Understanding Nonsuicidal Self-Injury: Origins, Assessment, and Treatment, edited by M. K. Nock
I often find it disconcerting to discover how much I have yet to learn about matters I know a lot about. Such is the bane of the information explosion. The best remedy for the unavoidable accumulation of ignorance is a good book that synthesizes current knowledge. Befitting Matthew Nock's expertise, Understanding Nonsuicidal Self-Injury performs this invaluable service ably in a way that will benefit clinicians and researchers equally.
Nock defines nonsuicidal self-injury (NSSI) as “the direct, deliberate destruction of one's own body tissue in the absence of suicidal intent” (p. 9), a definition that excludes the closely related behavior of overdosing for the purpose of temporarily rendering oneself unconscious. The most common methods of NSSI are skin cutting, banging or hitting, and burning. Nock carefully classifies NSSI as a nonsuicidal subset of self-injurious thoughts and behaviors distinguished by the absence of any intent to die; also in this nonsuicidal subset are suicide threats and gestures as well as thoughts of NSSI. The book concentrates on NSSI as commonly manifested in normally developing, nonpsychotic persons. Yet some attention is devoted to stereotypic NSSI (of extremely high frequency in conjunction with developmental disabilities and neuropsychiatric disorders), and the phenomenon of major NSSI is also noted (e.g., rare episodes of severely self-mutilating behavior such as are associated with psychotic disorders). Throughout this volume contributors hew to careful definition, which is essential for progress in research.
Contributors devote considerable attention to elucidating the various functions of NSSI, understanding of which is crucial to progress in clinical interventions. In his fascinating chronicle of the cultural history of NSSI, Favazza notes that NSSI has been recorded “in all cultures since the earliest days of humankind” and makes the bold point that it “might be seen as tapping into traditions that attempt to foster healing spirituality” (pp. 28–29). From this perspective, “self-injury” reflects the outsider's point of view—not that of the patient who seeks a restorative experience. Nock's elegant functional model provides a useful template for clinicians to disentangle the potentially complex motivation for NSSI and thereby to enhance patients' awareness of the chain of events culminating in episodes. The model includes the “healing” function of NSSI: Nock distinguishes positive reinforcement (reward) from negative reinforcement (escape from an aversive state) and effects that are automatic (internal) versus social (interpersonal). The most commonly reported function of NSSI is automatic negative reinforcement (escape from emotional pain); yet automatic positive reinforcement also constitutes an incentive for NSSI (e.g., evoking a feeling of being alive or finding the sight of blood soothing). Patients rightly take umbrage at the stereotypical view that their NSSI is a “manipulative” attempt to “get attention,” and, to the extent that they are motivated by automatic reinforcement, such social censure reflects misunderstanding.
Yet Nock's work also underscores the expressive and communicative functions of NSSI, and its effects on interpersonal relationships are profound. Social positive reinforcement includes the attention-getting effect of NSSI (e.g., seeking solace), whereas social negative reinforcement entails escaping from interpersonal challenges (e.g., inducing others to back off demands or threats). As clinicians know well, the intertwined reinforcing functions of NSSI tend to contribute to vicious circles: Behavior that serves to diminish unbearable emotional states associated with conflicts in attachment relationships may be motivated partly by positive or negative social reinforcement; yet this behavior ultimately exacerbates those interpersonal conflicts, escalating emotional pain and the need for the automatic negative reinforcement.
The volume is comprehensive in reviewing epidemiology and a range of assessment instruments. Chapters on etiology include attention to biological mechanisms (most prominently, the endogenous opioid system), childhood maltreatment and attachment disturbance, as well as modeling and social contagion—the latter now disturbingly evident in interactions over the Internet. Clinicians might be particularly eager to peruse chapters on treatment, which include psychopharmacology as well as behavioral and cognitive–behavioral interventions, with dialectical behavior therapy prominent among them. Notwithstanding the proliferation of research and concomitant understanding of NSSI that this volume exemplifies, Nock is hardly sanguine about the state of the art. He concludes that it is premature to propose an integrated theoretical model for the multidetermined behavior of NSSI and, concomitantly, “To date, no psychological or pharmacological treatments have convincingly demonstrated an ability to reduce the likelihood of NSSI, and no treatments for NSSI appear on existing lists of evidence-based treatments” (p. 324). As always, with all we know, we have much to learn.
Jon G. Allen, PhD
The Menninger Clinic
Houston, TX 77080