Case Series on Effectiveness of Cutting-Down Program for Managing Non-Suicidal Self-Injury Among Adolescents

Abstract

Background:

Non-suicidal self-injury (NSSI) is an emerging issue among adolescents with a growing prevalence in clinical settings. It is a multi-faceted condition in terms of psychiatric comorbidities, variation in the form and method of self-harm, body area, the pattern of the wound and the function served, and therefore, understanding and managing it adequately in routine clinical practice is a challenge. There is a need for research to focus on in-depth understanding of the effectiveness of and process issues for existing interventions for NSSI in adolescents.

Aim:

The present research is a case series aimed at examining the effectiveness of the cutting-down programme (CDP), a manualized cognitive behaviour therapy programme, in reducing the frequency and intensity of NSSI acts and urges in two adolescents. The objectives of the study were to examine the effect of the CDP on depressive symptoms, dysfunctional attitudes, emotion regulation, experiential avoidance and global functioning in adolescents with NSSI, and to explore the association of patient motivation and patient perception of therapy with therapy outcome in adolescents with NSSI.

Method:

For the study, two adolescents with NSSI who presented to the Department of Child and Adolescent Psychiatry, NIMHANS, Bangalore, were recruited using purposive sampling. They were assessed using the MINI-International Neuropsychiatric Interview for Children and Adolescents (MINI Kid Screen 7.0.2). In addition, standardized were used to assess the severity and functions of NSSI, borderline personality disorder, depression, emotion regulation skills, dysfunctional attitudes, psychological flexibility and global functioning. The participants were also assessed on a semi-structured interview to assess NSSI every week during the intervention. Baseline measures were repeated when the CDP was completed. Further, the non-specific factors such as patient’s perceptions of therapy and patient motivation were assessed using the standardized scales.

Results:

The CDP was found to be effective in reducing the NSSI among the two adolescents. It also improved their depressive symptoms, dysfunctional attitudes, emotion regulation, experiential avoidance and global functioning. The therapy outcome was related to the participants’ motivations and perceptions of therapy.

Conclusion:

The CDP is an effective intervention for reducing NSSI acts. However, client characteristics such as perception and motivation for therapy will play a role in therapy outcome.

Introduction

Non-suicidal self-injury (NSSI) is the deliberate, self- inflicted damage of body tissue without suicidal intent and for purposes not socially or culturally sanctioned. ¹ This condition is highly prevalent with onset during adolescence and overlaps with and can increase the risk of suicide in individuals.^2–5 Non-suicidal self-injury is transdiagnostic phenomenon, that is, it can occur in individuals with different psychiatric disorders, ⁶ which can involve different methods, such as cutting, burning, scratching, or self-hitting, and can have different functions or reasons.^7,8 The phenomenon is diverse in clinical presentation, psychological correlates, and etiology, but is poorly understood with a dearth of research especially in India. ⁹

The present case series discusses the clinical presentation and psychotherapeutic treatment of two adolescents with NSSI. They presented with similarities and differences in the form and intensity of self-harm, psychiatric diagnosis, clinical history, and therapy outcome. The intervention used was the Cutting-Down Program (CDP), ¹⁰ which is a manual-based cognitive behavioral therapy (CBT) with components of dialectical behavioral therapy (DBT). It has been adapted for self-harm in adolescents by Taylor et al. ¹⁰ from an existing intervention called the Manual-Assisted Cognitive Therapy (MACT) for recurrent deliberate self-harm or parasuicide in adults. ¹¹ The CDP can be delivered over 8-12 sessions, which could be extended with optional sessions.

With this background, the present case series was undertaken to enhance understanding about NSSI and its treatment. The effectiveness of CDP in reducing intensity and frequency of NSSI and secondary psychological variables such as depressive symptoms, dysfunctional attitudes, emotion regulation, experiential avoidance, and global functioning, and the role of non-specific factors of patient motivation and patient perception of therapy in therapy outcome has been discussed.

Operational Definition

NSSI. Presence of or history of self-inflicted injury on one’s body without suicidal intent, as indicated in self-report measures or evident on observation.

Case Descriptions

This case series consists of two cases of adolescents who presented with NSSI with at least one instance of self-harm behavior in the past one year to the Department of Child and Adolescent Psychiatry, NIMHANS, Bangalore. Both adolescents were diagnosed with psychiatric conditions other than psychotic disorder, autism spectrum disorder, or intellectual disability, and did not engage in self-injury due to another mental or medical condition. The cases were selected using purposive sampling.

Case 1

The first case, participant A, is a 17-year-old female adolescent from an urban background and upper-middle socio- economic status. There is a significant personal history of child sexual abuse (CSA), bullying and peer victimization from peers and teachers, criticality by parents and teachers, academic stress and body image issues due to her dark skin complexion, and past history of an interrupted suicide attempt at the age of 10. The patient had a difficult temperament as a child and an insecure avoidant attachment style. There is history of one romantic relationship with multiple break-ups and instability. There is medical history indicating polycystic ovary syndrome. The participant was diagnosed with post-traumatic stress disorder, dysthymia, moderate to severe depressive episode, and a history of specific learning disability (SLD), with an insidious onset, continuous course, and total duration of illness being eight years.

Case 2

The second case, participant B, is a 16-year-old female adolescent, from a semi-urban background and upper-middle socio-economic status. There is past psychiatric history of panic attacks, mood fluctuations, and suicide attempt at the age of 16. The personal history suggests bullying by peers and teachers and IPR issues with father. The family history is suggestive of alcohol dependence and antisocial personality traits in father, dysthymia in mother, and domestic violence. The patient had an easy temperament as a child but an insecure anxious attachment style. There is history of one romantic relationships with frequent arguments. The participant was diagnosed with recurrent depressive disorder and current episode moderate to severe depression with an insidious onset, continuous course, and total duration of illness being two years.

Assessments

The participants were screened using MINI Kid Screen 7.2. ¹² For NSSI, they were assessed on Functional Assessment of Self-Mutilation (FASM), ¹³ and assessed weekly for NSSI acts (frequency of acts) and urges (intensity on a scale of 1-10) using a semi-structured interview prepared by researcher. They were further assessed on 6-item Kutcher Adolescent Depression Scale (KADS-6), ¹⁴ McLean Screening for Borderline Personality Disorder (MSI-BPD) ¹⁵ , Difficulties in Emotion Regulation Scale (DERS-18), ¹⁶ Acceptance and Action Questionnaire (AAQ-II), ¹⁷ Dysfunction Attitude Scale-Short Form 1 & 2 (DAS-SF), ¹⁸ Client Motivation for Therapy Scale (CMOTS), ¹⁹ and Children’s Global Assessment Scale (CGAS). ²⁰ After psychotherapy, post-assessments, parental rating of therapy outcome, and patient’s perception of therapy using the individual therapy process questionnaire (ITPQ) ²¹ were assessed.

The participants both met the criteria of major depressive disorder (MDD), dysthymia, and social phobia, on the MINI Kid Screen 7.0.2. In addition, participant B met the criteria for panic disorder. Both participants received scores above the cut-off on KADS, indicating possible depression. Participant A met the cut-off on MSI-BPD, indicating possible borderline personality traits.

Non-Suicidal Self-Injury Profile

The assessments and interviews indicated that both adolescents started engaging in NSSI at the age of 14 years. The methods of self-harm reported by both included cutting as most frequent, followed by self-hitting, and scratching, while one of them also reported excoriation of wounds. The total number of NSSI instances for participant A was 15, while it was 80 for participant B, corresponding to the intensities of “mild” and “severe,” respectively, on the Clinician Rated Severity of NSSI. ²² The functional analysis and context of NSSI was explored using FASM, and it revealed that participant A experienced severe pain during self-harm, reported 5-6 cuts per episode of self-cutting, inflicted injury mostly on hands and shoulders, with each episode lasting 10-15 min, and would engage in NSSI to feel alive or relaxed or have a sense of control over situations. Participant B reported moderate pain, making 5-10 or up to 20 cuts, inflicting injury on thighs, stomach, or wrist, with each episode lasting for 30 min, and for the function of overcoming numbness, punishing self, or eliciting a reaction from others. Both engaged in NSSI alone, tried to conceal their injuries from others, and primarily engaged in it to deal with negative emotions.

Therapeutic Intervention

The CDP, a manual-based CBT for self-harm behavior, was delivered to participants in 15-16 weekly sessions. The manual was followed for the structure, modules, and worksheets; however, to address the issue of cultural appropriateness of the intervention, specific examples from participants’ life experiences were discussed with different coping strategies or skills. The intervention had four modules, namely, “Getting Started”; “Feelings, Thoughts, and Behaviors”; “Coping”; and “On You Go”. The focus of these modules was on enhancing therapy motivation, identifying reasons for NSSI, testing alternative behaviors to NSSI, improving coping mechanisms, mindfulness, distress tolerance, stabilization of alternative behaviors, managing emotional crises, and preventing relapse. The treatment fidelity was ensured in terms of design, training, delivery, receipt, and enactment of the psychotherapy. ²³

Therapy Outcome

The NSSI acts reduced considerably for both participants; however, the NSSI urges fluctuated throughout the intervention. This is represented in Figures 1 and 2.

Figure 1.

Changes in Frequency of NSSI Acts of Participants Weekly.

Figure 2.

Changes in Intensity of NSSI Urges of Participants Weekly.

The parents of participant A reported that both NSSI acts and urges had reduced after the intervention. However, parents of participant B reported that although NSSI acts had reduced after the intervention, she continued to experience urges to engage in NSSI. The depression ratings on KADS-6 improved for both participants, but for participant A, it still met the criteria for “possible depression”. The scores of both participants improved for dysfunctional attitudes, experiential avoidance, and global functioning after intervention. On DERS-18, the scores improved for emotional clarity, engaging in goal- directed behavior in presence of difficult emotions, and acceptance of emotions for both participants, while for emotional awareness and emotional regulation strategies, scores remained unchanged for at least one participant.

Furthermore, in terms of patients’ motivation for therapy, the findings on CMOTS indicate that one participant had consistently higher levels of motivation on the domains of intrinsic motivation, integrated regulation, identified regulation, introjected regulation, and lower on external regulation and amotivation as compared to the other participant. While the patients’ perceptions of therapy ‘based on ITPQ’ revealed that both participants reported the in- session impact, that is, clarification of meaning or understanding of the motivations behind their actions and behavior and the learning to cope with specific situations. They recognized the collaborative nature of the therapy and experienced therapeutic alliance during therapy. However, both patients reported the actual emotional experience of the problem in therapy sessions, and therefore, they had some amount of fear of opening up and sharing their experiences in the therapy sessions.

Discussion

The Case Series highlights the muti-faceted nature of NSSI, which can coexist with varied psychiatric vulnerabilities and psychosocial stressors. It discusses the profile of NSSI in two adolescents, with self-cutting as the most frequent method of NSSI and managing negative emotions as the most common reason.

The role of psychotherapy using a manualized intervention, the CDP was explored, and the study suggests that structured psychotherapy may be useful in reducing NSSI acts and urges in adolescents. In the present case series, the intervention reduced the NSSI frequency considerably, although lapses in NSSI were noted intermittently during the therapy in both adolescents. There was an improvement in the suicidality, depressive symptoms, dysfunctional attitudes, experiential avoidance, emotion regulation, and global functioning of the adolescents after intervention. This is in accordance with research that indicates that interventions that focus on skill training, intensive focus on self-injurious behavioral outcome, and addressing maladaptive behaviors are effective in reducing NSSI. ²⁴ However, further research is necessary to ascertain the effectiveness of CDP among the Indian adolescent population, due to small sample size and lack of generalizability of the findings of the case series. Despite being effective, psychotherapy for adolescents with NSSI has challenges and process-related issues, such as motivation for therapy and patient’s perception of therapy. The non-specific factors of patient motivation and perceptions of therapy were found to have an association with therapy outcome. Although both participants had similar findings on ITPQ, which was a measure of their perceptions of therapy, the participant with high intrinsic motivation also had a relatively better outcome in therapy, establishing motivation for change as an important factor in predicting reduction in NSSI after psychotherapy. ²⁵

There are various critical aspects to consider while using the CDP for adolescents who engage in self-harm. First, there seems to be an impact of adverse childhood experiences of the patients on the therapy outcome using CDP, as was observed for one participant (with history of childhood abuse and trauma) who improved but showed relatively lesser gains than the other. This participant also had lower therapy motivation than the other. An intensive intervention with a supportive rather than skills-focused framework may be better suited for cases with childhood trauma. Second, the CDP presented another challenge in terms of its time-limited format as opposed to the need for a long-term intervention for some patients. It was noted that while one patient improved, the other continued to report some difficulties such as remnant depressive symptoms and mood fluctuations, for whom therapy sessions were continued by the team. Although the CDP intervention allows the intervention to be tailored to individual patients’ needs and to be expanded with additional modules, some patients may benefit from long-term psychotherapy beyond the scope of CDP. Further, there were practical challenges in implementation, for example, more time needed to review the presenting concerns brought up each week by the patients and difference in pace of understanding and acquiring skills during therapy of each patient. Finally, there are multiple factors that may have influenced therapy outcome, including role of medications, homework compliance by the participants of the given worksheets and strategies, and other ongoing psychosocial factors.

Conclusion

NSSI in adolescence is a multifaceted phenomenon with diverse clinical presentations, etiologies, methods, reasons, and functions. The CDP is an intervention, which was effective in reducing NSSI acts and urges in the present case series, and in improving secondary outcomes of suicidality, depressive symptoms, dysfunctional attitudes, experiential avoidance, emotion regulation, and global functioning in both adolescents, although with challenges and process-related issues. The therapy outcome for adolescents with NSSI is intricately linked with multiple factors, including diagnosis of the patient, patient motivation, and patient perceptions of therapy. There is a need for further research to ascertain the effectiveness of CDP among the Indian adolescents.