Opinion Research Paper

A Summary of “Cognitive-Behavioral Therapy for Deliberate Self-Harm”

Slee, N., Arensman, E., Garnefski, N., & Spinhoven, P. (2007). Cognitive-behavioral therapy for deliberate self-harm. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 28(4), 175.

Summary of Journal 

Deliberate self-harm is defined as the intentional wounding of one’s own body with or without apparent suicidal intentions. Research indicates that individuals who practice deliberate self-harm (DSH) form a diverse population, with different psychological and psychiatric needs. To effectively meet the needs of self-harmers, therapists need to create customized treatment plans that meet the needs of an individual patient. Slee, Arensman, Gernefski and Spinhoven (2007) review and analyze three specific DSH cognitive-behavioral theories to identify what is required to create flexible and individualized treatment programs. They then offer an overview of the best practice therapeutic techniques that can be utilized to meet the needs of DSH patients.
The first cognitive-behavioral approach to DSH reviewed is Dialectical Behavioral Therapy (DBT) (1993). In his work with suicidal patients with borderline personality disorder, Linehan discovered that patients often got discouraged and frustrated when the focus was on simply changing their thoughts, feelings and behaviors. Linehan created a more philosophical alternative treatment program using Zen practices. Along with traditional cognitive-behavioral techniques, Linehan introduced emotion regulation, distress tolerance, mindfulness and other Zen techniques that focused on establishing a calmer, non-judgmental and neutral attitude. The goal of the DBT therapy is to encourage a mindful attitude and discourage impulsive and mood dependent behavior. To create an environment and therapeutic relationship that is conducive to DBT, a therapist must also use Zen practices, including maintaining a nonjudgmental attitude and validate and recognizing the patients emotional distress. DBT relies on a strong, supportive, trusting and cooperative therapist-patient relationship. Because of the philosophical nature of DBT, it is difficult to summarize the effectiveness of the treatment. However, studies have been promising, with reduced DSH incidences, fewer hospitalizations, and increased general feeling of well-being in patients treated using DBT. It has not been shown to improve depression, substance abuse problems or suicidal ideation more than conventional cognitive-behavioral therapy. DSH appears to be most effective for treating DSH. The researchers suggest that DBT could be modified to specifically target other patient issues, but they recognize that the therapy requires an approach that may be unrealistic in routine clinical practice.

One approach to treating DSH that that may be more practical is

The Cognitive-Behavioral Approach of Berk et al. (2004) which involves a short intensive ten session cognitive treatment for DSH. The treatment is focused on reducing repetition of DSH and establishing a crisis plan, an analysis of the patients irrational feelings towards self-harm, and the use of coping cards. This approach has also shown promise in recent studies, with a therapy group %50 less likely to self-harm than subjects in the control group. They also reported lower levels of depression. This cognitive approach seems to be also effective at treating other problems, and is particularly useful for patients unable to commit to long term therapy.
The third therapeutic framework the authors examine is Rudd et al. (2001), which targets a broader range of patients, and focuses primarily on DHS. In this theory, the researchers identified what they call the “suicidal mode”, which is a combination of suicidal ideation, mixed moods, “death-related behaviors” and physiological reactions to thoughts and feeling. Focusing on these suicidal cognitions, Rudd et al. (2001) look at the patients worldview and belief systems, which often have recurring themes of social anxiety, low self-esteem and a lack of coping skills. Successful treatment involve changing the way the patient thinks about themselves and their external relationships. Like Linhan (1993), this framework relies on a trusting therapeutic relationship, which offers the support necessary for the patient to develop the skills to change their thinking processes and core beliefs about their identity.
Using these three cognitive-behavioral theories as a framework, the authors look to define the most effective techniques that can be used to tailor a flexible and responsive treatment program. Linhand (1993) and Rudd et al. (2001) both focus on the control of emotional distress. It is important, using these approaches, to encourage the patient to feel their emotions without judging and reacting to them. This mindfulness allows the patient to control mood and reduce impulsivity. to emotion-related action tendencies (Lynch et al., 2006). Instead of responding impulsively to the emotions, the individual is able to focus on alternative thoughts and release the negative emotions. Hopelessness can be reduced by focusing on the reduction or elimination of negative self thoughts and views of the future.
Slee et al. (2007) have developed a series of clinical application that can be used in two phases of the therapeutic process. During phase one, the therapist helps the individual identify and understand the most recent DSH incident. This allows the patient to start communicating and understanding the causes of their self-harm. Furthermore, it allows the therapist to develop a case formulation that is based on the individualized triggers or psychological problems that are at the root of the self-harm behavior. During phase two, the therapist and patient identify the problems areas, which may be irrational thoughts, mood imbalances or social problems. Once these irrational thought processes are identified, a treatment program is created and helpful beliefs and thought processes, such as mindfulness or impulse control can be introduced and these tools used by the patient during stressful stations. The treatment plan involves goal setting, the acquisition of coping skills, and addressing the specific problems associated with the patients DSH. These can be enhancing mood tolerance, increasing activity, or improving problem solving skills, communication and other social functioning. After case formulation, and establishment of a treatment plan, the third step of an effective cognitive-behavioral treatment plan is relapse prevention, which uses techniques like mindfulness to reduce repetition of the thoughts associated with self-harm. The authors conclude that creating tailored plans for patients who engage in DSH is important because of the heterogonous population. It is a complex problem that is often part of other psychiatric disorders. The analyses of the three cognitive-behavioral theories were used to create a treatment protocol with four mechanisms of change.

Individuals who engage in self-harm may be crying for help, and compassionate and supportive therapy is essential to help people who are vulnerable and hopeless. Using elements from the three cognitive-behavioral theories on DSH, the authors offer an interesting theoretical framework that therapists can use to address the problems associated with patients who engage in self-harm. The three theories examine the root causes of DSH. Linehan (1993) uses Zen Buddhist techniques to alleviate patients over-reliance on their emotions. He even advocates for using humor to lighten the mood, and this seems like a very positive idea, that may help patients who are in a very dark place emotionally. Using these techniques a patient can feel and express emotions without allowing them to control their behavior. If a patient is calm and rational, they are less likely to react impulsively and engage in self-harm. This is closely related to Rudd et. al (2001) which addresses suicidal modes, which are negative and spiraling emotional thought that leads to a cycle of despair and hopelessness. Often, a patient commits self-harm or has suicidal ideation because they are unable to change their thinking patterns and processes. Everything is the end of the world, and there is no hope or solution to the problems. It reminds me of the quote that “suicide is a permanent solution to a short term problem.” Using mental tools and tricks to give patients the coping skills they need to function, seems to be a large part the cognitive-behavioral therapies for DSH. The Mindfulness and other zen techniques used in Linehan (1993) can reduce the dark suicide mode of thinking discussed in Rudd et. al (2001). The authors do a very good job of taking the three theoretical approaches and creating a concrete action plan that can be used in a clinical setting. The also come up with four common themes that make these theories effecting in DSM treatment. This is a practical and useful way to take theoretical research and make it applicable for therapists who are dealing with patients with these overwhelming problems. It is also a very effective paper because it allows therapists to create a tailored program using different elements of the three theories, depending on the patients needs. DSH is a complex problem that usually involves co-occurring disorders, with a diverse population with different needs and requirements. One weakness of the study was the strong similarities of the three theories. A more strongly contrasting or opposing idea might help strengthen the others, or help the reader in understanding the overall theoretical framework of cognitive-behavioral theories on DSH. However, the three theories support each other, and can be used together, or elements taken from each, to create a plan that works for a specific person and therapeutic relationship. By breaking the three theories down into four essential mechanisms, and then offering a three step plan, the authors have made a valuable contribution; a tool that can used by therapists to encourage better outcomes for DSH patients in the future.

Reference

Slee, N., Arensman, E., Garnefski, N., & Spinhoven, P. (2007). Cognitive-behavioral therapy for deliberate self-harm. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 28(4), 175.