A Case Report of Dialectical Integrative Therapy for Self-Injuring Behavior (Individual and Family Therapy) ()
1. Introduction
Non-suicidal self-injury (NSSI) is a serious public health problem among adults and adolescents (Ose et al., 2021). The difficulty of treatment lies in repeated self-injury behavior (Gonzales & Bergstrom, 2013). NSSI epidemiological survey shows that the prevalence rate of adolescents is about 17% - 18%, with lifetime prevalence ranging between 25% and 35%, and the situation varies slightly in different countries (Baetens et al., 2014). The systematic review of longitudinal studies showed that the prevalence of NSSI peaked around the middle of puberty and then decreased gradually (Baetens et al., 2014).
At the same time, NSSI has a high comorbidity rate with SA and Si. In NSSI patients, 27.8% of patients have Si, and in Si patients, 13% of patients have NSSI. The prevalence of SA in patients with NSSI behavior was more than 7 times higher than that in patients without NSSI behavior. This shows that NSSI symptoms cannot be viewed and treated separately (Ose et al., 2021).
Dialectical behavior therapy and cognitive behavior therapy are considered to be more effective NSSI intervention methods (Kothgassner et al., 2020). At present, DBT is considered to be a more effective method for the treatment of NSSI, but there is still insufficient evidence to give the results. In addition, in the process of clinical operation, DBT needs therapists who have received relevant course system training to operate, which makes it difficult to popularize DBT in clinical practice (Prada et al., 2018).
We tried to explore a psychotherapy method for self-injury behavior of NSSI patients. The dialectical integration psychotherapy used in this case is an integrated psychotherapy idea put forward by Professor Li in 2011, that is, to integrate a variety of psychotherapy technologies with a concept of dialectical logic, rather than simply a patchwork of methods.
Dialectical integration psychotherapy takes the philosophical thought of materialist dialectics as the guiding principle and guides clinical thinking according to the law of materialist dialectics. Dialectical integration psychotherapy combines materialist dialectical theory with the basic theory of psychotherapy and dialectical materialism of various psychotherapy techniques through five categories: Dialectical phenomenon and essence, causes and results, content and form, inevitability and contingency, reality and possibility, and flexibly applies it according to specific clinical cases.
This case summarizes the psychotherapy process of a 17 repeated self-injuring girl, and mainly presents the process of using this idea to intervene in self-injuring behavior.
2. Case Description
Statement: This case report was approved by the Ethics Committee of the Taizhou Second people’s hospital, China. The guardian and the patient signed the informed consent form.
Chief complaint: self-injury for 4 years, depression, the tension in front of people.
Current medical history: 17-year-old only daughter, who began to be in a bad mood four years ago, did not concentrate in class, lost memory and interest. She thought she was useless. She cut her arms on both sides (big arm and small arm) with a knife to punish herself. The wound was deep and scarred, it was difficult to sleep, and it was easy to wake up. Obvious tension, avoid communication with people and feel flustered and sweaty on crowded occasions. During the course of the disease, there were no impulsive, running out, weird and other behaviors, and they took care of their own lives. Start psychotherapy in November 2019.
Growth history: the patient lived with his grandparents before primary school. His grandfather was very strict in discipline. If he was bullied or had bad grades outside, he would be scolded by his grandfather when he came home. During primary school, she was often bullied by boys. When she came home, she told her grandparents that Grandpa would always let her find the reason for herself. In junior high school, she began to contact animation and met a netizen on the Internet. Self-injurious behavior occurred after and has been concealed. Fear of places with many people, fear of talking and looking at each other, aggravated after high school (after the age of 16). Parents often quarrel and seldom accompany their daughters. Father has high expectations of his daughter.
3. Diagnostic Assessment
3.1. General State
The visitor enters the consulting room by himself, accompanied by his mother, with neat and clean clothes, low voice, slow speaking speed, clear consciousness, accurate orientation, contact, communication and cooperation, and good self-knowledge. Obvious scars on both forearms and forearms. There was no obvious disharmony among knowledge, emotion and intention, no hallucinations, illusions and other sensory and perceptual disorders, and no psychotic symptoms were found.
3.2. Mental Examination
No abnormality was found in physical examination, T: 36.2˚C, R: 19 times/min, BP: 98/66 mmhg, good nutrition, no yellow staining of skin and mucosa, no swelling of superficial lymph nodes of the whole body; The neck is soft, the thyroid gland is not swollen, the respiratory sound of both lungs is clear, and there is no dry and wet rale; The heart rate was 87 beats/min, the rhythm was uniform, and there was no text and pathological murmur in each valve area; The abdomen is soft and flat, without tenderness and rebound pain, the abdomen does not reach the mass, the mobile voiced sound is invisible, and the bowel sound is 4 times/minute; There was no concave edema in both lower limbs. There is no difference in blood routine and biochemical examination.
3.3. Diagnosis
NSSI compliant diagnostic criteria (Gratz et al., 2015):
1) Over the past year, the person has for at least 5 days engaged in self-injury, with the anticipation that the injury will result in some bodily harm. No suicidal intent. The act is not socially acceptable.
2) preoccupation: thinking about self-injury frequently occurs, even when it is not acted upon; contingent response: the activity is engaged in with the expectation that it will relieve an interpersonal difficulty, negative feeling, or cognitive state, or that it will induce a positive feeling state, during the act or shortly afterward. Hamilton Depression Scale (Snaith, 1977), HAMD: 26, Hamilton Anxiety Scale (Thompson, 2015), HAMA: 23 min. (ICD-10 diagnostic criteria were used in medical records, severe depression).
3.4. Details on the Therapeutic Intervention
3.4.1. Opening Stage (2 Consultations)
The first two consultations used basic psychotherapy techniques, including empathy and unconditional positive attention, with the main purpose of establishing the foundation for follow-up treatment and improving treatment compliance
3.4.2. Treatment Stage Individual and Family Therapy (18 Consultations)
1) Dealing with general issues (techniques used include clarification, concretization, midwife debate, etc.)
Data collected: including the time, place, cause, and frequency of self-injury behavior and mode of the first self-injury.
Partial dialogue
Therapist: I saw your wound. This doesn’t seem to be the first time you’ve done this. Patient: (nod). T: You also know that most of your peers don’t have such behavior, but you did. It seems that this method can help you a little, right? (Separate the individual from the behavior style to reflect the individual’s choice of behavior style).
P: Yes, I feel relaxed when I see the bleeding.
T: This feeling of relaxation seems hard for you to get in other ways? (Determine the feeling of self-injury).
P: Yes, it’s a feeling that’s hard to describe. T: This feeling means something to you, but people don’t seem to do it early in life. (Remind the patient that this is an acquired behavior).
P: Yes, although there are some difficulties in primary school, I won’t do so.
T: Would you like to say when you first did this? (Determine when this selection first occurs).
The patient talked about her childhood experience. Her grandparents were strict in discipline and blamed more. Her parents lacked company. In junior middle school, her academic performance decreased, and she was very depressed and upset. She made friends of the opposite sex online and determined the relationship between male and female friends. Each time the netizen had a conflict, the other asked her to do so. Later, breaking up with netizens will still cut themselves when they are sad and upset.
T: It seems that every occurrence of self-injury behavior is accompanied by a bad emotional state? P: (Nod).T: After you found that this way can vent some of your emotions, you began to try more and more? (Understand the frequency of self-injurious behavior).
P: Nod. I have it almost several times a week. T: But now, it seems that the situation is getting worse and worse? P: Yes, at first, I would not be depressed for many days. Now, even if I scratch myself, my psychology is still depressed and painful. T: It seems that this approach does not solve the fundamental problem. P: Nod.
T: If this is an acquired practice and solves some individual difficulties, individuals seem to tend to use it more frequently. Do you have such experience? (Understand this choice to determine the frequency of occurrence again).
P: Yes, I often do. More and more. T: You know, most people don’t do this. You did it, and the time it happened is related to emotion. The explanation I can find is that you encountered a dilemma that most people haven’t encountered, right? (Continue to express understanding and lead the topic to the most troubled situation of the patient).
P: Nod. T: Would you like to talk about your difficulties? P: Silence. T: Maybe you feel very embarrassed. In short, I respect you. Let’s not talk about it now. However, if there is another way to make you more relaxed in a difficult situation, are you willing to try? (Connecting dilemmas to new ways).
P: Nod.
When she realized that self-injury behavior was related to a dilemma and self-injury was not the only solution to this dilemma, She showed her willingness to observe her self-injuring behavior and the situation at that time (After that, we used cognitive therapy to correct the patient’s self-blame concept and family therapy to support the patient so that the relationship between the patient and his family began to change. During this period, the patient’s self-injury behavior decreased from 1 - 2 times a week to 2 times in 4 weeks).
2) Deal with special problems: Discussion on the characteristics of individual self-injury behavior (8 consultations, once every two weeks).
Key point: Regard the case as a whole, find the contradictions and promote the transformation of contradictions.
Partial dialogue:
Therapist: I see you always wear long sleeves. Trying to hide the wound? Patient: Yes, I don’t want to be seen.
T: I have been in contact with some patients. They don’t seem to be afraid of being discovered by others, or even hope to be seen by others. P: I don’t want to.
T: I know, you must have your reason. Last time we talked a lot about childhood and interpersonal relationships, as well as your avoidance of the crowd. Maybe the reason has something to do with these things. P: (Silent).
(When talking about the interpersonal relationship, the patient showed thoughtfully, bowed his head and hesitated, and her wound was deeper and longer than the common self-injury behavior. It can be seen that the patient’s mood was extremely bad in a certain emotional state, which may be related to interpersonal relationships. Tracing back to the whole interpersonal relationship of the patient, combined with the time point when the self-injury behavior occurred, it seems that netizens are important in grade 2 of junior middle school. It seems that some serious things have happened between her and netizens. I speculate more about the love relationship, so I began to pave the way slowly and for a long time. The paving process is summarized below).
Therapist: your age is growing at high speed. You are tall, your body has changed, and you are beautiful. Growth and development is a magical and beautiful feature of life. P: (embarrassed).
T: But at this age, although the body has grown up, psychologically, it may not be able to face and deal with these changes, but also have some exciting feelings and impulsive practices. You will also pay special attention to your emotions during this period or meet the right person. However, the emotion at this time is impulsive and strong, which is difficult to deal with.
P: (nodding) yes, we had a great chat. I sent him my photos and he invited me out to play.
T: Where did you go? P: I went, but I regret it.
(At this time, I realized that it seems that there is not only a problem in the relationship, but also the patient shows self-blame and shame. The problem may be related to sex and needs to rationalize her experience. Literature research shows that the reduction of shame plays an important role in the treatment of self-injurious behavior. (Rizvi and Fitzpatrick, 2021).
T: It seems that something unexpected has happened. No matter what it is, let’s look back on it and only regard it as an experience, just an experience, okay?
P: (A sigh of relief). T: Emotion has been a complex thing since ancient times. It is very normal to deal with it badly. Not to mention that you are still young. At the same time, girls are often vulnerable to coercion and injury in the process of dealing with emotional relations.
P: (Keep head down and nod hard).
(Later, the patient slowly told me the details about sex between the two people. I used more psychodynamic methods to help her understand the impact of childhood on herself and express more repressed feelings by understanding herself).
3.4.3. End Stage (2 Times)
The therapist and the patient reviewed the treatment process together, and discussed possible difficult situations and coping methods in the future. The patient realized that awareness of emotions without judgment is an important method of self adjustment. At the same time, the patient has made it clear that the therapist is an observer and companion, and is ready to be separated from the therapist. Both sides say goodbye to each other.
3.4.4. Follow-Up and Outcomes
At present, the patient began to study art and worked part-time during the holidays, and there was no self-injury behavior.
4. Discussion
4.1. Treatment Ideas of Dialectical Integration Therapy for Self-Injury Behavior
When using this method to deal with patients’ self-injury behavior, the first step is to deal with the universal characteristics, that is, self-injury behavior, without distinguishing between cuts or scratches. At this time, the key to treatment is the therapist’s understanding of self-injury behavior. First, the therapist should see this behavior as a result. There is a result, and there must be a cause. Even if self-injury is regarded as dangerous, it is reasonable and logically related to this contradiction between cause and result. The therapist guides the patient to think about why he chose self-injury to deal with the current situation rather than other ways, then discusses the rationality and reasons for this behavior or related events, and treats traumatic events without focusing on the change of self-injury behavior. After dealing with universality, the key to treatment is to find contradictions. Guide the patient to see the contradiction, deepen the conversation, deal with the contradiction and promote the transformation of the contradiction (Figure 1).
4.2. The Logic of Dialectical Integration Therapy in Individual Therapy and Family Therapy
In this case, the therapist treated self-injury behavior and family therapy according to the idea of dialectical integration therapy.
Treatment ideas and application techniques for self-injuring behaviors: do not stop a certain behavior, and pay attention to its causes and results.
1) The time of occurrence of self-injury behavior and events before and after it (unconditional active attention);
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Figure 1. Strategies of applying dialectical integration therapy to deal with self injuring behavior
2) Identify that self-injuring behavior is an acquired behavior style and explore its causes (psychodynamic therapy);
3) Clarify the role of self-injury behavior on patients, on the one hand, relieve their emotions; on the other hand, cause pain and seek medical treatment (unconditional positive attention);
4) Identify the similarities and differences between the patient’s self-injury behavior and the general self-injury behavior, and carry out discussion (unconditional active attention);
5) Make clear the feelings and behaviors of the visitors after the self-injuring behavior is found by their families.
Ideas and techniques of family therapy in this case：
1) It is clear that the patient is a member of the family, and the change of individual status also means a problem for the overall function of the family;
2) Discuss the impact on family members and everyone’s feelings before and after the patient’s medical treatment;
3) It is clear that the most prominent contradiction, in this case, is the patient’s concealment of symptoms and experiences and the conscious or unconscious neglect of family members;
4) Talk to family members individually to discuss grievances and expectations of other family members;
5) Discover that there are concealments and secrets among family members;
6) Talk to each family member and tell them to be prepared;
7) Reveal secrets, feel changes, and rebuild trust. (Not every secret can be disclosed).
The characteristics of dialectical integration therapy are:
1) Not in a hurry to stop a symptom;
2) Understand the status of the client from a dialectical point of view and choose the current technology;
3) In the process of a specific conversation, introduce dialectical points of view.
The difference between dialectical integration therapy and general integration therapy lies in:
First, how to select the current entry point and technology. (Current main contradiction and secondary contradiction).
Other therapies are to screen one or several technologies for intervention according to a certain symptom of the patient. The first step of dialectical integration therapy is to take the course and living state of the visitor as a whole, explore the current main contradiction, and select technologies according to the characteristics of the contradiction. This contradiction may or may not be the symptom itself. For example, for patients with self-injuring behavior or anorexia, DIT does not necessarily give priority to the symptoms and instead deals with the most important contradictions in life.
Second, how to understand symptoms. (Universality and particularity of contradictions, etc.) In general therapy, symptoms are still regarded as prominent problems or diseases. DIT holds the view of continuous development of the patient’s condition. It tends to understand emotional diseases as the process of changing from one state to another and pays attention to the initial state, process and disease state. Through analyzing the 5 pairs of contradictions in the process, i.e., cause and result, phenomenon and essence, content and form, inevitability and contingency, different psychotherapy techniques were integrated to achieve the curative effect. For example, the understanding of dialectical integration therapy for depression is that patients change from a better state to a depressed state. Although the transition may not have a very clear time point, patients report that their recent status is different from that of a few weeks or N years ago. In response to this, the therapist will discuss the reasons for the change with the patient. When the therapist points out that the current state of the disease can be changed, the patient will become more confident.
Third, pay attention to family therapy and treat family function from a dialectical point of view. (Relationship between whole and part)
The patient’s mode of thinking and mode of emotional response can be found from the early stage of life, so dialectical integration therapy will put the patient and his symptoms in the family as a whole and treat the symptoms as changes in family functional status. Therefore, when the patient’s state changes, we should not only pay attention to the individual but also pay attention to the overall functional changes of the family and pay attention to the important events in the family at that time. For example, if the branches are dry, we should pay attention to the roots.
Dialectical integrative therapy holds some views on the cross diagnosis of mental diseases.
1) Dialectical integrative therapy regards psychological diseases as a special psychological state;
2) This therapy believes that there is a process from quantitative change to qualitative change in the change of mental state, that is, from an important event or a certain period of the event, the individual’s state changes, which can be learned from the history of each patient with mental disease. And pay attention to the content of the quantitative change (which may be continuous neglect or abuse) and the result of qualitative change (loss of interest or self-injury);
3) Although the current state makes individuals and families feel pain, the changes brought about by this state are meaningful;
4) In the course of treatment, pay attention to the opportunity of state change and the opportunity of seeing a doctor;
5) Pay attention to the changes in the relationship between individuals and families before and after treatment.
5. Conclusion
In this case, when DIT is used to deal with patients’ self-injury behavior, the first step is to deal with the general feature, that is, self-injury behavior, without distinguishing between cuts or scratches. At this time, the key to treatment is the therapist understands of self-injury behavior. First, the therapist should see the results of this behavior. If there is a result, there must be a reason. Even if self-injury is considered dangerous, it is reasonable and logical in this causal contradiction. The therapist guides the patient to think about why he chose self-injury to deal with the current situation rather than other ways and then discusses the rationality and reasons for this behavior or related events, treating traumatic events without paying attention to the changes of self-injury behavior. After dealing with the universality, find out the particularity of the current patient’s self-injury behavior (the wound is deep and deliberately hidden). Guide patients to see contradictions, deepen dialogue, deal with deep-seated psychological problems and introduce family therapy. In the process of family therapy, the therapist pays attention to the problems and secrets of the family itself and affects the visiting state by solving the main contradictions presented by the family.
This treatment process has achieved a good curative effect, which can provide a reference for clinical psychotherapy of NSSI.
Acknowledgements
Thanks for the cooperation of all the medical staff in the psychological department and psychosomatic Department of Taizhou Second People’s Hospital.
Funding
This study was supported by the 2020 Zhejiang medical and health science and technology plan project. The project name is “Attention bias and cognitive behavioral intervention of adolescents with Non-suicidal Self-injury Behavior”, project number 2020KY362, the leader of the project is Wang Yong, and the undertaking unit is Taizhou Second People’s Hospital.
NOTES
*Dongyang Chen and Yong Wang contributed equally to this work and should be considered co-first authors.
#Corresponding author.