How can we stop our children from hurting themselves? Stages of change, motivational interviewing, and exposure therapy applications for non-suicidal self-injury in children and adolescents.

Abstract

Whoever studies the behavior of human beings cannot escape the conclusion that we must reckon with an enemy within the lines. It becomes increasingly evident that some of the destruction which curses the earth is self-destruction ... (Menninger, 1938, p. 4). The psychoanalyst Karl Menninger made some rather grim observations in Man Against Himself as he was explicating Freud's concept of thanatos or 'death instinct.' Relative to the converse idea of eros, the 'life instinct,' Menninger drew morbid conclusions about the mechanisms that he believed comprised dialectic in human development. He saw an paradox: on the one hand, the individual's essential motivation for autonomy, pride, and companionship, and on the other, the compulsion to self-inflict physical injury in reaction to unresolved shame, doubt, guilt and alienation. Menninger was commenting on what most researchers and clinicians regard today as deliberate, non-suicidal self-injury (NSSI). His remarks were compelling, and in hindsight, even prognostic. NSSI has become increasingly prevalent among children and adolescents (Kamen, 2009). The incidence of youth self-injury has risen in our schools and homes, affecting all socioeconomic classes. Further still, self-harming children may be experiencing any number of psychiatric disorders--from major depressive disorder, to obsessive-compulsive disorder, to bulimia and anorexia, to alcohol and substance abuse (see Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, M, 2006; Lofthouse, Muehlenkamp, & Adler, 2009). Studies also show that professionals who work with youth who self-injure find it to be one of the most challenging of psychological and behavioral issues (Nixon and Heath, 2009). Mental health professionals, pediatricians, school counselors and teachers, and youth workers have all conveyed that they feel ill-equipped to help these children. Consequently, some researchers are convinced that the problem of NSSI is woefully understudied and misunderstood (Prinstein, 2008). The fundamental premise of this paper, however, is that we need not be so discouraged. Pathological self-injury has been clinically studied for over 85 years (see Doctors, 1981), and applied behavior analysts have been validating operant conditioning models of NSSI for over 30 years (see Miltenberger, 2005). So, we can affirm with empirical conf idence that NSSI is a complex of learned responses that are reinforced in the context of psychobiological and environmental events. We can also remediate NSSI through the precision of functional analysis and behavioral interventions directly linked to that analysis (e.g., see Miller, Rathus, & Linnehan, 2007). Behavioral-environmental explanatory models that examine the antecedent conditions, complex topography and reinforcement systems of NSSI have the strongest empirical validation, relative to psychoanalytic and general biopsychosocial theories (Messer and Fremouw, 2007). Validated assessment and treatment protocols have allowed us to target NSSI behaviors and their functions so that we can help those youth who engage in NSSI (e.g., Nixon and Cloutie r, 2005). By the same token we know which theories of self-injury to rule-out due to unverified (and un-verifiable) theory, case study methodology and anecdotal evidence (e.g., Dalden, 1990; McAndrew and Warne, 2005; Williams, 2005; Suyemoto and MacDonald, 1995; Zila and Kiselica, 2001). With NSSI, we are dealing with a complex and dangerous mental health problem; however, we do not have an inescapable paradox on our hands. Rather, we are in a good position, conceptually and empirically, to evolve the behavioral analysis, assessment process, and treatment of NSSI. Research on the etiology and treatment of NSSI integrates knowledge from neurobiological, cognitive-behavioral, operant conditioning, and socioemotional principles and theories (Nixon, Aulakh, Townsend, & Atherton, 2009). …