Characterising self-harm and implications for empirical research
1.1 What is Self-harm?
The NICE guidelines define self-harm as self-poisoning or self-injury, irrespective of the apparent purpose of the act. Other authors (e.g Whitlock, 2010) define self-harm as acts of deliberate, self-inflicted physical damage with no explicit intention of committing suicide and for reasons not socially accepted. Although self-cutting is probably the best well known method of self-harm, other methods include self-hitting (battery), pinching, scratching, biting or even burning (Greydanus and Shek, 2009). Moreover, the part of the body where self-harm is conducted varies significantly. Injuries inflicted on the face, eyes, jugular area, breast, or genitals are particularly important as they hint a greater level of psychological distress and, potentially, indicate a worse prognosis for treatment (Whitlock, 2010). Effectively, this suggests a point for consideration when analysing the effectiveness of psychological therapies.
Self-harm has also been statistically correlated with suicide (Whitlock, 2010), with a 4-year cohort study by Cooper, Kapur, Webb, Lawlor, Guthrie and Mackway-Jones (2005) reporting approximately a 30-fold increase in risk of suicide, compared with the general population.
In the most recent edition of the Diagnostic and Statistical Manual (DSM-V) self-harm is now a distinct condition, recognising the possibility of self-harm existing outside of a Borderline Personality Disorder (BPD) diagnostic; however, in the previous version of the manual self-harm was considered a symptom of BPD (Cohen, 2014).
1.2 Why do people Self-harm?
Greydanus et al. (2009) have developed and etiological list of self-harm that includes suicidal ideation, feelings of hopelessness, low self-esteem, depression, impulsivity, family dysfunction and conflict, bullying and intimidation in school, poverty and others. Effectively, the reasons are so varied that call for a multifaceted ecological model. Additionally, some authors (e.g., Whitlock, 2010; Hawton, Saunders, O’Connor, 2012) suggest that the etiology of self-harm can be observed from three perspectives: while the psychological perspective primarily explains individuals self-harm in light of emotion regulation theories, i.e., as a means to reduce psychological pain and distress by redirect own attention to a concrete stimulus, the social/cultural perspective distinguishes the interpersonal contributions to self-harm initiation and maintenance. Finally, the biological/genetic perspective suggests that people that self-harm have low levels of endogenous opioids and self-harm serves as a way to restore normal levels (Whitlock, 2010).
1.3 The Treatment of Self-Harm
The standard method to care for self-harm has been hospitalisation; however, this is an expensive approach that has not demonstrated consistent results in controlled clinical trials (Muehlenkamp, 2006; Slee, Arensman, van der Leeden, Garnefski and Spinhoven, 2008). Several complementary treatment and alternative approaches have been suggested and tried (for a review, see Kerr, Muehlenkamp and Turner, 2009), ranging from pharmacologic treatments, psychodynamic therapies – including Transference-Focused Psychotherapy, and Mentalization-Based Therapy –, Family Therapy or Group Therapy and Cognitive-Behavioral Therapies (CBT).
Muehlenkamp (2006) suggests that CBT-based therapies may have the highest chances of reducing self-harm. Indeed, the systematic method of analysing and changing patient’s cognitive processes, associated behaviours and emotions could represent a potential treatment match for the deficiencies in the emotion regulation mechanism (Muehlenkamp, 2006). In particular, Dialectic Behaviour therapy (DBT) – developed by Linehan (1993, cited in Muehlenkamp, 2006) to treat individuals with BPD – is considered the gold standard for its efficacy and effectiveness (Miller and Smith, 2008). The main treatment goals of DBT are to address motivational obstacles during treatment, help clients develop new coping skill sets, and promote the generalization of the new skill sets in day-to-day situations. (Muehlenkamp, 2006). Moreover, the dialectical component offers a solution to any bottlenecks arising during treatment as a result of the rigid thinking and behavioural pattern and emotional extremes that characterise self-harm patients (Koerner & Dimeff, 2007). Finally, DBT works under the assumption that self-harm is the product of a biological vulnerable individual acting in a pervasively invalidating environment (Koerner & Dimeff, 2007), thus further contributing to addressing the ecological model of the etiology.
1.4 The Research Question
Several studies have supported the efficacy of DBT in reducing both the number of self-harm acts (Slee , Arensman, Garnefski, Spinhoven, 2007). However, the nature of self-harm – with its diverse aetiology and complex symptomatology, association with BPD and risk factors – and the philosophical approach that characterises DBT could limit the generalisation of each of these studies.
The purpose of this literature review is then to answer the question:
Is Dialectical Behavioural Therapy (DBT) an effective treatment approach for reducing self-harm?
In answering this question, 10 empirical studies will be reviewed and its strengths, limitations and findings critically discussed. Given the range of CBT-based techniques and, by definition, the significant overlap in methodology, only empirical studies explicitly mentioning the use of CBT as treatment will be analysed. Furthermore, because Randomised Controlled trials (RCT) are the most rigorous way of determining whether a cause-effect relation exists between treatment and outcome, priority in the analysis will be given to this type of studies. Finally, it should be noted that most of the empirical studies discuss self-harm in the context of a diagnosis of BPD and use the term parasuicide to identify self-harm behaviours that do not have an immediate suicide intention.
2. Dialectical based treatments for Self-harm
Findings and limitations from empirical studies
Koons et al. (2001) recruited 20 Women Veterans with Borderline Personality Disorder (BPD) to participate in a 6 months RCT involving DBT and treatment as usual (TAU). The researchers concluded for the general efficacy of DBT in a number of psychological measures. Importantly, only the patients in the DBT condition showed a significant decrease in number of parasuicide acts. Koons et al. (2001) also reported that the training received by therapist and their enthusiasm might have confounded the results. Despite the significant clinical changes produced by DBT, any generalisation from this study is limited by its low power. Moreover, the period of treatment is probably too short to support long-term inferences.
In a RCT involving 23 heroin dependent women, Linehan et al. (2002) report DBT being as effective as a Comprehensive Validation Therapy with 12-Step (CVT + 12S) in reducing self-harm acts. An independent 16 month follow-up suggested that the elements that make DBT effective in reducing self-harm could be common to other therapies. Researchers also acknowledged another possible confound resulting as a consequence of using different therapists in each condition. In addition, the clinical population in this study does not support a generalisation.
Similar findings are reported in a 12-month Dutch randomised control study involving 64 women diagnosed with BPD (Verheulvan den Bosch, Koeter, deRidder, Stijnen and van den Brink, 2003). Verhuel et al. (2003) reported that the acts of self-harm decreased significantly over the treatment year for DBT patients, while it increase for patients in the TAU condition. However, the researchers acknowledge that the results might have been biased by the greater enthusiasm displayed by the DBT therapists. Support for the effectiveness of DBT in treating BPD and self-harm, in particular, was also reported in a two-year RCT controlled trial by Linehan et al. (2006). Crucially, this study addressed some of the limitation identified in previous studies – it had a large sample size (111 participants); it was conducted over a longer period of time; and TAU was conducted by experts in order to maximise internal validity – making its results more general.
In addition to RCTs, a number of other studies have investigated the effectiveness of DBT in reducing self-harm. Low, Jones, Duggan, Power and MacLeod (2001) studied the use of DBT to treat 10 female self-harming women resident at Ramptom Secure Hospital, in the UK. Importantly, rates of self-harm were gathered monthly from ward records, representing a trustworthy measure. Results showed a significant decrease in self-harm acts from the pre-treatment baseline up to the 6 months follow-up. Interestingly, the variable measuring dissociative experiences – closely associated with mindfulness, a skill learned in DBT – reduced significantly from pre-treatment baseline (Low et al., 2001). However, this study suffered from several limitations, the most important of which were the lack of a control group and the small sample size. Furthermore, the researchers report that two patients with limited cognitive abilities dropped the study suggesting DBT may not be suitable for a clinical population with these characteristics.
Similarly, a study by Comtois, Elwood, Holdcraft and Simpson (2007) reported the successful implementation of DBT in a large outpatient community mental health center. Thirty-eight female patients – 91% of which has and history of self-harm – were enrolled in a DBT program for, at least, 4 months. After 1 year the medically treated self-inflicted injuries had reduced from 2 during the pre-treatment period to 0. Other measures of success – e.g., psychiatric-related emergency room visits, total psychiatric inpatient admissions, total crisis related psychiatric hospitalizations – have also appreciated significant decreases (Comtois et al., 2007). The researchers concluded that their results were similar to those of other RCTs, but the difference in design warrant caution in any comparison. Furthermore the sample size was small and contained several outliers.
Turner (2000) randomly assigned a group of 24 participants meeting the criteria for BPD to either a one year long treatment using DBT or one year long treatment using client-centered therapy (CCT). All participants had initially been treated in local hospital emergency services for suicide attempts. Outcome assessment consisting of independent assessor ratings and patient self-reports at pre-treatment, 6-month, and 12-month revealed that patients in the DBT condition showed significantly improvements in areas of self-regulation and conducted significantly fewer acts of self-harm. Interestingly, Turner (2000) reports that the quality of therapeutically alliance explained as much variance in improvement as the treatments across all outcome indicators, suggesting CBT to be less sensitive to the quality of the therapist. Combined, these studies suggest that DBT is associated with a significant decrease in self-harm acts, but the lack of a control group and the small sample sizes are important limitations.
Although one important goal of DBT is to limit hospitalisation, some studies report the adaptation of the therapy for the use in hospitalization programs (Bohus et al., 2004). In a pilot study by Bohus, Haaf, Stiglmayr, Phol, Boehmeand and Linehan (2000), 24 female inpatients were treated for BPD including self-harm. Eighty-eight per cent of the patients who committed self-harm before the treatment reduced the behaviour within the first month. However, 3 patients who had not cut themselves prior to being admitted reported single acts of cutting following release. In the same line of other studies (e.g. Low et al., 2001) these researchers also report a significant decrease in dissociative experiences. In a subsequent study, Bohus et al. (2004) compared the results of applying DBT to treatment as usual (TAU). Sixty-two per cent of patients in the DBT condition who conducted acts of self-harm before the treatment abstained from doing at post-assessment, compared to 31% in the TAU condition. However, the absence of a random assignment of patients to each condition, as well as the absence of a longer term follow-up, limits conclusions.
Kröger et al. (2006) also studied the application of a 3 months DBT inpatient treatment (44 female vs. 6 male); the results obtained support the idea of using DBT in inpatient settings. Although one strong point of this study is that psychological measures were taken in a 15-month follow-up, these measures are not fully valid since 78% of patients received varied outpatient treatments in the period in between discharge and the follow-up. On the negative side, no measure of self-harm was obtained, although Kröger et al. (2006) extrapolate from previous studies that this would have been a major favourable outcome.
Overall, these studies recommend the adaptation of DBT to inpatient settings. Unfortunately, the majority of the studies revised contain several limitations that would recommend caution in any generalisation, namely the lack of control groups, which could to regression to mean as an alternative explanation, small or uncontrolled follow-up periods not supporting long-term conclusions, and the use of medication during in treatment.
Research gaps and future directions
Based on the literature reviewed, DBT seems to be an effective therapeutic approach for treating self-harm behaviours. The design of the majority of the studies was, however, faulty or limited in a number of aspects that indicate caution at the moment of generalising. In particular, most of the studies were limited by their small statistical power, their short duration (including follow-up) and the narrow subset of self-harm clinical population used. Moreover, six of the studies are severely limited by the absence of a control group.
Moreover, the association between self-harm and BPD is not without consequences for the empirical study of self-harm, in particular because the patients participating in the studies that have been reviewed had a number of other of psychopathologies (e.g depression, suicide ideation) and were being pharmacologically treated. As a consequence improvement in self-harm behaviour could also have been the result of the pharmacological treatment.
Interestingly, none of the studies reviewed used the part of the body suffering the injury as an independent variable. Having in mind that this factor closely relates to the level of psychological stress and might affect treatment prognosis (Whitlock, 2010), this could well be a topic for future research.
Out of this literature review, it stands out that the therapist might have an influence in the outcome. Four of the studies (Turner, 2000; Koons, 2001; Linehan, 2002; Verhuel, 2003) suggested the quality or the enthusiasm of the therapist might result in a more effective therapy. This highlights the need for well define guidelines and protocols for conducting DBT.
Looking ahead, the collective findings suggest that longitudinal, statistical well-powered studies involving self-harm patients without the spectrum of symptoms associated with BPD are needed to make any conclusions on effectiveness of DBT solid and reliable.
Bohus, M., Haaf, B., Stiglmayr, C., Phol, U., Boehme, R., & Linehan, M. (2000). Evaluation of inpatient dialectical behavior therapy for borderline personality disorder: A prospective study. Behaviour Research and Therapy, Vol 38, 878–887.
Bohus, M., Haaf, B., Simms, T., Limberger, M.F., Schmahl, C., Unckel, C., et al. (2004). Effectiveness of inpatient dialectical behavior therapy for borderline personality disorder: A controlled trial. Behaviour Research and Therapy, Vol 42, 487–499.
Cohen, L. (2014). Stepping Out Of The Shadows: Non-Suicidal Self-Injury As Its Own Diagnostic Category. Columbia Social Work Review, Vol 5. Retrieved from http://cswr.columbia.edu
Cooper, J., Kapur, N., Webb, R., Lawlor, M., Guthrie, E., Mackway-Jones, K., & Appleby, L. (2005). Suicide after deliberate self-harm: a 4-year cohort study. The American Journal of Psychiatry. Vol 162(2):297-303.
Comtois, K.A., Elwood, L., Holdcraft, L.C., & Simpson, T.L. (2007). Effectiveness of Dialectical Behavior Therapy in a Community Mental Health Center. Cognitive and Behavioral Practice, Vol 14, 406–414.
Hawton, K., Saunders, K. E., O’Connor, R.C. (2012). Self-harm and suicide in adolescents. The Lancet, Vol 379: 2373–82.
Koons,C., Robins,C. J.,Tweed, J. L.,Lynch,T. R., Gonzalez,A. M., Morese, J.Q., et al. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, Vol 32, 371–390.
Kröger, C, Schweiger, U, Sipos, V, Arnold, R., Kahl, K. G., Schunert, T., Rudolf, S., Reinecker, H. (2006) Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting. Behaviour Research and Therapy, Vol 42, 1211–1217.
Lewis, S.P., Heath, N.L., St Denis, J.M., and Noble, R. (2011). The Scope of Nonsuicidal Self-Injury on YouTubeVol. Pediatrics, 127 (3), 552-557. doi: 10.1542/peds.2010-2317)
Linehan, M. M., Dimeff, L.A., Reynolds, S. K., Comtois, K.A.,Welch, S. S., Heagerty, P., & Kivlahan, D. R. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, Vol 67, 13–26.
Linehan, M. M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L., Korslund, K.E., Tutek, D.A., Reynolds, S.K., Lindenboim, N. (2006). Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry, Vol 63, 757-766.
Low, G., Jones, D., Duggan, C., Power, M., & MacLeod, A. (2001). The treatment of deliberate self-harm in borderline personality disorder using dialectical behavior therapy: A pilot study in a high security hospital. Behavioural & Cognitive Psychotherapy, Vol 29, 85–92.
Miller, A.L., Smith H.L. (2008) Adolescent non-suicidal self-injurious behavior: The latest epidemic to assess and treat. Applied and Preventive Psychology, Vol 12, 178–188.
Muehlenkamp, J.J. (2006). Empirically Supported Treatments and General Therapy Guidelines for Non-Suicidal Self-Injury. Journal of Mental Health Counseling, Vol 28(2), 166–185.
Slee N., Arensman E., Garnefski N., Spinhoven P. (2007). Cognitive-Behavioral Therapy for Deliberate Self-Harm. Crisis. Vol. 28(4):175–182