Running head: ARTICLE CRITIQUE 1

Emotional Regulation Therapy for Adolescents Engaged in Nonsuicidal Self-Injury: Article

Critique

Sierra Fox

Widener University
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Emotional Regulation Therapy for Adolescents Engaged in Nonsuicidal Self-Injury: Quantitative

Article Critique

Bjureberg et al.’s article explores the use of a new treatment for adolescents engaged in

nonsuicidal self-injury (NSSI) referred to as “emotion regulation individual therapy for

adolescents” or ERITA (Bjureberg et al., 2017, p. 1). Though the study suffers from some

significant limitations (regarding sample size/diversity, additional variables, etc.), it presents

valuable information regarding the potential acceptability and utility of ERITA as a feasible

treatment option for NSSI among adolescents.

Overview

This study was designed to address the lack of research regarding treatment options for

NSSI or NSSI Disorder (NSSID) among adolescents. While there has been some success with

treatments such as Emotional Regulation Group Therapy (ERGT) among adult women

struggling with NSSI/NSSID, little research has been done to provide options specifically for

adolescents engaged in NSSI. ERITA utilizes therapeutic and logistical elements of ERGT to

create individualized therapy treatments for adolescents, paired with a complementary online

parent program, and this study sought to evaluate the feasibility of ERITA as an accepted

treatment option for this underserved demographic.

Title, Abstract, and Purpose

The article’s title very clearly presents the key elements of the study, mentioning the

demographic involved (adolescents), the disorder to be addressed (NSSID), the type of treatment

being studied (ERITA), and the purpose of the study (to determine feasibility) (Bjureberg et al.,

2017). The abstract provides basic background on NSSI/NSSID and the purpose of the study,

indicating a need for this research on a therapy treatment focused on NSSI among adolescents. It
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briefly describes the methodology, explaining the use of pre-/post-treatment assessment, weekly

measures of emotional regulation and NSSI, and a 6-month follow-up (Bjureberg et al., 2017).

The abstract then provides basic information about the results/conclusions of the study, which

show substantial improvements in emotional regulation and function during the treatment as well

as at the follow-up, suggesting that this treatment is feasible and worth additional study.

Literature Review

The introduction provides a more thorough background on the issues of NSSI,

incorporating existing literature/research to explain the need for the study. It mentions 20 sources

related to the prevalence/occurrence/incidence of NSSI and/or the need for treatment options. Of

these sources, 15 are from the past decade, which is an acceptable number of recent sources for a

literature review (Holosko, 2006). Only 6 of the sources clearly focus on NSSI among

adolescents, but the lack of existing research is mentioned multiple times as justification for the

study itself. The literature does not necessarily present opposing viewpoints to those suggested

by the Bjureberg et al. study, but the issue of adolescent NSSI has only recently become a focus

of research, and most research has come to similar conclusions to that of this study.

Sample and Sampling

This feasibility study called for referrals from child/adolescent mental health services in

Stockholm and Malmö, Sweden. Initially, 21 adolescents were considered, but only 17 were

willing and qualified for the study’s criteria. That criteria included: “(a) 13-17 years of age; (b)

meeting diagnostic criteria for NSSID; (c) having engaged in ≥1 NSSI episode during the past

month; (d) having ongoing psychiatric treatment in the community at baseline; (e) having at least

one parent who committed to participate in the parent program; and (f) stability of psychotropic

medications for at least two months” (Bjureberg et al., 2017, p. 2). Additional exclusion criteria
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included diagnoses of certain cooccurring disorders (such as bipolar I disorder, substance abuse,

anorexia, etc.), as well as facility in Swedish. The sample was entirely female, despite no

attempts to exclude male participants; the authors acknowledge that male adolescents are less

likely to receive mental health treatment, and thus were difficult to find among the qualified

referrals.

Of the 17 participants, 29% were taking psychotropic medication, 82% had received

earlier psychological treatments, 41% met the criteria for borderline personality disorder, and

24% had actually attempted suicide (with 24% reporting interrupted attempts, 12% aborted

attempts, and 12% preparatory acts) (Bjureberg et al., 2017). The median frequency of NSSI

over the preceding year ranged from 8-390, with a median of 110. The most common

cooccurring disorder was ADHD (at 53%), but participants also reported depression, panic

disorders, conduct disorders, oppositional deficient disorder, social anxiety disorder, PTSD, and

separation anxiety (Bjureberg et al., 2017). The use of referrals from four clinics in Sweden for

the entirety of the sample, combined with the small sample size, do create limitations to the

external validity of the study; a more randomized approach with a larger sample size would have

allowed more diversity and applicability.

Data Collection

To determine a baseline before treatment with ERITA, all participants were assessed by

community healthcare professionals, measuring NSSI activity with the Clinician-Administered

Nonsuicidal Self-Injury Disorder Index and administering several other interviews. Community-

based healthcare professionals continued to conduct assessments along with participant self-

assessments throughout the treatment, using the adolescent-oriented 9-item Deliberate Self Harm

Inventory (DSHI-9) and the Difficulties in Emotion Regulation Scale (DERS) both pre- and
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post-treatment as well as at the follow-up. Weekly assessments also utilized a pared-down, 16-

item modification of the DERS during treatment. Additional questionnaires/scales included the

Borderline Symptom List and Borderline Personality Feature Scale for Children, and global

functioning was measured using the Children’s Global Assessment Scale (CGAS) (Bjureberg et

al., 2017).

Major Findings

The purpose of this study was to determine credibility/feasibility of the ERITA program

as a treatment option for adolescents with NSSID, and preliminary findings suggest that it has

the potential to have substantial efficacy in improving “past-month NSSI frequency, past-month

NSSI versatility, emotion regulation difficulties, self-destructive behaviors, and global

functioning” (Bjureberg et al., 2017, p. 10). The study maintained an 88% retention rate of

participants, as two participants left the program, citing discontentedness with the treatment. Of

the 15 remaining participants, substantial findings included that participants experienced

significant reduction in NSSI frequency/versatility both in the past month and between treatment

and follow-up. Substantial improvements in participants’ emotional regulation abilities and

global function were also reported, and the authors’ analyses did not find statistically significant

effects from use of medication or continued psychiatric treatment from a community provider

(Bjureberg et al., 2017). Because of the study’s limitations, it is difficult to apply these results in

broad terms to the larger population, but the results do suggest feasibility of the ERITA treatment

program for use among adolescents with NSSID.

Study Limitations and Recommendations for Future Research

As the purpose of this study was only to explore the viability of the ERITA treatment

option, it followed “recommendations for early evaluations of treatments” (Bjureberg et al.,

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2017, p. 10) by using an uncontrolled open pilot study, which does not include a randomized

control design/condition. Also, the internal validity of the study is potentially threatened by the

possibility of impact from concurrent medication and psychiatric treatment, the latter of which

was required for inclusion in the study. Though 83% of the participants reported only minimal

involvement with their community clinician, and contact with the provider/use of medication

showed no significant statistical prediction of improvement among participants, it is difficult to

separate the continued effect of the external treatment over the course of the study. The issues

with the limited sample size and recruitment are also an issue for the study’s ability to apply to a

broader community, and include problems such as the lack of male participants, the

disproportionate number of participants with BPD indicators, etc. The authors acknowledge

these limitations and recommend studying this treatment further using a randomized controlled

trial with a more representative sample.

References

The article’s references were as broad and comprehensive as the content allowed,

considering that the issue of adolescent NSSI has only recently become the subject of substantial

research. Inclusion of research on adult NSSI and use of ERGT in adult communities helped

justify the use of emotional regulation to treat NSSI/NSSID among adolescents, and a number of

the references validated the use of the uncontrolled pilot study. While there were not many

instances of opposing viewpoints among the references, there is not currently much research

available of that perspective, which limits the possibility of providing contrasting perspectives.

Writing Clarity and Readability

The article was clearly written, with little use of confusing jargon or unfamiliar

terminology. The information is accessible to readers of a variety of backgrounds, explaining all

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terms, findings, and conclusions for a broad audience. All abbreviations are clearly defined, and

even the concept of NSSI is explained with enough detail that someone unfamiliar with that or

any concepts mentioned would be able to understand the material.

Importance

The current lack of a researched treatment method for adolescents engaged in NSSI (and

potentially also for parents) requires studies such as this, to provide more efficient interventions

for this underserved demographic. Considering that NSSI/NSSID is “one of the strongest

predictors of future suicide attempts” (Bjureberg et al., 2017, p. 1), developing an intervention

for adolescents exhibiting NSSI could help mitigate future suicidal behavior. Additionally, this

program has the potential to provide better quality of life for adolescents engaged in NSSI,

through research-supported treatment in emotional regulation combined with parental

education/support.

Conclusion

The Bjureberg et al. article provides a clear and comprehensive overview of the

uncontrolled open pilot study of ERITA. The authors present significant justification for the

research, referencing the lack of researched treatment options for adolescent NSSI. Though the

study itself suffers from substantial limitations to both internal and external validity (due to the

nature of the sample and potential external variables), it accomplishes its goal of establishing

credible feasibility for ERITA, which could allow for the funding and support to design a

randomized controlled study.

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References

Bjureberg, J., Sahlin, H., Hellner, C., Hedman-Lagerlöf, E., Gratz, K. L., Bjärehed, J., …

Ljótsson, B. (2017). Emotion regulation individual therapy for adolescents with

nonsuicidal self-injury disorder: a feasibility study. BMC Psychiatry, 17, 1–13.

https://doi.org/10.1186/s12888-017-1527-4

Holosko, M. J. (2006). Primer for critiquing social research: A student guide. Belmont, CA:

Brooks/Cole.