Self-criticism and self-injury: Testing a novel diary-based treatment approach

Plain English summary of protocol

Background and study aims
The motivation to avoid pain and injury is a fundamental instinct. This makes nonsuicidal self-injury (NSSI) a very perplexing phenomenon. NSSI involves deliberate acts of self-harm without a specific wish to die. Increasingly common, NSSI is now a serious public health concern. What makes NSSI even more troubling, however, is its strong association with suicidal behavior. People who engage in NSSI are at high risk for later suicide. Despite numerous efforts there are few specific treatments for NSSI.

Through our previous work we have identified a novel treatment target - self-criticism. People who engage in NSSI report extremely high levels of self-criticism and self-hatred. Profoundly negative beliefs about the self are important because they remove a key barrier to NSSI and also motivate individuals to engage in self-injurious behaviors. Simply put, if you view yourself as bad, toxic, worthless or similar, you are likely to care little about your body. Harming it in an effort to feel better or to atone for being bad thus becomes a viable and potentially appealing option.

New approaches to the treatment of NSSI are very much needed. Our approach is based on our prior empirical work as well as our past experiences with people who engage in nonsuicidal self-injury. We seek to develop and test a new treatment that can be delivered directly to consumers via the internet and email. If this exploratory project is successful, our approach may help change the direction of current interventions for NSSI and lay the groundwork for highly focused prevention efforts.

Self-criticism is a major risk factor for engagement in NSSI. Self-criticism may be a promising treatment target, with some research showing success in reducing engagement in NSSI through increasing positive self-worth. Other research shows that people who engage in NSSI are less willing to endure painful experiences after their self-worth is increased.

The autobiographical self-enhancement training (ASET) intervention condition will examine a novel approach to targeting the mechanisms that drive NSSI behavior. The ASET treatment procedure was developed specifically for this study. It represents an adaptation of an approach we have created and used successfully with NSSI participants. The procedure seeks to undermine negative beliefs about the self by activating positive self-schemas. Participants will receive training in this approach. They will then use it daily for a period of 28 days, describing something specific and positive about themselves each day in brief writing task.

An expressive writing (EW) intervention will be used as a comparison treatment condition. EW involves writing about one’s emotions and in the context of describing stressful or upsetting experiences. Previous research shows that EW improves physical health and wellbeing. This study will be the first to examine expressive writing in the context of NSSI.

A journal writing (JNL) intervention will form the control condition. It will ensure that all study participants complete writing tasks. Participants in the JNL condition will write about daily events in their lives without any focus on emotional issues.

The online format of this study means that the interventions we are using can be made available to people regardless of where they live.

Who can participate?
People who used online forums related to suicide and psychopathology, were fluent in English, had daily internet access, and who had engaged in 2+ episodes of nonsuicidal self-injury in the past month were eligible to participate.

Benefits and risks of participating?
We did not expect significant risks to be associated with participating in this study. There was a potential risk that participants could find questions about self-harm to cause negative feelings or make them think about self-harm. Similarly, some people may have felt upset when responding to personal questions or when completing journal entries. However, we did not anticipate that these feelings would last for more than a few minutes. Moreover, if we learned that a participant was thinking about harming themselves, we provided them with a list of hotlines and resources to help keep them safe.
Regarding benefits, there was no guarantee of direct benefit to participants. However, participants may have benefited from extra monitoring and greater awareness of their thoughts and behaviors. There was also a chance that the activities may help them control self-harming behaviors, self-critical thoughts, or depression.

Where is the study run from?
The study was run entirely online, using Qualtrics. This means that participants were from both in and outside of the US, and they participated from their laptops or smartphones.

When is the study starting and for how long?
The study began on June 25th, 2016. The final participant completed the study on January 8th, 2017.

How long will the trial be recruiting participants?
Recruitment is now closed. The trial recruited participants for approximately 3 months.

Who is the main contact?
Jill M. Hooley (jmh@wjh.harvard.edu)

Contact information

Study information

Eligibility

Locations

Countries of recruitment

• Australia
• Canada
• Costa Rica
• Germany
• Hungary
• Ireland
• Japan
• Netherlands
• Portugal
• Romania
• Russian Federation
• Sweden
• United Kingdom
• United States of America

Study participating centre

Sponsor information

Funders

Funder type

Not defined

Results and Publications

Study outputs

Editorial Notes

27/06/2019: Publication reference and total final enrolment number added.