Academic journal article Journal of Mental Health Counseling

Counseling Adolescents Who Engage in Nonsuicidal Self-Injury: A Dialectical Behavior Therapy Approach

Academic journal article Journal of Mental Health Counseling

Counseling Adolescents Who Engage in Nonsuicidal Self-Injury: A Dialectical Behavior Therapy Approach

Article excerpt

Nonsuicidal self-injury (NSSI), the direct and intentional destruction of one's own body tissue in the absence of any intent to die, is becoming an alarmingly common behavior in adolescents of both sexes and across all racial and ethnic groups. The purpose of this article is to (a) provide a model for conceptualizing the onset and maintenance of this behavior, and (b) describe how a dialectical behavior therapy treatment approach can be applied to working with adolescents who engage in NSSI.

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Nonsuicidal self-injury (NSSI), the direct and intentional destruction of one's own body tissue in the absence of any intent to die (Nock & Favazza, 2009), is becoming an alarmingly common behavior in adolescents of both sexes and across all racial and ethnic groups, with estimated rates of 13-45% in community and 40-60% in clinical samples (Hilt, Nock, Lloyd-Richardson, & Prinstein, 2008; Latzman et al., 2010; Muehlenkamp, Williams, Gutierrez, & Claes, 2009; Nock 8: Favazza, 2009; Rodham & Hawton, 2009). These high prevalence rates are of concern because NSSI is associated with high potential for health risks and severe physical harm, as it generally involves cutting skin with a sharp instrument (occurring in 70-90% of individuals) and can also entail scratching, hitting, inserting objects under the skin, or burning the skin (Nock & Favazza, 2009). Because the average age of onset is between 12 and 14 (Nock, Teper, & Hollander, 2007), the transition to adolescence may be a period of vulnerability for development of NSSI (Guerry & Prinstein, 2010; Nock, 2010; Prinstein et al., 2010). Further, NSSI is associated with other serious disorders that emerge during puberty, such as eating disorders, substance abuse, and depression (Kerr & Muehlenkamp, 2010; Klonsky & Muehlenkamp, 2007; Muehlenkamp et al., 2009). In addition, although NSSI by definition does not constitute a suicide attempt, 50-75% of those with a history of NSSI have also made at least one suicide attempt (Nock & Favazza, 2009).

Because of its prevalence, severity, and onset during a high-risk period of development, it is important for mental health counselors to have a model for understanding the complex functions of this behavior and be familiar with effective approaches to treatment that address the unique needs of adolescents. Unfortunately, counselors report general uncertainty about conceptualization and treatment of NSSI (Healey, Trepal, & Emelianchik-Key, 2010). To help resolve this problem, this article describes research-based models for understanding the onset and maintenance of NSSI and how the dialectical behavior therapy (DBT) treatment approach can be applied in working with adolescents who engage in NSSI.

RISK AND MAINTENANCE MODELS FOR NSSI

According to Nock (2010), individuals who self-injure often possess genetic or environmental risk factors that contribute to the likelihood that they will engage in NSSI as adolescents. For example, there is evidence that adolescents who engage in NSSI have a genetic predisposition toward high emotional/cognitive reactivity (Nock, 2010). Compared to adolescents who do not self-injure, those who do display higher physiological reactivity during distressing tasks, demonstrate less ability to tolerate this distress, and show deficits in social problem-solving (Nock & Mendes, 2008). Adolescents who engage in NSSI are also more likely to report traumatic experiences in childhood (such as chronic illness, major surgeries, or parental loss) and are more likely to report receiving harsh or critical parenting during their childhood (Yates, Tracy, & Luthar, 2008). Further, they are likely to have endured aversive childhood experiences, with up to 79% of self-injuring individuals reporting a history of child abuse, maltreatment, and neglect (Yates, 2009).

The presence of these types of risks in a child's life creates intrapersonal and interpersonal vulnerability to NSSI and other types of maladaptive coping behaviors, such as eating disorders or substance abuse. …

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