Extending research on Emotion Regulation Individual Therapy for Adolescents (ERITA) with nonsuicidal self-injury disorder: open pilot trial and mediation analysis of a novel online version

Johan Bjureberg, Hanna Sahlin, Erik Hedman-Lagerlöf, Kim L Gratz, Matthew T Tull, Jussi Jokinen, Clara Hellner, Brjánn Ljótsson, Johan Bjureberg, Hanna Sahlin, Erik Hedman-Lagerlöf, Kim L Gratz, Matthew T Tull, Jussi Jokinen, Clara Hellner, Brjánn Ljótsson

Abstract

Background: Nonsuicidal self-injury (NSSI) is common among adolescents and associated with negative outcomes. However, treatments developed specifically for NSSI and the proposed NSSI disorder (NSSID) are scarce, and access to empirically supported treatments for NSSI in many areas is limited. Online treatments carry the potential to increase the availability of evidence-based treatments. Emotion regulation individual therapy for adolescents (ERITA) has shown promise in the treatment of adolescents with NSSID.

Method: The present study examined the feasibility, acceptability, and utility of an online version of ERITA. Twenty-five adolescents (aged 13-17) with NSSID and their parents were included in an uncontrolled open trial. Self-report and clinician-rated assessments of outcomes such as NSSI, self-destructive behaviors, emotion dysregulation, and global functioning were administered at pre-treatment, post-treatment, 3- and 6- month follow-up. Measures of NSSI, self-destructive behaviors, and emotion dysregulation were also assessed weekly during treatment.

Results: Ratings of treatment credibility, expectancy, and satisfaction were acceptable, and the therapeutic alliance and treatment completion rate (96%) were high. Adolescent participation in the treatment was associated with a statistically significant increase in past-month NSSI abstinence (p = .007), large-sized improvements in past-month NSSI frequency (55% reduction, 95% confidence interval [CI]: 29, 72; Cohen's d = 0.88, 95% CI: 0.73, 1.06) and global functioning (d = 1.01, 95% CI: 0.77, 1.32), and medium-sized improvements in emotion dysregulation (d = 0.75, 95% CI: 0.59, 0.90) and NSSI versatility (d = 0.63, 95% CI: 0.54, 0.77) from pre- to post-treatment. These improvements were further strengthened at 3-month follow-up and maintained at 6-month follow-up. The online therapist-guided parent program was associated with small- to large-sized (ds = 0.47-1.22) improvements in adaptive parent behaviors, and these improvements were maintained or further improved upon at 6-month follow-up. Moreover, in line with the theoretical model underlying ERITA, change in emotion dysregulation mediated changes in both NSSI frequency and self-destructive behaviors over the course of treatment.

Conclusions: Together, results suggest that online ERITA is an acceptable, feasible, and promising low-intensity treatment for adolescents with NSSID. The results of this open trial must be replicated in controlled studies.

Trial registration: ClinicalTrials.gov ( NCT02697019 ). Registered 2 March 2016.

Keywords: Emotion regulation; Emotion regulation individual therapy; Internet-based treatment; Nonsuicidal self-injury disorder; Online treatment; Self-injurious behavior.

Conflict of interest statement

Ethics approval and consent to participate

All participants were informed about the study in a way they could understand. Written consent on behalf of minors aged 14 and younger was provided by both (if two) legal guardians. In accordance with Swedish law (18 § etikprövningslagen [2003:460]) minors of age 15 and older provided written informed consent if judged to be sufficiently mature; otherwise, legal guardians(s) provided written consent on their child’s behalf. All participating parents provided written informed consent for their own participation. The study was approved by the Regional Ethical Review Board in Stockholm in November 2015 (ref nr 2015/1895–31/5).

Consent for publication

No individual details, images, or videos of participants were included in this manuscript; thus, specific consent for publication was not deemed necessary.

Competing interests

JB, HS, KLG, MTT, JJ, and CH report no competing interests. EHL and BL are shareholders of DahliaQomit, a company specializing in online psychiatric symptom assessment.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Participant flow through the study
Fig. 2
Fig. 2
Observed means and estimated regression lines show a significant decrease in difficulties in emotion regulation (p = .001), NSSI frequency (p < .001), and other self-destructive behavior (p = .012) during the course of treatment

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