Novel online daily diary interventions for nonsuicidal self-injury: a randomized controlled trial

Nonsuicidal self-injury (NSSI) involves intentional and self-directed harm (e.g., self-cutting, burning) that is enacted without suicidal intent [1]. Although it tends to be painful, dangerous, and stigmatized, NSSI is quite common in the general population, with lifetime prevalence rates of approximately 17% in adolescents and 5% in adults [2]. NSSI is associated with both physical and social-emotional harm in the short and long-term. A major concern is the strong link between NSSI and suicidal thoughts and behaviors both concurrently [3, 4] and prospectively [5].

All of this highlights the need for research on NSSI treatments. Unfortunately, few approaches to date have consistently reduced NSSI compared to active control treatments [6‐9]. One notable exception is the intervention developed by Franklin and colleagues [10]. This intervention, called Therapeutic Evaluative Conditioning (TEC), uses a form of Pavlovian conditioning [11] to increase aversion to self-injury stimuli (e.g., knives, blood) and to decrease aversion to the self (i.e., reduce self-criticism). Utilizing an online, app-based treatment and across three randomized control trials, TEC resulted in significant reductions in NSSI, suicide plans, and suicide attempts, compared to an active control treatment.

Franklin and colleagues’ [10] approach is notable for three primary reasons. First, it targeted two relatively novel treatment targets for NSSI based on growing evidence that high self-criticism and low aversion to NSSI stimuli are important NSSI risk factors [12]. Second, TEC reduced both NSSI and suicidal thoughts and behaviors, suggesting that these treatment targets may prove effective for a range of self-injurious thoughts and behaviors. Third, TEC was the first highly scalable, inexpensive, online treatment to be developed for NSSI. Results from Franklin et al.’s [10] study demonstrated that (a) targeting new risk factors such as self-criticism and diminished aversion to NSSI stimuli may be effective for reducing NSSI and (b) that it is possible to conduct online treatments for NSSI.

In the present study we sought to use this information to create a new, online treatment program for NSSI. Specifically, we conducted a randomized controlled trial (RCT) to evaluate Autobiographical Self-Enhancement Training (ASET) -- a novel, cognitive intervention for NSSI focused on reducing self-criticism and enhancing positive self-worth. To help reduce NSSI engagement, self-worth was selected as a primary treatment target for several reasons. First, people who engage in NSSI demonstrate lowered levels of self-worth across several domains, including body image [13], self-dissatisfaction [14], and self-criticism [15, 16]. Second, recent longitudinal research found that implicit and explicit self-criticism predicted continued NSSI engagement over a 4-week follow-up period above and beyond other relevant factors [17], suggesting that self-criticism may be an important NSSI risk factor and potential treatment target. Third, experimental research has demonstrated that pain endurance is elevated among people who engage in NSSI and that reducing self-criticism normalizes this [18]. Finally, as noted above, a recent treatment study designed to reduce self-criticism as well as increase aversion to NSSI stimuli decreased NSSI engagement over the treatment period [10]. Given this compelling body of research implicating self-criticism as an important NSSI risk factor, we hypothesized that decreasing self-criticism would result in lowered rates of NSSI engagement when compared to treatments targeting other factors. However, unlike the approach adopted by Franklin and colleagues [10] which involved conditioning, we used a more explicit method in an effort to target self-criticism more directly and in a manner that involved participants’ awareness, perhaps therefore improving treatment effects.

For the present RCT, we tested ASET against another potentially active treatment (expressive writing) and also against a control treatment (journaling). The ASET intervention was based on a cognitive intervention previously used for participants with NSSI histories. Specifically, Hooley and St. Germain [18] created a brief intervention that, during one in-lab session, significantly increased positive self-worth and decreased the amount of time participants were willing to endure pain compared to two comparison conditions. ASET was designed to test whether a similar cognitive intervention, administered online, would decrease self-criticism over time and to test whether these decreases would extend to subsequent decreases in NSSI compared to alternative interventions.

We also tested an intervention that involved expressive writing (EW). Expressive writing, a procedure first developed by Pennebaker and Beall [19] involves writing about stressful or upsetting experiences. Many years of research have established that expressive writing produces psychological and physical health benefits [20]. Although NSSI is used to regulate negative emotions [12], to date, no study has examined expressive writing as an intervention for NSSI. Finally, we used a journaling (JNL) condition as a comparison control intervention. This involved writing about daily events without any focus on emotional issues. The JNL intervention was developed to control for daily writing (which was integral to both the ASET and the EW conditions).

We predicted that, compared to the control (JNL) condition, ASET treatment would significantly reduce self-criticism, NSSI, and the desire to engage in NSSI. Depressive symptoms were included as a secondary treatment target because there is high comorbidity between depressive symptoms and NSSI [21]. Meta-analytic evidence further suggests that self-esteem (related to self-criticism) longitudinally predicts depression [22]. Similarly, because NSSI tends to be comorbid with suicidal thoughts and behaviors [3, 4], these were also selected as secondary treatment targets. We hypothesized that ASET would reduce depressive symptoms, suicidal thoughts, and suicidal behaviors compared to JNL. We also predicted that compared to the JNL condition, EW would provide general benefits and reduce feelings of depression. However, because EW does not target self-criticism, we did not predict that participants assigned to this condition would show significant decreases in self-criticism, desire to self-injure and engage in NSSI, or engagement in suicidal thoughts and behaviors.

There were no significant demographic or psychiatric treatment history differences among the three groups (all ps > .05). Additionally, there were no group differences in self-criticism at baseline (p = .34), or in self-reported episodes of past week, month, or year NSSI, suicide ideation, suicide plans, or suicide attempts (all ps > .05). However, there were significant differences in baseline depression (F(2) = 3.70, p = .03). Probing these differences in more detail, Bonferroni corrected post-hoc tests indicated that participants in the ASET condition had significantly lower depression scores than participants in the EW (p = .04), but not the JNL condition at baseline; no other group differences were statistically significant. Means for all baseline measures are provided in Table 3.

This study examined the efficacy of ASET, a novel cognitive intervention, in reducing self-criticism, as well as NSSI and suicidal thoughts and behaviors, among adults with a recent history of NSSI. Supporting our hypotheses, the ASET intervention produced greater reductions in self-criticism at the end of treatment compared to the control JNL condition. There was also a trend toward participants in the ASET condition showing lower levels of suicide ideation at post-treatment compared to participants assigned to EW. Reductions in self-criticism did not persist past the active treatment period, but the effect for suicide ideation was significant at the 3-month post-treatment follow-up. These results are especially notable in light of fewer completed daily writings and participant reports that ASET was less enjoyable than the other two conditions. Although participants liked the EW intervention overall, it was no more efficacious than ASET or JNL for any treatment outcome.

Replicating and extending previous findings [18], the current results demonstrate that an intervention targeting self-criticism decreases both self-criticism and suicide ideation among individuals with NSSI. It also warrants mention that, overall, all of our writing-based approaches provided clinical benefits and reduced episodes of NSSI. Given the high prevalence of NSSI behaviors in clinical and nonclinical populations [2, 33] as well as their concerning associations with suicide [5], highly scalable and disseminable treatments are needed to reduce these dangerous behaviors. These findings provide further evidence supporting the feasibility and acceptability of online interventions for NSSI.

Although these results are promising, they should be interpreted with caution. Despite significant reductions in self-criticism following the ASET intervention, levels of self-criticism continued to remain quite high for individuals in all treatment groups and reductions did not persist after treatment termination. Moreover, many clinical outcomes remained unchanged, such that no treatment was significantly more successful than the others in reducing overall NSSI episodes, suicide plans, suicidal behaviors, depression, desire to discontinue NSSI, or likelihood of engaging in future NSSI.

The finding that the JNL treatment reduced suicide ideation compared to EW was unexpected and warrants consideration. It is also interesting in light of recent findings from another RCT. Celano and colleagues [34] compared a positive psychology-based intervention with a cognition-focused control intervention among high-risk patients discharged from inpatient care. The cognition-focused intervention, which had some similarities to our JNL intervention, required participants to recount three events occurring each day, in an emotionally neutral manner, for the duration of treatment. Contrary to expectation, the cognition-focused intervention resulted in significantly larger reductions in hopelessness at the 6-week follow-up, and significant reductions in depression and suicidality at both 6 and 12 week follow-up assessments. Results suggest that encouraging people who may be at high risk for self-injurious thoughts and behaviors to think about their days in the absence of emotional content could be palliative. However, it is important to keep in mind that the JNL condition did not outperform EW or ASET in reducing NSSI episodes or other self-injury outcomes. Additional studies are needed to more fully evaluate the potential benefits of writing about the events of one’s day in a non-emotional manner.

Findings for the current study should also be considered in the context of the study’s limitations. First, participants were predominantly white and female young adults who were recruited from online forums related to self-injury and psychopathology. It is therefore unclear whether these findings would generalize to individuals of other ages, ethnicities, or genders recruited in other ways. All outcome data were also based on self-report. This is not unusual for studies of this type, as participant anonymity helps decrease the potential for demand characteristics. Nonetheless we acknowledge this as a limitation. The fact that participants were paid for their participation may also have impacted their willingness and motivation to complete the daily writing assignments and our moderate sample sizes may have precluded our ability to detect all but the largest treatment effects on clinical outcomes. Finally, all participants completed standard, once-daily, five-minute writing assignments. It is possible that higher dosages of each treatment (e.g., greater number of writing assignments per day; longer length of writing assignments) would produce greater reductions in self-criticism and self-injurious thoughts and behaviors.

One unexpected finding from the current study was that all participants improved over the course of treatment, regardless of the treatment condition to which they were assigned. In other words, all forms of daily writing were helpful. More specifically, all approaches reduced episodes of NSSI, self-criticism, depression, and suicide ideation. This could reflect regression to the mean, although improvement was not noted across all outcome variables. Another non-specific factor that should be considered is participants’ knowledge that members of the research team were paying attention to them and reading their daily writings. This sense of connection, however temporary, may have been helpful. Future studies involving journaling would do well to consider the possibility that this may be a more active treatment approach than might be apparent at first glance. With hindsight, it would have been advantageous to also include another comparison group that received no online intervention whatsoever, or one in which participants were receiving equivalent contact with researchers. This would have allowed us to determine more about whether the simple act of journaling in an emotionally neutral manner is beneficial for individuals with NSSI.

Overall, this study contributes important new information about the feasibility and efficacy of novel online interventions for NSSI. Findings further suggest that although self-criticism may be an important treatment target in NSSI, altering self-criticism appears to be particularly difficult for individuals with severe and recent NSSI histories and high levels of depression. People who engage in NSSI do not appear to like focusing on their positive attributes. This may be because their negative beliefs about the self are well established and entrenched. It is possible that more direct (one-on one) approaches are needed to provide additional direction and support for overcoming the cognitive challenges presented by considering alternative and more positive aspects of their identities. Alternatively, more covert or implicit approaches capable of enhancing positive self-concept without triggering resistance could be considered. In contrast, writing about negative emotions, such as occurred in the EW condition, appears to be much more enjoyable for people who engage in NSSI. One reassuring aspect of our data is the finding that such a focus on negative emotions in the context of expressive writing does not increase the likelihood of negative outcomes. This seems important to know.

Future research should examine the effects of ASET on self-criticism and self-injurious thoughts and behaviors among individuals with less severe clinical presentations. The potential for online interventions such as the one described here to prevent the development of NSSI should also be considered. Adolescence is a time of increased self-criticism and increased risk for NSSI. Interventions that focus attention on positive self-attributes may provide some protection against the development of NSSI. Further research is also needed to test the benefits of ASET as an adjunct to existing treatments, in addition to a stand-alone intervention. Although much remains to be learned, the current findings demonstrate that ASET is a feasible and potentially promising intervention that is cost effective, easily accessible, and highly scalable. The benefits of non-emotional journaling also warrant increased consideration.