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Treating Nonsuicidal Self-Injury with the Unified Protocol

Treating Nonsuicidal Self-Injury with the Unified Protocol. Noël Slesinger Jason J. Washburn. When is Treatment Needed for Self-Injury?. Repeated self-injury 5+ times in past year Any serious self-injury Serious = medical care Injury is more serious than expected

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Treating Nonsuicidal Self-Injury with the Unified Protocol

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  1. Treating Nonsuicidal Self-Injury with the Unified Protocol Noël Slesinger Jason J. Washburn

  2. When is Treatment Needed for Self-Injury? • Repeated self-injury • 5+ times in past year • Any serious self-injury • Serious = medical care • Injury is more serious than expected • Any suicidal thoughts or behaviors • If another disorder is present • Injuring when drunk or high • Strong urge to self-injure

  3. Alexian Brothers Level of Care Criteria

  4. Goals for Self-Injury Treatment • Initial Goal • Replace dangerous/impairing forms of self-regulation with safe/effective forms of self-regulation • Overall Goal • Assist with developing healthy, positive & proactive ways to respond to problems and distress – healthy self-regulation • Ultimate Goal • No self-injury

  5. General Treatment Goals • Increase motivation to use alternatives to NSI • Improve healthy emotional regulation • Develop and maintain a healthy and functional sense of self • Decrease suicidal thoughts, feelings, and behaviors • Increase the number and quality of healthy social supports and family functioning

  6. General Treatment Strategies • Psychoeducation • Self-Monitoring • Emotional differentiation & awareness • Functional analysis • Behavioral activation • Cognitive restructuring and reappraisal • Re-attribution • Acceptance strategies • Problem-solving training • Distress tolerance

  7. Unified Protocol

  8. Rationale for a Unified Protocol • Common, higher-order factors underlie all emotional disorders • Positive vs. Negative affect: • Heightened negative affect • More intense negative affect • Aversion to distress • Avoidance of affective experiences Barlow et al., 2010

  9. UP vs. Specific Evidence-Based Treatments • Transdiagnostic treatment • Addresses: • Comorbidity • NOS/Other Specified and Unspecified • Subthreshold • Simplified & focused treatment planning Barlow et al., 2010

  10. NSSI: Common Diagnoses Mental Disorders & Self-Injury 92.4% Affective

  11. NSSI: Borderline Personality n=559 BEST: Borderline Evaluation of Severity over Time

  12. UP Case Conceptualization • Negative emotional experiences • ↑ Frequency & Intensity • Positive emotional experiences • ↓ Frequency & Intensity • Distress in reaction to intense emotional experiences • Emotional experiences = Aversive Ehrenreich-May, 2015

  13. UP Case Conceptualization • Emotion-Driven Behaviors: • Control, avoid, and/or suppress emotional experience: • Situational avoidance • Avoid work, school, restaurants • Cognitive avoidance • distraction, suppression, worry • Subtle behavioral avoidance • Avoiding eye contact • Negative reinforcement of EDBs • Develop poor emotional self-efficacy Ehrenreich-May, 2015

  14. UP Goals • Goal #1: Increase acceptance & willingness to experience strong emotions • Increase cognitive flexibility • Improve cognitive re-appraisals • Use (emotion) exposureto promoteextinctionandincreasepositiveaffect • Goal #2: Reduce problematic avoidance, withdrawal and escape behaviors • Change action tendencies associated with disordered emotions • Reduce emotion avoidance Barlow et al., 2010

  15. Core principles from UP • Extinction learning • Reducing emotional avoidance • Interoceptive cues, intense emotions • Behavioral exposure • Identification and modification of maladaptive cognitions • Focus on internal emotional experiences • Thoughts, feelings, behaviors • Emotion (dys)regulation • Emotion regulation  internal experiences • Change action tendencies • Emotionally-driven behaviors Barlow et al., 2010

  16. UP Modules 1 2 3 4 5 6 7 8 Barlow et al., 2010

  17. Initial Session • Feedback from Intake Assessment • Previous & current attempts to manage emotions • Nature of emotional disorders • Rationale for a transdiagnostic approach to treatment • Outline of treatment components and skills to be learned • Setting general expectations • Emphasize new way of objectively observing experience Barlow et al., 2010

  18. 1-2 Sessions Module 1: Motivation Enhancement • Fostering and Enhancing Motivation • Decision Balance • Pros & cons of changing • Enhancing Self-Efficacy • Treatment goal setting • Emphasis on concrete goals & identifying specific steps Barlow et al., 2010; Conklin, 2015

  19. 1-3 Sessions Module 2: Understanding Emotional Experience • Goals: • Understand adaptive nature of emotions • Understand interacting components of emotional experiences • Understand antecedents & consequences of emotional experiences Physical Sensations Behaviors Thoughts Barlow et al., 2010; Conklin, 2015

  20. 1-3 Sessions Module 3: Emotional Awareness Training • Goals: • Increase present-focused attention of emotional experiences • Develop a non-judgmental stance toward emotional experience • Practice applying skills Barlow et al., 2010; Conklin, 2015

  21. 1-2 Sessions Module 4: Cognitive Appraisal & Reappraisal • Goals: • Introduce cognitive appraisal, automatic appraisal • Practice ways to evaluate and re-evaluate thinking patterns • Increase flexibility in appraisal Barlow et al., 2010; Conklin, 2015

  22. 2 Sessions Module 5: Emotion Driven Behaviors & Emotional Avoidance • Goals: • Introduce emotional avoidance & EDBs • Demonstrate ironic effects of suppression • Practice identifying & countering EDBs Barlow et al., 2010; Conklin, 2015

  23. 1-2 Sessions Module 6:Awareness & Tolerance of Physical Sensations • Provide rationale for provoking emotion through interoceptive activation • Physical feelings contribute to overall emotional experience • Repeated exposure to physical feelings facilitates habituation to the distress or discomfort about those feelings • Conduct in-session symptom induction exercises • Breathing through a thin straw, hyperventalization, spinning in circles, running in place, etc.. Barlow et al., 2010; Conklin, 2015

  24. 2-5 Sessions Module 7: Situational Emotion Exposures • Provide rationale for emotion exposure in a situational context • Practice skills learned in treatment • Real change  Full emotional experience & EDBs are modified • EDB’s change  appraisals more adaptive • Create hierarchy & conduct emotion exposure • Situational exposure • Imaginal exposure Barlow et al., 2010; Conklin, 2015

  25. 1-2 Sessions Module 8:Review & Relapse Prevention • Goals: • Review skills for coping with emotions • Identify & troubleshoot common/potential triggers • Promote skill generalization • Set long-term goals • Discuss steps to pursuit goals • Include exposure practice Barlow et al., 2010; Conklin, 2015

  26. UP for Adolescents • M1: Treatment Orientation & Enhancing Motivation (1-2) • M2: Emotion Education (2-3) • M3: Behavioral Activation (0-2) • M4: Awareness and Tolerance of Physical Sensations (1-2) • M5: Being Flexible in Your Thinking (2-3) • M6: Emotional Awareness and Mindfulness (1-3) • M7: Situation--‐Based Emotion Exposures (1+) • M8: Relapse Prevention (1) • O1: Keeping Safe/Dealing with Difficult Times (0-3) • O2: Parenting the Emotional Adolescent (0-3) Ehrenreich-May, 2015

  27. Unique Aspects of UP-A • Broadening range of emotion states • Emphasize ↑ Positive Affect • Positive emotion exposures • Problem-­solving • Behavioral activation • Address anger • Improve interpersonal communication • Parent Involvement • Adolescent-friendly labels, descriptions, and examples of skills Ehrenreich-May, 2015

  28. UP: Case Example • Demographics: • 18-year-old, Latina, college student • Presenting problem: • Anxiety, NSSI • NSSI Characteristics • Onset age 12 • Superficial cutting/scratching on forearms, thighs • ~2 times a month • “Somewhat intense” urges a couple times a week • Function =  “get control” of intense anxiety  • Triggers: • Distressing interpersonal situations • “Overwhelmed” by her school and work demands Bentley et al., 2017, doi: 10.1002/jclp.22452

  29. UP: Case Example Formulation • Views negative emotions as unacceptable • Mother verbally abusive when patient cries • Mother critical of perceived failures • Attempted to live up to mother’s expectations • Expectations: • Maintain a perfect GPA • Stay thin • Not express emotional vulnerability • Results = anxiety, depression, eating disorder, NSSI Bentley et al., 2017, doi: 10.1002/jclp.22452

  30. UP: Case Example Formulation • Behavioral strategies to avoid negative emotions: • NSSI • Limiting social interactions • Vacillating between procrastination-perfectionism • Avoiding her mother • Avoiding looking in mirrors • Cognitive strategies to avoid/relieve negative emotions: • Rumination about perceived as failures • Worry about things going wrong in the future • Suppression of unwanted memories. • Fantasizing about suicide as a way out Bentley et al., 2017, doi: 10.1002/jclp.22452

  31. UP: Case Example Formulation • Behavioral & cognitive coping strategies: • Maintain low self-esteem • Maintain negative core beliefs Bentley et al., 2017, doi: 10.1002/jclp.22452

  32. UP: Case Example Formulation • Negative perceptions of the experience of emotion • NSSI • Frequent and intense negative affect • High degree of negative reactivity to intense emotions Bentley et al., 2017, doi: 10.1002/jclp.22452

  33. UP Modules 1 2 3 4 5 6 7 8 Barlow et al., 2010

  34. Cognitive Flexibility • Laura: My mom called, and was going on about how it “isn't fair” that I never visit her because she still pays part of my tuition…. Of course I don't. I hate being around her. •  Therapist: Right. What happened next? •  Laura: Well, by the time I hung up, I was … at a 100 out of 100. I was super angry, and also really anxious … I kept thinking about what would happen if she stopped paying my tuition. •  Therapist: What else were you thinking? •  Laura: I'd have to drop out of college, and move back in with her … I can't handle seeing my mom right now. •  Therapist: How did thinking about those things make you feel? Bentley et al., 2017, doi: 10.1002/jclp.22452

  35. Cognitive Flexibility •  Laura: I just kept feeling worse. I was imagining, like, what it would be like to move back home. I think I'd regress to … how it used to be. I can't do it … I felt really hopeless. •  Therapist: Based on what we talked about last week, how might you view these thoughts? •  Laura: [pause] Well … I mean … [pause] I guess I was jumping to conclusions? Like, she didn't say she was going to stop paying my tuition … it just felt like that was going to happen. •  Therapist: Okay, we can work with that. What about the other trap we talked about? •  Laura: [pause] Catastrophizing? [therapist nods] Yeah … I guess that too. I mean, stopping my tuition became … like, going back to how I was back in high school. •  Therapist: It seems like these automatic thoughts made you feel even more emotional. Bentley et al., 2017, doi: 10.1002/jclp.22452

  36. Emotion Exposure Bentley et al., 2017, doi: 10.1002/jclp.22452

  37. Mindful Emotion Awareness Training Bentley et al., 2017, doi: 10.1002/jclp.22452

  38. UP for Adolescents • M1: Treatment Orientation & Enhancing Motivation (1-2) • M2: Emotion Education (2-3) • M3: Behavioral Activation (0-2) • M4: Awareness and Tolerance of Physical Sensations (1-2) • M5: Being Flexible in Your Thinking (2-3) • M6: Emotional Awareness and Mindfulness (1-3) • M7: Situation--‐Based Emotion Exposures (1+) • M8: Relapse Prevention (1) • O1: Keeping Safe/Dealing with Difficult Times (0-3) • O2: Parenting the Emotional Adolescent (0-3) Ehrenreich-May, 2015

  39. Challenges to the UP • Psychotherapy is still hard! • Patients less likely to respond: • Fearful of emotion • Difficulty with skill acquisition • Doesn’t address everything • ADHD, Substance Abuse, Psychosis • Still sequential Ehrenreich-May, 2015

  40. NoelSlesinger2007@u.northwestern.edu j-washburn@northwestern.edu www.abbhh.org/selfinjurybook

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