The impact of ambivalence on recovery from non-suicidal self-injury: considerations for health professionals

DSM-5 non-suicidal self-injury disorder in a community sample: comparing NSSI engagement, recency and severity among emerging adults

Up to one in five emerging adults engage in non-suicidal self-injury (NSSI). Providing a better understanding of factors that differentiate between who engages in lifetime NSSI and who is more likely to engage in recent and clinically severe NSSI can provide meaningful information for prevention and intervention of NSSI. The present study (n = 669) considered NSSI lifetime engagement (no prior history of NSSI vs. lifetime NSSI), recency [past NSSI (>12 months ago) vs. recent (≤12-month) NSSI], and clinical severity among those with recent NSSI (subthreshold vs. DSM-5 NSSI disorder). The prevalence of NSSI disorder was 8.4% in emerging adults aged 18 to 26 years old. Higher anxiety levels were related to NSSI engagement, but only depressive symptoms and NSSI versatility were consistently associated with more recent NSSI and NSSI disorder. A stepped-care approach may be required in addressing NSSI among emerging adults.

Developmental pathways of repetitive non-suicidal self-injury: predictors in adolescence and psychological outcomes in young adulthood

BACKGROUND

Much longitudinal research has been carried out on non-suicidal self-injury (NSSI) during the last decades, but there still is a lack of studies of the individual developmental pathways of NSSI from adolescence into young adulthood. The aim of the present study was to investigate individual developmental pathways of repetitive non-suicidal self-injury (repNSSI) from adolescence into young adulthood, including adolescent predictors and psychological outcomes in young adulthood. Three developmental pathways were targeted: stable adolescence-limited repNSSI; repNSSI prolonged into young adulthood; and late-onset repNSSI; with no repNSSI as comparison.

METHODS

Data were taken from a cohort of compulsory school students (N = 1064) in grades 7-8 in a Swedish municipality. The cohort was followed longitudinally, and this study included all individuals (n = 475) with NSSI data from three waves: T1 (when they were 13-15 years old); T2 (one year later); and T3 (ten years later). RepNSSI was operationalized as self-reports of at least 5 instances of NSSI during the past six/twelve months.

RESULTS

The two pathways that involved stable repNSSI were observed significantly more often than expected by chance, with the strongest overrepresentation for the Prolonged RepNSSI pathway. Still, most adolescents who engaged in stable repNSSI stopped this before reaching young adulthood. Those who stopped did not, however, show a significantly better psychological adjustment in young adulthood than those who continued. Compared to participants with no repNSSI, participants who had stopped still reported significantly more stress, anxiety, and emotional dysregulation. As to the prediction of late onset NSSI, the findings were less robust, but sporadic NSSI at T1 and poor sleep at T2 were significant predictors, whereas depressive symptoms fell just short of significance at both timepoints.

CONCLUSIONS

The present results indicate that among adolescents who engage in stable adolescent repNSSI (1) significantly more individuals than expected by chance still engage in repNSSI ten years later, and (2) those who stop engaging in repNSSI do not show significantly better psychological adjustment than those who still engage in it. The present findings also indicate that late onset of repNSSI as reported in young adulthood to some extent is predictable from symptom measures ten years earlier.

A longitudinal investigation of non-suicidal self-injury persistence patterns, risk factors, and clinical outcomes during the college period

BACKGROUND

Although non-suicidal self-injury (NSSI) is known typically to begin in adolescence, longitudinal information is lacking about patterns, predictors, and clinical outcomes of NSSI persistence among emerging adults. The present study was designed to (1) estimate NSSI persistence during the college period, (2) identify risk factors and high-risk students for NSSI persistence patterns, and (3) evaluate the association with future mental disorders and suicidal thoughts and behaviors (STB).

METHODS

Using prospective cohorts from the Leuven College Surveys (n = 5915), part of the World Mental Health International College Student Initiative, web-based surveys assessed mental health and psychosocial problems at college entrance and three annual follow-up assessments.

RESULTS

Approximately one in five (20.4%) students reported lifetime NSSI at college entrance. NSSI persistence was estimated at 56.4%, with 15.6% reporting a high-frequency repetitive pattern (≥five times yearly). Many hypothesized risk factors were associated with repetitive NSSI persistence, with the most potent effects observed for pre-college NSSI characteristics. Multivariate models suggest that an intervention focusing on the 10-20% at the highest predicted risk could effectively reach 34.9-56.7% of students with high-frequency repetitive NSSI persistence (PPV = 81.8-93.4, AUC = 0.88-0.91). Repetitive NSSI persistence during the first two college years predicted 12-month mental disorders, role impairment, and STB during the third college year, including suicide attempts.

CONCLUSIONS

Most emerging adults with a history of NSSI report persistent self-injury during their college years. Web-based screening may be a promising approach for detecting students at risk for a highly persistent NSSI pattern characterized by subsequent adverse outcomes.

Profiling ambivalence in the context of nonsuicidal self-injury

BACKGROUND

We aimed to identify profiles of ambivalence among individuals with a history of non-suicidal self-injury (NSSI) and tested whether profiles differed across various theoretically informed constructs: NSSI-related characteristics, cognitive (outcome expectancies, self-efficacy to resist NSSI), emotional (psychological distress, difficulties in emotion regulation), personality, and incentives to engage/not engage in NSSI.

METHODS

Individuals with a lifetime history of NSSI (n = 224) reported the extent to which they wanted to and did not want to engage in NSSI and completed well-validated measures of the constructs of interest.

RESULTS

Latent profile analysis indicated four ambivalence profiles (avoid: n = 39; moderately ambivalent: n = 85; highly ambivalent: n = 30; approach: n = 70). The profiles differed across a number of NSSI-related characteristics, cognitive, emotional, and incentive-related variables. Differences between the ambivalence profiles and the avoid/approach profiles varied across constructs. For example, the ambivalence and approach profiles were similar for NSSI-related outcome expectancies, but the ambivalence and avoidance profiles were similar for self-efficacy to resist NSSI.

CONCLUSION

Findings highlight variation between the desire to engage or not engage in NSSI that are consistent with the notion of ambivalence. Understanding these differences may allow for a more person-centered approach in treatment for NSSI.

Reasons for recovery and readiness to change among adolescents and young adults engaging in self-injury

Background

Non-suicidal self-injury (NSSI) typically begins during adolescence and the process of treatment and recovery can be challenging. We examine NSSI through the lens of the Transtheoretical Model of Change, a framework that views the process of change as five stages, with differing degrees of readiness to change.

Methods

Thirty participants, both adolescents and young adults (14 to 35 years), were recruited from a tertiary care neuropsychiatric hospital. The participants were predominantly female and had self-injured at least once in the last year. They completed the Inventory of Statements about Self Injury, the University of Rhode Island Change Assessment and the Reasons to Stop Self-Injury Questionnaire.

Results

Seventy-three percent were in the contemplation stage with respect to their readiness to change, while the rest were in the pre-contemplation stage. Participants endorsed a range of vulnerability and resilience related reasons to stop injuring; reasons related to self-efficacy, the addictive nature of NSSI, self-efficacy and impact on interpersonal relationships were prominent levers for the recovery process. Preliminary trends indicated that participants in the contemplation stage endorsed reasons to stop self-injuring more strongly than those in pre-contemplation.

Conclusion

The findings carry implications for assessment, the amplification of reasons for recovery and individualized interventions to support the recovery process with individuals who engage in NSSI.

Cognitive-emotional networks in students with and without a history of non-suicidal self-injury

BACKGROUND

Contemporary models of non-suicidal self-injury (NSSI) suggest that emotional vulnerabilities, negative self-schemas, and beliefs about NSSI work together to differentiate students who self-injure from those who do not. However, it is unclear how these mechanisms are differentially related among students with and without a history of NSSI. Considering this, we used a network analysis approach to explore how students with and without a history of NSSI vary in processing their emotional experiences in relation to their self-concepts and beliefs about NSSI.

METHOD

A sample of 480 university students (M_age = 21.18, SD = 2.43; 73.5 % female) completed self-report measures about their perceived emotional experiences (e.g., emotional reactivity, emotion regulation difficulties), self-concepts (e.g., self-esteem, self-efficacy), and NSSI.

RESULTS

A network comparison test revealed that students with a history of NSSI perceived themselves to have difficulties regulating particularly intense, unwanted negative emotions. In light of this, students with a history of NSSI expected some benefits of NSSI (e.g., emotion regulation) regardless of potential barriers (e.g., pain). Conversely, for students without a history of NSSI, expecting NSSI to have aversive outcomes was tied to expecting NSSI to have few benefits.

LIMITATIONS

The cross-sectional design limits inferences to be made about the network structures.

CONCLUSIONS

Students with and without a history of NSSI appear to differ in their cognitive processing of negative emotions and strategies used to deal with these emotions.

Is ceasing self-injury enough? Differences in psychological health between people reporting behavioral cessation of non-suicidal self-injury and those who consider themselves to have stopped self-injuring

OBJECTIVE

This study examined the overlap between considering oneself to have stopped nonsuicidal self-injury (NSSI) and the actual cessation of the behavior in terms of days self-injured in the last month and last year, and how these operationalizations are associated with constructs related to NSSI recovery.

METHODS

A cross-sectional survey including measures of coping, emotion dysregulation, psychological distress, general self-efficacy, and self-efficacy in resisting NSSI was answered by 144 adults aged 17-81 years (Mage [SD] = 21.43 [7.32]).

RESULTS

Having self-injured for ≥5 days in the last year was overly inclusive of individuals who currently considered themselves as having stopped NSSI (39.02%). Considering oneself to have stopped NSSI was associated with better emotion regulation (Cohen's d = 0.45), and higher general self-efficacy and higher self-efficacy to resist NSSI (d = 0.59-0.64) than behavioral cessation. Not actually engaging in NSSI was only associated with self-efficacy to resist NSSI in risk contexts, such that fewer days self-injured in the last year increased confidence (partial η2  = 0.085).

CONCLUSION

Accounting for whether an individual considers themselves as having stopped NSSI or not may complement estimates of behavioral cessation, and strengthen outcomes associated with NSSI recovery.

Revisiting Social Stigma in Non-suicidal Self-injury: A Narrative Review

Non-suicidal self-injury (NSSI) is highly prevalent in our community. Yet, there is a significant discrepancy between the number of individuals engaging in NSSI and those who seek treatment for NSSI. This discrepancy can be due to the high social stigma associated with the behavior. The impact of NSSI stigma is significant and can impair the quality of life in the individuals engaging in NSSI, delay help-seeking, reduce access to mental health care and further fuel misinformation. Even though the symptomatology, risks, and demographics of NSSI have received attention in terms of research, there is limited literature on NSSI stigma and its consequences. With that background set, this review provides a bird's-eye view of the different levels of stigma in NSSI (public, self, and health care), associated discrimination, the various aspects of such stigmatization (NSSI-related language, physical scarring, misinformation, the media), and, finally, the collaborative clinical-outreach interventions for mitigating NSSI-associated social stigma. If NSSI is indeed recognized as a clinical disorder, future research would need to focus on these constructs of stigma and treat them with the same importance as the one given to clinical studies of intervention and symptomatology in NSSI.

Review: Young people's recovery processes from mental health problems - a scoping review

BACKGROUND

Recovery from mental illness and mental health problems is relatively well-researched among adults, but evidence that focuses on the recovery experiences of young people and what characterizes it is scarce. With this in mind, this article aims to map out the existing research in order to identify prevailing knowledge about the recovery of young people between the ages of 12 and 25.

METHOD

Drawing on scoping review methodology, this article is based on an analysis of 33 articles conducted in the USA, Australia, and Europe.

RESULTS

Our findings reveal that young people express both similar and divergent lines of reasoning about recovery compared with adults. Our findings also indicate that young people often fluctuate in the way they view recovery, and that they thus tend to be ambivalent about what recovery means. Parents usually highlight the importance of professionals facilitating recovery, while care staff problematize the organizational frameworks available as aggravating circumstances for implementing personal recovery. Young people, parents, and care staff consistently describe recovery as a way to, despite lingering problems, enable a satisfying life.

CONCLUSIONS

Through this review, we outline the need for a more distinct focus on agency and participation in young people's recovery processes, at the same time as family involvement needs to be further investigated and operationalized.

Cognitive and emotional factors associated with the desire to cease non-suicidal self-injury

Background

Due to cognitive and emotional differences between individuals who have and have not stopped self‐injuring, we explored these in the context of desire to stop.

Method

Australian university students (n = 374) completed cognitive and emotional measures. Comparisons were made between those who had self‐injured in the past 12 months and those who had not, and between individuals who reported wanting to stop self‐injuring and those who did not.

Results

Approximately 20% of participants did not want to stop self‐injuring. Cognitive emotional factors (psychological distress, self‐efficacy to resist, difficulties regulating emotion, interpersonal functions, and outcome expectancies) differentiated individuals who had and had not stopped, but could not explain differences in desire to stop.

Conclusion

Factors associated with desire to stop are not the same as factors underlying behavioural cessation. Motivational approaches to changes in self‐injurious behaviour would be beneficial for clinicians and their clients.

"What I couldn't do before, I can do now": Narrations of agentic shifts and psychological growth by young adults reporting discontinuation of self-injury since adolescence

PURPOSE

We explore young adults' narrations of life events in association with nonsuicidal self-injury (NSSI) discontinuation, psychological growth, and agency.

METHODS

Transcripts from eleven face-to-face interviews with individuals who quantitatively reported injuring themselves in adolescence (2007-2008) but not in young adulthood (2017) were narratively analysed.

RESULTS

We found that at starting points, a period preceding an agentic shift in the narrative, participants endured stressful living conditions and mental illness. During this period, participants perceived no point in trying to initiate change because they did not perceive themselves as having the capacity to do so and nor could they adequately utilize any formal or informal support. After a turning point that enabled agency due to gaining a sense of belongingness, liberation, or perspective, participants underwent a process of attaining psychological well-being. However, narrating psychological growth also required momentum points, encompassing the management of and moving on from stressful contexts, along with the recognition of milestones marking improvement relative to the starting points.

CONCLUSIONS

NSSI discontinuation was narrated in conjunction with psychological growth when participants also experienced themselves as situated within an agentic context, because agency is understood as necessary to react to and manage current and future life circumstances.