Also, it may be helpful to ask, "How did you learn to hurt yourself?" This examines both the functions of NSSI and the possibility of contagion. Contact with peers who also engage in NSSI may positively reinforce this maladaptive behavior. Knowledge of active behavioral contagion suggests the need for changes in the adolescent's social environment, which may include limiting unsupervised access to certain friends or the Internet. While the clinician will likely view NSSI as a serious issue, the adolescent may not see it as a problem. It is extremely important to ask, "Do you think this is a problem?" Discovering where the adolescent is on the Stages of Change (Transtheoretical) model will inform the therapeutic approach that will most likely be successful.25 The Stages of Change model is a general approach to helping patients change behavior.25 It recognizes that changes in behavior may involve a patient moving gradually from being uninterested in change (precontemplation) to considering change (con-templation) to deciding and preparing to make a change.25 Other helpful questions for the interview are included in Table 1.
General therapeutic approaches
Information gathered about the self-injurious behavior, especially core psychological problems and triggers, can be used to develop interventions. Asking questions using the Stages of Change model as a framework may allow a patient to begin thinking about change as well as the benefits and barriers to change (Table 1). In addition, it is useful to help patients identify alternative ways to reach goals associated with this behavior, such as feeling strong, connected, in control, and independent.26 Clarifying questions may be very powerful, such as, "Who is in control of your life—the cutting or you?" It is also wise to highlight the other aspects of NSSI that may be distasteful to the patient, including scarring, secrecy, shame, wound infections, doctor visits, stigma, the potential for addiction to the behavior, and accidental death.
In my experience, the majority of NSSI cases improve following disclosure and supportive therapeutic techniques. NSSI also may be reduced through the treatment of comorbid mental health conditions. Therapeutic approaches involving cognitive restructuring, behavioral modifications, motivational interviewing, assertiveness training, and teaching alternative coping mechanisms are the common practice. Several comprehensive guidebooks discussing self-injury and its treatment are available. Walsh27 and Conterio and Lader28 describe contingency management, including treatment participation agreements and replacement skills; cognitive-behavioral assessment of self-injury, using the terms "Self-Injury Log" and "Impulse Control Log," respectively; and ways to address common cognitive distortions for self-injurers.
Treatment participation agreements involve the terms, structure, goals, and rewards of the recovery plans. Replacement skills cover alternative coping strategies to soothe or manage anxiety and tension, or at the very least temporarily deflect attention from self-injury; such activities include writing in a journal, mindful breathing, muscle relaxation, exercise, communicating with others, listening to music, and visualizing pleasant scenes.27,28 Logs chart the antecedents, the behavior itself, and the consequences of self-injury (or not self-injuring) in an attempt to eventually make the connection between thoughts, feelings, and behaviors.27,28 Often the logs later incorporate replacement skills; in which case, it may be known as a "Brief Skills Practice Log."27,28
The use of negative replacement skills, such as snapping a rubber band against the wrist or writing on the arm with a red marker (which may symbolically resemble self-injury without causing tissue damage), is controversial.27,28 Understanding the Stages of Change model and how to assess for motivation to change is important given Conterio and Lader's requirement for their program that "in the initial screening the patient must demonstrate a heartfelt and internal motivation to stop injuring."28If self-injury continues despite attempts with the interventions already described, or if the self-injurious behavior is severe, then pharmacotherapy and/or other more specific and intensive psychotherapeutic interventions should be considered.
Psychotherapy for self-injury
Dialectical behavioral therapy (DBT) is perhaps the best-studied psycho-therapeutic intervention for NSSI. Although a thorough explanation of DBT is beyond the scope of this article, it is a variation of cognitive-behavioral therapy (CBT) that also includes mindfulness training. Through individual and group skills training, patients learn emotional regulation, how to cope with negative affect, and problem-solving techniques. DBT has demonstrated direct and sustained effects for individuals with BPD and self-injury in at least 7 well-controlled trials with different patient populations, including adolescent inpatients.29-31 In these studies, researchers found decreases in the percentage of patients with self-inflicted injuries, number of self-inflicted injuries, and medical risk of injuries.
However, traditional DBT may not be unique in its ability to treat NSSI. In randomized controlled trials, a program that uses CBT techniques called "manual-assisted cognitive treatment" demonstrated efficacy for reducing both the severity and frequency of deliberate self-injury in patients with BPD.32There is also some evidence for therapeutic interventions that do not rely on the principles of CBT. In a recent long-term trial comparing DBT with nonbehavioral community treatment, NSSI was reduced equally by both protocols.30 A psychoanalytically oriented partial hospital program also showed reductions in self-injury.33