk factors and developmental gaps that make the client more vulnerable to self-injurious behavior. Identifying clients experiencing or with a history of poor interpersonal relationships and family discord may suggest these clients also have difficulty with emotional regulation and inadequate skills for coping with negative emotions. Early identification of such risks may shape treatment and allow the psychologist to target development of needed emotion regulation skills more quickly. Psychoeducation or family interventions might also be warranted when such risks are identified, even in the absence of information about self-injurious behavior.

Messina, E.S. & Iwasaki, Y. (2011). Internet use and self-injurious behaviors among adolescents and young adults: An interdisciplinary literature review and implications for health professionals. Cyberpsychology, Behavior, and Social Networking, 14(3), 161-168. doi:10.1089/cyber.2010.0025.

Summary

This review is an excellent resource for developing a general understanding of the function and use of the internet as it relates to self-injurious behavior. The authors conducted an interdisciplinary literature review and categorized themes into “pros” and “cons” of internet usage as it relates to self-injurious behavior. It was found that, at their best, self-harm message boards often served as sources of self-worth validation, support and safe places for venting. The notion of the message board as a safe place was reiterated by many users, who reported feeling more comfortable using these platforms to discuss and explore their behaviors and feelings than talking with a friend, family member or therapist. Most participants reported a decrease in self-injury in part due to involvement with these message boards. On the other hand, many professionals are concerned that message boards and interactions therein normalize self-injurious behaviors. Unfiltered or poorly moderated message boards can often serve as a trigger for increased self-injury and provide encouraging materials such as new techniques and ways to reduce the scarring that might result from self-injury.

Practical Implications

It is important to inquire about internet usage by clients in general. It is important to ask clients who self-injure whether they visit websites about self-injury and if so, how often and what level of involvement they have with such websites. Clinicians are encouraged to visit websites identified by clients to gain first-hand information about what the client is exposed to and how these sites are used. A clinician who understands the client’s triggers for self-injury and where they come from will be more able to detect these potential triggers on regularly visited sites. It may also be fruitful to identify and recommend other sites on self-injury that offer healthier support to interested clients, as well as facilitate the development of appropriate support within existing social networks.

Kleespies, P.M., AhnAllen, C.G., Knight, J.A., Presskreischer, B., Barrs, K.L., Boyd, B.L., & Dennis, J.P. (2011). A study of self-injurious and suicidal behavior in a veteran population. Psychological Services, 8(3), 236-250.

Summary

United States military veterans who were medical or psychiatric patients enrolled at a Northeastern VA health care system were each given a “post self-injury” interview. The interview was based on three well-established measures: the Suicide Intent Scale, Risk-Rescue Rating Scale and Self-Harm Behavior Questionnaire. The interview and nature of the study were designed to learn about the frequency and type of self-injurious behaviors as well as how these behaviors relate to intent to die. Patients tended to rate their risk of suicide significantly higher than those assessing them. Most who reported self-harm behaviors in the past rated their behaviors as moderate to high lethality regardless of the objective immediate lethality of those methods. Women and younger veterans were less likely to self-injure with suicidal intent, and women and those who were experiencing a divorce or separation were more likely to be repeat self-injurers. More than 80 percent of participants viewed their self-injuries as impulsive acts, which is of concern since impulsivity is a personality trait often seen in those who commit suicide. Planned self-injury was associated with greater reports of intent to die. Those participants who committed suicide over the course of the study were most likely to have been in combat.

Practical Implications

Clinicians and clients may not share the same belief regarding the intent and lethality of the self-injurious behavior. Objectively, some behavior may not be lethal but the intent might be suicide. Understanding the client’s belief is critical in determining whether such actions are truly self-injurious but non suicidal, or whether suicide is a desired outcome. Recognition of this difference in perspective may ensure more accurate assessment of current and future risk and might suggest different treatment interventions. The finding that those who committed suicide over the course of the study were most likely to have seen combat emphasizes the substantial risk combat soldiers are exposed to and the necessity of finding a way to give soldiers a more thorough mental health assessment and make services accessible and convenient for those returning from combat.

Smith, H.P. & Kaminski, R.J. (2011). Self-injurious behaviors in state prisons: Findings from a national survey. Criminal Justice and Behavior, 38(1), 26-41. doi: 10.1177/0093854810385886

Summary

In order to improve knowledge about the rates of self-injury in correctional facilities, 473 US correctional facilities were surveyed and 273 responses were received. Approximately 89 percent of the respondents were chiefs, directors, administrators or supervisors of mental health professionals at the respective correctional facility. Almost every respondent reported at least one known case of self-injurious behavior (SIB) and most facilities had at least one serious self-injurer. Some facilities reported up to one third of its inmates participating in SIB as well as almost one tenth of its inmates seriously self-injuring. The forms of SIB occurring in prisons ranged from medication overdoses to ingesting caustic solutions and foreign objects to hunger strikes and self-abuse. An overwhelming number of self-injurious incidents involved the use of an object to self-harm, posing a substantial challenge for those working to prevent access to such tools. SIB is most often treated through therapeutic and psychotropic interventions, but more punitive responses such as restraint, control and isolation were also reported. Isolation is of particular concern because of its known tendency to increase the number of future attempts. Many prisons are also using suicide protocols for assessment and response to SIB, which may address immediate safety issues but not the reasons for the behavior. While all-female facilities had higher rates of self-injury, they did not have higher rates of serious self-injury. Serious self-injurers were more likely to be found in specialized maximum security units in likelihood because they had been transferred to such facilities because of risk or problematic behavior.

Practical Implications

Mental health services in correctional facilities are frequently underresourced. Advocacy for the health and safety of both inmates and employees is needed to insure an appropriate number of mental health professionals and more accurate screening measures in facilities. An overworked system is more likely to gather insufficient information, increasing the risk for individual inmates as well as providing inaccurate portrayal of correctional system operations. Increased information and improved assessment of self-injurious behavior will provide a clearer picture of the pattern of such behavior and will better allow correctional staff to prevent or reduce the exchange of goods to inmates that might be used for self-injury.