Background
Nonsuicidal self-injury (NSSI) is defined as the deliberate self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned [
1]. NSSI disorder (NSSID) was introduced in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 [
2]) as a disorder for further study. NSSID has a prevalence of 3.1 to 6.7% in adolescent community samples [
3,
4], and both NSSI and NSSID have been associated with a variety of negative outcomes, including general psychopathology and suicide attempts [
5,
6]. Despite the potentially severe consequences of NSSI and NSSID, there are few publications on interventions specifically designed to treat NSSI [
7‐
10]. Moreover, although a recent review of treatments for suicidal and nonsuicidal self-injurious behaviors among adolescents [
9] identified three treatments as promising (including dialectical behavior therapy [
11,
12], mentalization-based treatment [
13], and cognitive behavior therapy [CBT]; [
14,
15]), the authors concluded that no treatment for NSSI in adolescents (when analyzed separately from suicide attempts) is superior to treatment as usual.
To address the relative lack of effective treatments for youth with NSSI, we developed emotion regulation individual therapy for adolescents (ERITA [
16]). ERITA is a 12-week, acceptance-based behavioral individual therapy adapted from emotion regulation group therapy (ERGT) for NSSI in adults [
17,
18]. Similar to ERGT, ERITA was developed specifically to decrease NSSI among adolescents by improving emotion regulation skills. In the initial pilot study of ERITA, this treatment was delivered to adolescents in a traditional face-to-face format. The parents also participated in a parallel online parent program developed to increase their ability to interact effectively with their adolescents to decrease their child’s NSSI. The utility, acceptability, and feasibility of face-to-face ERITA for NSSID was supported in the open pilot trial including 17 adolescents (aged 13–17 years) and their parents [
16]. Participants rated the treatment as credible, and both the treatment completion rate (88%) and treatment attendance were high. Intent-to-treat analyses revealed large-sized uncontrolled effects from pre- to post-treatment in past-month NSSI frequency, emotion dysregulation, self-destructive behaviors, and global functioning, as well as a medium-sized effect in past-month NSSI versatility. All of these improvements were either maintained or further improved upon at 6-month follow-up. Moreover, change in emotion dysregulation mediated the observed improvements in NSSI during treatment, providing preliminary support for the theoretical model underlying ERITA [
16].
ERITA was developed to provide a targeted and effective intervention that could be easily and widely implemented at a low cost. However, Internet-delivered CBT (ICBT) has the potential to further increase accessibility to evidence-based treatments by eliminating the effects of geographical distances between patients and providers, allowing for less therapist time per patient, and facilitating flexible scheduling at times that are convenient for families [
19]. Therapist-guided ICBT has been shown to be effective for several psychiatric and physical disorders in adolescents (for a review, see [
20]). There is also research indicating that ICBT is at least as efficacious as face-to-face CBT for a range of psychiatric disorders in adults [
21]. Further, given research indicating that individuals with stigmatizing illnesses are more likely to use the Internet than traditional health care services to seek help [
22], online treatment may be particularly suitable for the treatment of NSSI, given its association with shame [
23] and low levels of disclosure [
24]. Nonetheless, although there have been some efforts to develop web-based interventions for suicidal behaviors (e.g. [
25]), online interventions have not (to our knowledge) been evaluated specifically for individuals who engage in NSSI.
Thus, given both evidence for the utility and feasibility of ERITA delivered face-to-face and the advantages of the ICBT format, we adapted ERITA to an online intervention. Following recommendations for early research on novel interventions [
26,
27], the present pilot study examined the feasibility, acceptability, and utility of this online ERITA in an uncontrolled open pilot trial. We expected high levels of treatment module completion, low treatment attrition, and high treatment credibility and satisfaction. Further, we expected to find significant improvements from pre- to post-treatment in adolescent NSSI, emotion regulation difficulties, psychological inflexibility, global functioning, and symptoms of borderline personality disorder (BPD), as well as parents’ ability to respond effectively to their children’s negative emotions. We also anticipated that these improvements would be maintained or further improved upon at 3- and 6-month follow up periods. Finally, we hypothesized that change in emotion dysregulation would mediate improvements in NSSI and self-destructive behaviors during treatment.
Discussion
NSSID is common among adolescents and associated with a wide variety of negative outcomes. However, treatments developed specifically for NSSI are scarce, and access to empirically-supported treatments for this behavior is limited [
9]. Online treatments carry several advantages compared to traditional face-to-face psychological treatments and may be particularly useful for treating NSSI, as this behavior is associated with high levels of shame and non-disclosure [
23,
24]. Support for the feasibility and acceptability of online ERITA was provided by findings of high levels of treatment module completion and low treatment attrition, acceptable ratings of treatment credibility, expectancy, and satisfaction (by adolescents and their parents), as well as strong ratings of therapeutic alliance. Providing initial support for the utility of this online treatment for NSSI, participation in the study was associated with significant, medium- to large-sized improvements in past-month NSSI frequency and versatility, emotion regulation difficulties, and global functioning from pre- to post-treatment. Moreover, all of these improvements were either maintained or further improved upon at 3- and 6-month follow-ups. Not only are these findings promising and suggestive of the utility of this online treatment, they are comparable to the findings obtained in previous trials of face-to-face versions of ERITA and ERGT [
16‐
18,
51,
52]. Notably, however, the mean therapist time per family in the current study was approximately one third of the time required in brief face-to-face treatments for NSSI (e.g., [
16,
66]) and this substantial reduction in therapist time was managed without a related loss in the feasibility, acceptance, or utility of the intervention. Moreover, consistent with past research on ICBT for adults [
67], the therapeutic alliance was strong and comparable to the ratings obtained in the face-to-face trial of ERITA [
16]. This is notable given that most therapist support was only provided online; although telephone contact was allowed between therapists and participants, this option was not used for most participants. Even so, participant enrollment in the treatment was associated with durable improvements in behavioral problems, emotion regulation difficulties, and global functioning.
The high treatment completion rates and overall positive findings obtained in this study may be due, in part, to some of the advantages of online interventions in general, such as the structured treatment format, lesser impact of therapist drift, lack of a need to schedule appointments, and greater access to the treatment material. It may also reflect the particular utility of the method of communication inherent to online treatment for individuals with stigmatizing behaviors (e.g., secure self-disclosure [
68]). In order to further develop and refine online treatments, future research should include qualitative interviews exploring the experience of participating in online treatments for NSSI.
Despite the positive results found in many domains, only small non-significant improvements were found in BPD symptoms at follow-up. These findings suggest that this brief treatment may not be sufficient to address BPD symptoms beyond emotion dysregulation, NSSI, and other self- destructive behaviors, and that this online treatment may be needed to be incorporated into an overall treatment approach for individuals with BPD for long term remission. However, only 20% of the participants in the present sample met diagnostic criteria for BPD at baseline; thus, replication in larger samples, including larger proportions of adolescents with BPD, is needed before any conclusions regarding the treatment’s utility for BPD symptoms can be drawn.
Family support is important in the treatment of adolescents with self-injurious behaviors [
69]. Consistent with both expectations and the intended purpose of the parent program, the online ERITA parent program was associated with small- to large-sized improvements in parental punitive and minimizing responses to adolescents’ expressions of negative emotions and parental encouragement of their children’s emotional expressions. Given past findings that parental invalidation is associated with higher levels of adolescent externalizing problem behaviors, and parental validation is associated with lower levels of emotion dysregulation [
70], these findings may, at least in part, account for some of the observed improvements in adolescent NSSI and emotion dysregulation. Contrary to expectations, however, no improvements were found for parental distress reactions to children’s negative emotions. These results suggest that behavioral responses to children’s emotions may be more amenable to brief interventions (and easier to change) than emotional reactions, highlighting the utility of teaching parents’ adaptive ways of responding to children’s distress regardless of their own emotional reactions to that distress. Indeed, even with increased knowledge about the function of and motivations for NSSI, it is reasonable to expect that parents still experience strong emotional reactions to the occurrence of NSSI in their child. However, our findings suggest that, even in the context of high levels of emotional distress, parents can respond behaviorally in an effective manner, possibly due to the emotional awareness and validation skills taught in the parent course. Overall, these findings are encouraging and highlight the utility of further research examining the role of changes in parental behaviors and parents’ own emotion regulation skills in treatment outcomes among adolescents with NSSI and other maladaptive behaviors.
Consistent with past research on both ERGT [
71,
72] and ERITA [
16], results of the present trial provided further support for the mediating role of change in emotion regulation difficulties in NSSI improvements during treatment. Change in emotion regulation difficulties also mediated improvements in self-destructive behaviors during treatment. These findings provide further support for the underlying role of emotion regulation difficulties in the maintenance of self-destructive behaviors, as well as for emotion regulation as a key mechanism of change in ERGT-based treatments.
Several limitations warrant mention. First, the absence of a control group and/or randomized controlled design precludes any conclusions regarding the effects of this treatment versus the passage of time or other factors. Likewise, ten participants (40%) reported having some form of face to face treatment contact while engaged in the online ERITA. However, it is important to note that five of these reported minimal contact with this treatment provider over the course of treatment. Thus, it is unlikely that the observed improvements in this trial were the result of these additional treatment contacts alone. Nonetheless, further research examining the effects of this treatment in a randomized controlled trial is needed. Second, the majority of participants were self-referred and highly educated, potentially limiting the generalizability of this sample to more complex or severe patient populations. However, findings that 60% of the adolescents in this sample had a history of psychological treatment and rates of co-occurring psychiatric disorders were high suggest that the sample may be representative of a clinical sample in terms of treatment history and psychological burden. Third, the relatively small sample size limits the generalizability of our findings and reduces our statistical power. Finally, the sample largely consisted of girls, limiting our ability to generalize our results to boys.
Conclusions
The present study provides preliminary support for the acceptability, feasibility, and utility of an online version of ERITA for adolescents with NSSID and their parents, as well as the theory underlying the treatment. Given the benefits of an online treatment format, particularly with regard to therapist time, patient ease and flexibility of scheduling, access to treatment in underserved areas, and its usefulness for stigmatized behaviors, further research examining the efficacy of online ERITA in a larger-scale randomized controlled trial is needed.
Acknowledgements
We thank Professor Lars-Gunnar Lundh and Dr. Jonas Bjärehed for scientific advice; Olivia Simonsson, Julia Stensils, and Linn Bjureberg for help with study administration; Gunnar Dagnå for support in graphical design of the web platform and app; and the team at BarnInternetPsykiatrin at the Child and Adolescent Mental Health Service in Stockholm for invaluable support and know-how when treating adolescents over the Internet.