Development and evaluation of a predictive algorithm and telehealth intervention to reduce suicidal behavior among university students.

BACKGROUND: Suicidal behaviors are prevalent among college students; however, students remain reluctant to seek support. We developed a predictive algorithm to identify students at risk of suicidal behavior and used telehealth to reduce subsequent risk. METHODS: Data come from several waves of a prospective cohort study (2016-2022) of college students (n = 5454). All first-year students were invited to participate as volunteers. (Response rates range: 16.00-19.93%). A stepped-care approach was implemented: (i) all students received a comprehensive list of services; (ii) those reporting past 12-month suicidal ideation were directed to a safety planning application; (iii) those identified as high risk of suicidal behavior by the algorithm or reporting 12-month suicide attempt were contacted via telephone within 24-h of survey completion. Intervention focused on support/safety-planning, and referral to services for this high-risk group. RESULTS: 5454 students ranging in age from 17-36 (s.d. = 5.346) participated; 65% female. The algorithm identified 77% of students reporting subsequent suicidal behavior in the top 15% of predicted probabilities (Sensitivity = 26.26 [95% CI 17.93-36.07]; Specificity = 97.46 [95% CI 96.21-98.38], PPV = 53.06 [95% CI 40.16-65.56]; AUC range: 0.895 [95% CIs 0.872-0.917] to 0.966 [95% CIs 0.939-0.994]). High-risk students in the Intervention Cohort showed a 41.7% reduction in probability of suicidal behavior at 12-month follow-up compared to high-risk students in the Control Cohort. CONCLUSIONS: Predictive risk algorithms embedded into universal screening, coupled with telehealth intervention, offer significant potential as a suicide prevention approach for students.

Who are we missing? Self-selection bias in nonsuicidal self-injury research.

BACKGROUND: Despite the threat of self-selection bias to the generalizability of research findings, remarkably little is known about who chooses to take part in non-suicidal self-injury (NSSI) research specifically. We aimed to establish the extent of willingness to take part in NSSI research within a commonly sampled population before assessing whether individual differences in demographic characteristics, NSSI lived experience, and participation experiences were associated with willingness to take part in future NSSI research. METHODS: New Zealand university students (n = 3098) completed self-report measures of their NSSI, psychological distress, emotional dysregulation, experience of their participation in the current study, and willingness to participate in future NSSI research. RESULTS: Most participants (78.2%) indicated that they were willing to take part in future NSSI research. Men, older participants, people with NSSI lived experience, and those with more frequent past-year NSSI were more likely to be willing to take part in future NSSI research. Participants who reported a more positive subjective experience of the current study also indicated greater willingness. CONCLUSIONS: Findings demonstrate systematic differences in who is willing to take part in NSSI research. Future research should implement methodological and statistical approaches to mitigate the impact of self-selection bias on NSSI research.

Is ceasing self-injury enough? Differences in psychological health between people reporting behavioral cessation of non-suicidal self-injury and those who consider themselves to have stopped self-injuring.

OBJECTIVE: This study examined the overlap between considering oneself to have stopped nonsuicidal self-injury (NSSI) and the actual cessation of the behavior in terms of days self-injured in the last month and last year, and how these operationalizations are associated with constructs related to NSSI recovery. METHODS: A cross-sectional survey including measures of coping, emotion dysregulation, psychological distress, general self-efficacy, and self-efficacy in resisting NSSI was answered by 144 adults aged 17-81 years (Mage [SD] = 21.43 [7.32]). RESULTS: Having self-injured for ≥5 days in the last year was overly inclusive of individuals who currently considered themselves as having stopped NSSI (39.02%). Considering oneself to have stopped NSSI was associated with better emotion regulation (Cohen's d = 0.45), and higher general self-efficacy and higher self-efficacy to resist NSSI (d = 0.59-0.64) than behavioral cessation. Not actually engaging in NSSI was only associated with self-efficacy to resist NSSI in risk contexts, such that fewer days self-injured in the last year increased confidence (partial η2 = 0.085). CONCLUSION: Accounting for whether an individual considers themselves as having stopped NSSI or not may complement estimates of behavioral cessation, and strengthen outcomes associated with NSSI recovery.

Applying social cognitive theory to nonsuicidal self-injury: Interactions between expectancy beliefs.

ObjectiveA measure was recently developed which assesses self-efficacy to resist NSSI across differing contexts. The aim of this study was to examine how self-efficacy to resist NSSI across contexts interacts with NSSI-related outcome expectancies when differentiating NSSI history. Participant: 501 Australian college students aged 17-40 years (M = 21.21, SD = 2.36). Method: Participants completed online questionnaires. Results: Self-efficacy to resist NSSI when in contexts considered to be protective or of high risk moderated the relationships between NSSI-related outcome expectancies and recent engagement in NSSI. Participants who expected NSSI to result in communication were more likely to have recently engaged in NSSI if they held weak self-efficacy to resist NSSI in protective contexts. Expecting NSSI to result in diminished self-worth was protective against weak self-efficacy to resist NSSI. Conclusion: Results support the application of Social Cognitive Theory to NSSI and provide future avenues for exploring NSSI-specific cognitions.

Understanding Self-Injury: A Person-Centered Approach.

Nonsuicidal self-injury is a common and serious concern because of its association with multiple psychiatric difficulties and illnesses as well as its robust association with suicidal thinking and behavior. Yet many individuals who self-injure find it difficult to talk about their experiences, and many service providers find addressing self-injury challenging. Accordingly, and commensurate with a recent and growing trend in the field, this Open Forum presents a person-centered framework for discussion of self-injury. This conceptualization emphasizes the distinct experiences and needs of individuals, which can help cultivate stronger rapport and greater engagement when implemented during interactions with people who self-injure. In turn, this framework is conducive to improving service provision while contributing to greater confidence and job satisfaction for providers.

The Language of Self-Injury: A Data-Informed Commentary.

ABSTRACT: Nonsuicidal self-injury (NSSI) is a behavior that can be perplexing to many people. Usually engaged as a means of regulating intense or unwanted emotions, it seems to counter the human instinct to avoid pain and harm to the self. The language people use to talk about NSSI, and individuals who engage in the behavior, can contribute to the significant stigma that is associated with NSSI. In this data-driven commentary, we report on the language clinicians and researchers typically use when talking about NSSI, and the language they consider appropriate to use. We observed some disparity in the language people use and what they deemed appropriate. Notably, researchers and clinicians report underusing terms that people with lived experience find most appropriate (someone with a history of self-injury; someone with lived experience of self-injury). We call on all researchers and clinicians to be mindful of the language they use to discuss NSSI and adopt person-centered and respectful language at all times.

Thoughts and beliefs about nonsuicidal self-injury: An application of social cognitive theory.

OBJECTIVES: According to Social Cognitive Theory, the anticipated consequences of a behavior (outcome expectancies), coupled with our belief in our ability to successfully perform the behavior (self-efficacy), determine the likelihood of engagement in a behavior. We explored whether the relationship between nonsuicidal self-injury outcome expectancies and self-injury was moderated by self-efficacy to resist nonsuicidal self-injury. Participants: Five hundred and sixteen college students aged 18-26 years (M = 20.60, SD = 1.86). Methods: Self-report measures were completed online. Results: The relationship between expecting self-injury would result in pain or emotion regulation and engaging in self-injury was moderated by a belief in the ability to resist self-injury. People who had never self-injured were more likely to believe that self-injury would cause physical pain and believe they could resist self-injury. A belief in the ability to resist self-injury countered expectations that self-injury would result in emotion regulation. Conclusion: Results may inform college-based prevention and intervention efforts.

Self-injury recovery: A person-centered framework.

Growing interest has been paid to the concept of non-suicidal self-injury (NSSI) recovery. In research, and sometimes clinical practice, the focus has been on NSSI cessation, with recovery operationalised with reference to the time since someone last self-injured. Yet, perspectives from people with lived experience of NSSI indicate that recovery is much more complex. Drawing on recent empirical work, and the voices of people with lived experience of NSSI, we outline a new framework for conceptualizing NSSI recovery. We argue that recovery is nonlinear and multifaceted, comprising: Realistic Expectations and Setbacks; Normalizing Thoughts and Urges; Fostering Self-efficacy; Identifying Strengths; Finding Alternatives; Addressing Underlying Adversities; Addressing and Accepting Scarring; Navigating Disclosures; and Self-acceptance. In presenting research and clinical implications of this new framework, we propose that this framing offers a more complete understanding of NSSI recovery-one conducive to optimizing wellbeing and promoting resilience among individuals with lived experience.

Guided Internet-delivered cognitive behaviour therapy for perfectionism in a non-clinical sample of adolescents: A study protocol for a randomised controlled trial.

BACKGROUND: Perfectionism is elevated across a range of psychopathologies and has been shown to impede treatment outcomes. There is also evidence suggesting elevated perfectionism may contribute to the onset and maintenance of non-suicidal self-injury. There is a growing body of evidence suggesting that Internet-delivered cognitive-behavioural therapy for perfectionism reduces perfectionism and symptoms of psychological disorders and that reductions are maintained at 3-month and 6-month follow-up. There may also be reductions in non-suicidal self-injury, although no study has investigated this potential benefit. Given that associations between perfectionism and psychopathology are observed across both adults and adolescents, the need for the development of interventions targeting adolescents is essential for early intervention and prevention. METHODS: The present study will employ a randomised controlled trial to examine the efficacy of 8-week guided Internet-delivered cognitive-behavioural therapy for perfectionism in adolescents compared to a waitlist control group. The primary outcome is perfectionism, and secondary outcomes include symptoms of psychological disorders, well-being, and non-suicidal self-injury. Outcomes will be assessed at pre-intervention, post-intervention, 1-month follow-up, 3-month follow-up, and 6-month follow-up. A minimum of 240 participants will be recruited online through social media, Australian universities, and schools across Australia. Generalised linear mixed models will be used to test for changes in outcomes between the intervention group and the waitlist control. DISCUSSION: The outcomes of this trial will contribute to the literature on perfectionism and psychopathology in adolescents, as well as the efficacy of guided Internet-delivered interventions for adolescents. TRIAL REGISTRATION: The trial was registered on the 20th of June 2019 at the Australia New Zealand Clinical Trials Registry (ACTRN12619000881134). TRIAL STATUS: This is protocol version 1.0. Participant recruitment began on 31 July 2019 and is still actively running with an anticipated completion date in the fourth quarter of 2020.

Advocacy for improved response to self-injury in schools: A call to action for school psychologists.

Over the past several years, nonsuicidal self-injury (NSSI) has emerged as a widespread concern in school settings worldwide. However, despite significant strides in NSSI research, there remains a substantial knowledge gap with respect to what school staff know. Unfortunately, this can contribute to stigma and ineffective responding when working with students who self-injure. In light of its high rates and the risks with which NSSI associates, including death by suicide, this is worrisome. Accordingly, there is a pressing need for advocacy in schools to ensure that NSSI is prioritized and for proper knowledge and training be offered to school staff. The current article serves as a call to action for school psychologists as leaders and advocates in meeting these needs. We begin by articulating the central issues pertinent to low NSSI literacy and high NSSI stigma in schools, followed by a series of research-informed recommendations for timely and effective advocacy. By virtue of undertaking these initiatives, school staff will be better able to respond to the needs of youth who self-injure and advocate for them. This, in turn, can foster an enhanced school climate and greater student well-being. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Rethinking self-injury recovery: a commentary and conceptual reframing.

A growing body of research has focused on understanding what may contribute to cessation of self-injury. Although these efforts are of value, cessation represents just one component of self-injury recovery. Exclusive or primary focus on cessation may foster unrealistic expectations for those with lived experience of non-suicidal self-injury (NSSI). Accordingly, this commentary discusses the importance of expanding the concept of NSSI recovery beyond cessation in both research and clinical domains. We conclude by presenting a person-centred and non-stigmatising conceptual reframing of recovery.

Nonsuicidal Self-Injury-Related Differences in the Experience of Negative and Positive Emotion.

OBJECTIVE: Emotional experience is argued to contribute to the initiation and maintenance of nonsuicidal self-injury (NSSI). We investigated whether individuals with/without a history of NSSI differed in their dispositional experience of negative and positive emotion, as well as their state responses to negatively and positively valenced movie clips. METHOD: Undergraduates (n = 214, Mage  = 21.33, 73.8% female, 35.5% reporting NSSI) completed measures of NSSI and dispositional emotional experience. Participants also viewed a sad and amusing movie clip and provided sadness/amusement ratings at seven time-points. RESULTS: Relative to participants with no history of self-injury, participants reporting NSSI indicated more reactivity, intensity, and perseveration of dispositional negative emotion; however, differences were negated after adjusting for mental illness. Unexpectedly, individuals with a history of NSSI responded less intensely to the sad clip, although they demonstrated perseveration of sadness over time. Participants reporting NSSI also indicated less reactivity, intensity, and perseveration of dispositional positive emotion and, in response to the amusing film, reported less amusement at all time-points. CONCLUSIONS: Considering different dimensions of negative and positive emotion may enhance understanding of NSSI. Future research should disentangle which dimensions of emotional experience are unique to NSSI and which are shared with mental illness more generally.

Attention biases in perfectionism: Biased disengagement of attention from emotionally negative stimuli.

BACKGROUND AND OBJECTIVES: Perfectionism is associated with the development and maintenance of several psychological disorders. Consequently, efforts to better understand perfectionism have potential transdiagnostic impact. One mechanism proposed to underlie perfectionism is an attention bias towards information signalling threats to perfectionism whereby people with elevated perfectionism selectively attend to threatening stimuli. METHOD: The present study assessed whether two core dimensions of perfectionism, perfectionistic strivings and perfectionistic concerns, are characterised by a threat-related attention bias, and whether this bias was characterised by attention being more rapidly captured by the stimuli (engagement bias), or of greater difficulty to disengage attention (disengagement bias). Participants (N = 108) completed measures of perfectionistic strivings and concerns, and symptoms of psychological distress before completing a modified dot-probe task to measure attention biases. Attention bias index scores were calculated across three factors: engagement bias vs disengagement bias, perfectionism relevant vs irrelevant stimuli, and negative vs positive emotional stimuli. RESULTS: Overall, perfectionistic concerns were associated with a disengagement bias for negative stimuli, regardless of whether stimuli were perfectionism relevant or not. No other significant main or interaction effects were observed. LIMITATIONS: The study was cross-sectional in design, and no temporal or causal inferences could be made. Additionally, participants were from a community sample and therefore replication is required in clinical populations. CONCLUSION: These findings demonstrate that individuals higher in perfectionistic concerns experience difficulty withdrawing their attention from emotionally negative stimuli. These findings contribute new information to our theoretical understandings of perfectionism and provide support for the cognitive-behavioural model of perfectionism.

Applying a cognitive-emotional model to nonsuicidal self-injury.

The recently proposed cognitive-emotional model of nonsuicidal self-injury (NSSI) draws on emotion regulation models and social cognitive theory to understand the onset, maintenance, and cessation of NSSI. We tested the prediction of the model that the relationship between emotional reactivity and NSSI is moderated by specific cognitions about self-injury (i.e., self-efficacy to resist NSSI, NSSI outcome expectancies), emotion regulation, and rumination. A sample of 647 university students aged 17-25 years (M = 19.92, SD = 1.78) completed self-report measures of the constructs of interest. As expected, we found that emotional reactivity was positively related to NSSI, particularly for people who had weak self-efficacy to resist NSSI. However, emotional reactivity was negatively related to NSSI for people who were more likely to use expressive suppression to regulate emotion. Implications for the theoretical understanding of NSSI are discussed.

Emotional cascade theory and non-suicidal self-injury: the importance of imagery and positive affect.

Grounded in Emotional Cascade Theory, we explored whether rumination and multisensory imagery-based cognitions moderated the relationships between affect and both odds of non-suicidal self-injury (NSSI), and frequency of the behaviour. A sample of 393 university students completed self-report questionnaires assessing the constructs of interest. Contrary to expectations, rumination did not emerge as a significant moderator of the affect-NSSI relationship. However, the relationship between affect and frequency of NSSI was moderated by the use of imagery. Further, the relationship between negative affect and NSSI was moderated by positive affect, underscoring the need to consider both negative and positive affect in models of NSSI. Most youth who self-injured reported thinking in images while the urge to self-injure was strong, with 53% thinking in images at least half the time. Future work is needed to explore how positive and negative affect work in concert to govern NSSI, and how imagery might either exacerbate or reduce risk of NSSI.

Thoughts, images, and appraisals associated with acting and not acting on the urge to self-injure.

OBJECTIVES: The aim of this study was to examine the frequency, content, and appraisals of thoughts and images occurring during urges to engage in non-suicidal self-injury (NSSI). METHOD: Undergraduates (N = 154) with a history of NSSI completed an online survey of their thoughts, images, and appraisals when they acted on urges to engage in NSSI as well as when they resisted urges to self-injure. RESULTS: Most (>90%) participants reported experiencing both thoughts and images during urges to engage in NSSI. During urges that resulted in self-injury, self-critical and hopeless thoughts were most distressing, and thoughts about relief from emotional distress were most comforting. Images of the anticipated injury were most common. During urges that did not result in self-injury themes of the futility of NSSI, positive self-talk, and the impact on others were most common. Images were most frequently of the negative impact on self and others, and the anticipated injury. Appraisals encouraging NSSI occurred when individuals did and did not act on their urges, but concurrent strong discouraging appraisals appeared to be protective on occasions when urges did not result in self-injury. LIMITATIONS: Retrospective self-report was used to assess cognitive content. Generalisability of findings to non-student samples needs to be assessed. CONCLUSIONS: Findings from this study may inform comprehensive assessment of thoughts and images associated with urges to engage in NSSI. NSSI interventions may need to promote thoughts, imagery and appraisals that discourage NSSI whilst simultaneously modifying cognitions that encourage NSSI.

Adverse Life Experience and Psychological Distress in Adolescence: Moderating and Mediating Effects of Emotion Regulation and Rumination.

The current study tested whether emotion regulation and rumination moderated and/or mediated the relationship between accumulated adverse life experience and psychological distress in adolescence. In class, Australian high school students (n = 2637, 12-18 years, 68% female) from 41 schools completed well-validated measures of adverse life experience, emotion regulation, rumination and psychological distress, and were followed up 1 year later (n = 1973, 75% retention rate). Adjusting for age, gender and baseline psychological distress, adverse life experience predicted psychological distress 1 year later. Expressive suppression and rumination were positively associated with psychological distress. Cognitive reappraisal was negatively associated with psychological distress and moderated the relationship between adverse life experience and psychological distress. This relationship was also partially mediated by cognitive reappraisal, expressive suppression and rumination. Promoting cognitive reappraisal and minimizing expressive suppression and rumination may be useful strategies to improve mental health for adolescents who have experienced adverse life events. Future research should examine whether adolescents who have experienced adverse life events can be trained in effective emotion regulation strategies and whether this training can prevent development of psychological maladjustment. Copyright © 2015 John Wiley & Sons, Ltd.

Do childhood callous-unemotional traits drive change in parenting practices?

This study examined the relationship between callous-unemotional (CU) traits and parenting practices over time in a mixed-sex community cohort (N = 1,008; 52.6% boys), aged 3 to 10 years (M = 6.5, SD = 1.3). Measures of CU traits, externalizing psychopathology, parenting practices, and socioeconomic risk factors were collected at baseline, and parenting practices and CU traits were reassessed at 12-month follow-up. CU traits uniquely accounted for change in three domains of parenting (inconsistent discipline, punishment, and parental involvement). Likewise, multiple domains of parenting (positive parenting, parental involvement, and poor monitoring/supervision) uniquely predicted change in CU traits. These seemingly bidirectional dynamics between CU traits and parenting were found to be largely moderated by child age and sex. Results partially replicate previous findings regarding the association between quality of parenting and prospective change in CU traits, and provide initial evidence that CU traits disrupt parenting practices over time.

Life scripts for emotionally charged autobiographical memories: A cultural explanation of the reminiscence bump.

Two studies examined the ability of the life script account to explain the reminiscence bump for emotionally charged autobiographical memories among Malaysian participants. In Study 1 volunteers, aged 50-90 years, participated in a two-phased task. In the first phase, participants estimated the timing of 11 life events (both positive and negative) that may occur in a prototypical life course within their own culture. Two weeks later the participants retrieved the same set of events from their lives and reported how old they were when those events occurred. In the second study 92 undergraduate students produced life scripts for the same 11 events. The findings revealed reminiscence bumps in both life script and retrieval curves for the memories judged happiest, most important, most in love, and most jealous. A reminiscence bump was also noted for success, although this was later in the lifespan than other reminiscence bumps. It was suggested that the life scripts can be used as an alternative account for the reminiscence bump, for highly positive and occasionally for negative autobiographical memories.

Brief report: emotion regulation and coping as moderators in the relationship between personality and self-injury.

Self-injury without conscious suicidal intent is an increasingly prevalent phenomenon particularly among adolescent populations. This pilot study examined the extent and correlates of self-injurious behaviour in a school population sample of 393 adolescents (aged 13-18 years) using a self-report questionnaire. Specifically, we aimed to determine whether personality was related to self-injury and whether this relationship was moderated by emotion regulation or coping strategies. Few personality and coping variables were directly related to self-injury after controlling for age and psychopathology. However the relationship between personality and self-injury was moderated by coping skills and emotion regulation. We suggest future research explore these relationships in order to determine the role of coping skills and emotional regulation training in prevention of self-injury.