A controlled trial of personal construct psychotherapy for deliberate self-harm

Investigating self-concept in self-harm: A repertory grid study

OBJECTIVES

The way that individuals perceive themselves and others may be relevant in understanding difficulties with self-harm. Repertory grids provide a relatively underutilized means of investigating self-concept in people who self-harm. This study aimed to examine the association between self-concept, captured through a repertory grid method, and self-harm.

METHOD

Ninety-eight participants with a history of self-harm took part in the study. A repertory grid was used to derive distances between four elements ('current self', 'ideal self', 'self-harming self', and 'others who self-harm'). Associations between these distances and measures of self-harm behaviour, well-being and perceived recovery, were estimated.

RESULTS

Repertory grid distances were significantly associated with self-harm. When adjusting for covariates, self-harm in the past year was positively associated with a greater distance (or less perceived similarity) between current and ideal self, and a smaller distance (greater perceived similarity) between current self and others who self-harm. Repertory grid distances were also associated with well-being and perceived recovery.

CONCLUSIONS

The results are consistent with the idea that self-perception is associated with self-harm and related difficulties. The results also highlight the potential utility of repertory grids as a tool for exploring self-concept. The cross-sectional nature of the study precludes inferences about directionality or the temporal characteristics of associations.

PRACTITIONER POINTS

More recent experiences of self-harm may be reflected in the way individuals perceive or construe themselves. The way in which individuals who self-harm perceive or construe themselves may also be related to their current well-being and perceived recovery. Repertory grids may be a useful tool in clinical practice for investigating self-concept in those who self-harm. Repertory grids may provide a more idiographic, clinical outcome assessment in those who self-harm.

A feasibility study highlighting challenges in evaluating a structured, psychological treatment for self-harm in adult psychiatric inpatient settings

BACKGROUND

Despite being the most common reason for admission to psychiatric inpatient services, no evidence-based treatment currently exists for self-harm in this setting. Dialectical Behavioural Therapy (DBT) trials have found promising results in treating self-harm in outpatient settings; however findings for inpatient settings are still limited.

METHOD

A single-arm feasibility trial was conducted examining a DBT-informed 'Coping with Crisis' (CwC) group protocol, which focused on self-harm and crisis management strategies. Twenty-four participants were recruited from an inpatient ward in a National Health Service (NHS) Trust in the UK. The Inventory of Statements about Self-Injury and Distress Tolerance Scale were administered at baseline and post-therapy. Data was collected on the rates of recruitment, retention, session attendance, outcome measure completion, adverse events and participant feedback, in order to inform the design of a main study.

RESULTS

Findings indicated that it was feasible to run the CWC group and research study on an inpatient ward. However, there were several challenges in recruiting to target (80% achieved) and retaining participants (38% of consented participants completed). A number of implementation issues were identified and recommendations have been made to inform future group and study designs.

Toward a Constructivist Model of Radicalization and Deradicalization: A Conceptual and Methodological Proposal

This article identifies common features of existing models of radicalization and deradicalization, such as the transition from uncertainty to certainty, before integrating these in a model based upon personal construct theory. It is proposed that the personal construct concepts of validation and invalidation are particularly relevant to processes of identity change such as radicalization and deradicalization. Thus, it is argued that radicalization occurs when major invalidation of an individual's construing is followed by the development of a new radicalized view of the world that provides a turning point in his or her sense of identity and a more structured and certain view of the world. There is likely to be seeking out of validation for this view in interactions with others who share similar views or by extorting evidence for the individual's radical constructions. These constructions are likely to involve extreme negative views of another group, by contrast to members of which, and possibly by taking extreme action against this group, the individual's new self-construction may become further defined. These same processes can be seen to operate in deradicalization, and it will therefore be argued that the model has implications for the development of deradicalization programs. A further advantage of the model is that it has an associated personal construct methodology, particularly repertory grid technique, that may be used to investigate processes of radicalization and deradicalization. As illustrations of such investigations, results will be summarized from a repertory grid study of Salafist Muslims in Tunisia, some of whom had returned from fighting in Syria, and an analysis of the writings of the Norwegian mass murderer Anders Breivik. The findings of these investigations are argued to be consistent with the personal construct model of radicalization and deradicalization.

Construing and body dissatisfaction in chronic depression: A study of body psychotherapy

The frequent association of depression with somatic symptoms suggests that body psychotherapy may be an appropriate therapeutic intervention for people with chronic depression. Using a subset of twenty-three participants from a randomized controlled trial that had demonstrated the effectiveness of such an intervention in reducing depressive symptoms, the present study investigated whether it may also impact aspects of construing which have been associated with depression. Patients presenting with chronic depression were randomly allocated to a treatment group or a waiting list group, which received body psychotherapy after a period on a waiting list. Correlations between repertory grid, questionnaire, and visual analogue measures indicated that depression and bodily dissatisfaction were associated with features of the content and structure of construing. There were no significant changes while patients were on the waiting list, but during treatment reduction in depression and bodily dissatisfaction, together with increase in self-esteem and quality of life, were accompanied by an increase in the salience of construing of the bodily self.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm.

OBJECTIVES

To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH.

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures.

MAIN RESULTS

We included 55 trials, with a total of 17,699 participants. Eighteen trials investigated cognitive-behavioural-based psychotherapy (CBT-based psychotherapy; comprising cognitive-behavioural, problem-solving therapy or both). Nine investigated interventions for multiple repetition of SH/probable personality disorder, comprising emotion-regulation group-based psychotherapy, mentalisation, and dialectical behaviour therapy (DBT). Four investigated case management, and 11 examined remote contact interventions (postcards, emergency cards, telephone contact). Most other interventions were evaluated in only single small trials of moderate to very low quality.There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55 to 0.88; number of studies k = 17; N = 2665; GRADE: low quality evidence), but with no reduction in frequency of SH (mean difference (MD) -0.21, 95% CI -0.68 to 0.26; k = 6; N = 594; GRADE: low quality).For interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition when compared to TAU: group-based emotion-regulation psychotherapy (OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83; GRADE: low quality), mentalisation (OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134; GRADE: moderate quality). Compared with TAU, dialectical behaviour therapy (DBT) showed a significant reduction in frequency of SH at final follow-up (MD -18.82, 95% CI -36.68 to -0.95; k = 3; N = 292; GRADE: low quality) but not in the proportion of individuals repeating SH (OR 0.57, 95% CI 0.21 to 1.59, k = 3; N = 247; GRADE: low quality). Compared with an alternative form of psychological therapy, DBT-oriented therapy was also associated with a significant treatment effect for repetition of SH at final follow-up (OR 0.05, 95% CI 0.00 to 0.49; k = 1; N = 24; GRADE: low quality). However, neither DBT vs 'treatment by expert' (OR 1.18, 95% CI 0.35 to 3.95; k = 1; N = 97; GRADE: very low quality) nor prolonged exposure DBT vs standard exposure DBT (OR 0.67, 95% CI 0.08 to 5.68; k = 1; N =18; GRADE: low quality) were associated with a significant reduction in repetition of SH.Case management was not associated with a significant reduction in repetition of SH at post intervention compared to either TAU or enhanced usual care (OR 0.78, 95% CI 0.47 to 1.30; k = 4; N = 1608; GRADE: moderate quality). Continuity of care by the same therapist vs a different therapist was also not associated with a significant treatment effect for repetition (OR 0.28, 95% CI 0.07 to 1.10; k = 1; N = 136; GRADE: very low quality). None of the following remote contact interventions were associated with fewer participants repeating SH compared with TAU: adherence enhancement (OR 0.57, 95% CI 0.32 to 1.02; k = 1; N = 391; GRADE: low quality), mixed multimodal interventions (comprising psychological therapy and remote contact-based interventions) (OR 0.98, 95% CI 0.68 to 1.43; k = 1 study; N = 684; GRADE: low quality), including a culturally adapted form of this intervention (OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167; GRADE: low quality), postcards (OR 0.87, 95% CI 0.62 to 1.23; k = 4; N = 3277; GRADE: very low quality), emergency cards (OR 0.82, 95% CI 0.31 to 2.14; k = 2; N = 1039; GRADE: low quality), general practitioner's letter (OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932; GRADE: moderate quality), telephone contact (OR 0.74, 95% CI 0.42 to 1.32; k = 3; N = 840; GRADE: very low quality), and mobile telephone-based psychological therapy (OR not estimable due to zero cell counts; GRADE: low quality).None of the following mixed interventions were associated with reduced repetition of SH compared to either alternative forms of psychological therapy: interpersonal problem-solving skills training, behaviour therapy, home-based problem-solving therapy, long-term psychotherapy; or to TAU: provision of information and support, treatment for alcohol misuse, intensive inpatient and community treatment, general hospital admission, or intensive outpatient treatment.We had only limited evidence on whether the intervention had different effects in men and women. Data on adverse effects, other than planned outcomes relating to suicidal behaviour, were not reported.

AUTHORS' CONCLUSIONS

CBT-based psychological therapy can result in fewer individuals repeating SH; however, the quality of this evidence, assessed using GRADE criteria, ranged between moderate and low. Dialectical behaviour therapy for people with multiple episodes of SH/probable personality disorder may lead to a reduction in frequency of SH, but this finding is based on low quality evidence. Case management and remote contact interventions did not appear to have any benefits in terms of reducing repetition of SH. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to these interventions is inconclusive.