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Book Review   |    
Barent Walsh
Psychiatric Services 2009; doi: 10.1176/appi.ps.60.1.127
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edited by Mary K. Nixon and Nancy L. Heath; New York, Routledge, 2008, 398 pages, $35

Dr. Walsh is executive director, The Bridge of Central Massachusetts, Worcester.

In the past decade two forms of "social contagion" regarding the phenomenon of self-injury—such as self-inflicted arm and body cutting, self-hitting, burning, and excoriation—have emerged. The first is an explosion of the behavior itself within previously unknown settings, such as middle schools, high schools, and universities. The second is a related proliferation of book-length publications devoted to the topic. Some of these publications have been memoirs or novels, others have been self-help books, and still others have been scholarly works written for academics or mental health or school professionals.

Editors Nixon and Heath's Self-Injury in Youth: The Essential Guide to Assessment and Intervention falls into the third category of these publications. At the outset, it should be said that this book is one of the most important thus far on the challenging subject of nonsuicidal self-injury (NSSI). It is an edited volume with all the benefits and limitations that tend to be associated with such efforts. On the positive side, a wide range of noted experts is represented and these authors speak to very specific topics and areas of expertise. However, the chapters tend to be short, and because of space limitations, few subjects are explored at great length.

Nixon and Heath's definition of self-injury resembles those from many previous authors; it reads: "Non-suicidal self-injury (NSSI) can be defined as purposely inflicting injury that results in immediate tissue damage, done without suicidal intent and not socially sanctioned within one's culture." Thus this book is about people who deliberately and frequently hurt themselves without suicidal intent.

The book begins with the claim that it is "unique in the area, being specifically designed for use by professionals across numerous disciplines and settings" and that it is "the first to provide a practical guide for a range of practitioners in a variety of settings who are encountering youth with NSSI." This claim seems to be a bit overreaching. Several authors have written works regarding NSSI that have had broad applicability across diverse client populations and professionals. Nonetheless, there is no doubt that this book makes a number of significant contributions.

One such example is the chapter by Heath, Schaub, Holly, and Nixon that reviews prevalence studies of NSSI. This contribution is a treasure trove for any graduate student or professional looking for a concise discussion regarding the characteristics of NSSI, past and present. The chapter reviews the extensive empirical literature of prevalence studies (more than 30). The authors note that current evidence suggests that approximately 15% to 20% of adolescents in the community admit to engaging in NSSI at least once.

Another chapter that deserves special mention is the discussion of the functions of adolescent NSSI by Richardson, Nock, and Prinstein. This chapter is an update of Nock and Prinstein's seminal article from 2004. The chapter conceptualizes NSSI as having four functions based on basic behavioral reinforcement principles and presents empirical evidence in support of the model. More specifically, "the four factor functional model" purports that self-injury is initiated and maintained by: automatic- or internal-negative reinforcement (NSSI reduces feelings of anxiety or rage), automatic-positive reinforcement (NSSI produces feelings of euphoria), social-negative reinforcement (NSSI allows a person to escape an uncomfortable social context), and social-positive reinforcement (NSSI results in a significant-other reconnecting). The most frequently endorsed reason for self-injuring across studies is the function of automatic-negative reinforcement.

It is important that the four-function model is included in this book because it can be especially useful in assessing self-injury. In working with any client, it is very helpful to ascertain whether NSSI is being maintained primarily for internal, affect regulation purposes or by external, interpersonal influences. In the former case, teaching emotion regulation skills can be the appropriate course of action in treatment. In the latter, dealing with social contagion variables may be more to the point.

A pre-eminent strength of this book are the chapters on neurobiology and the use of medication in the treatment of NSSI among youths. These chapters represent the first major update in book form on the biology and psychopharmacology of NSSI since Simeon and Hollander's 2001 book. Although my training in social work does not allow me to critique the medical content of these two chapters, I can say that both chapters are reasonably accessible for the non-medically trained professional.

The chapter by Plener, Libal, and Nixon on the use of medication for NSSI may be the most important contribution in the book. The chapter provides a thorough review of medication studies, which are graded as to methodological rigor. Especially helpful for medical practitioners is the treatment algorithm for adolescents with NSSI. The algorithm presents a decision tree for medication intervention based on axis I disorders, axis II disorders, and nonspecific "cluster symptoms." This chapter should be required reading for physicians and psychiatrists prescribing medication for youths with NSSI.

The book also provides a complete review of instruments that have been used to measure NSSI. Cloutier and Humphreys evaluate these instruments using criteria proposed by the National Institute of Mental Health regarding the "development, selection, and use of instruments for treatment planning and outcomes assessment." Researchers who want to explore the conundrums of self-injury using valid and reliable instruments will find this chapter especially helpful. Another notable chapter focuses on dealing with NSSI in schools. Lieberman, Toste, and Heath discuss warning signs for NSSI, provide suggestions for teachers in responding to the behavior, review a school protocol, and discuss strategies for preventing social contagion. This chapter is one of the most approachable and pragmatic in the book.

Although this book has a wealth of strengths, like any other, it also has its limitations. I found the chapter on individual psychosocial interventions to be disappointing because of its extreme brevity (16 pages). Although the chapter refers to all the appropriate empirically validated treatments, providing only a single page on motivational interviewing, cognitive-behavioral treatment, and dialectical behavior therapy does not go far in assisting practitioners. Few could read this chapter and proceed with a treatment of NSSI. Although any one book can provide only so much in terms of both rigor and scope, this book is one of the best yet written on the always challenging topic of NSSI. Any researcher who strives to understand self-injury or any practitioner who tries to alleviate self-injury should have this volume close at hand as it is an indispensable reference.




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