PIT study: research into the Protocol Imaginary execuTion of self-injury.

Self-injury is becoming a bigger problem. Self-injury means: deliberately
inflicting damage or pain to one's own body. The International Society for the
Study of Self-Injury defines non-suicidal self-injury as follows: the
deliberate, self-inflicted damage of body tissue without suicidal intent and
for purposes not socially or culturally sanctioned (www.itriples.org). With
self-damaging behavior there is always physical injury, which is an expected
consequence of the behavior. In the definition, seq. not including suicidal
feelings and thoughts. Finally, this definition does not include: behavior that
harms the body, but is accepted within society or is part of cultural,
spiritual or religious rituals (www.itriples.org). With self-injury, the
intention is not to die, but to continue living. Examples of self-injury
include deliberate cutting, scratching or burning in one's own skin, hitting
itself and banging your head against a wall. Even when someone poisons himself
and, for example, deliberately takes more than the prescribed amount of
medication, we can speak of self-harm (S. de Klerk, A. van Emmerik, A. van
Giezen, 2010). A prerequisite for this is that the action is not intended by
the person to die.

Self-damaging behavior occurs in people of all ages, social classes and
ethnicities, in both women and men. Given the difference in definitions, the
prevalence figures should be mentioned with caution. Research shows that
self-damaging behavior is most common in adolescents and young adults; 18-25%
of this group indicate that they have damaged themselves at least once in their
lives (www.trimbos.nl, 2017). In the general population, the incidence of
self-damaging behavior is between 14 and 600 people per 100,000 per year. Of
the psychiatric patients who were admitted, 4.3 - 20% experienced self-damaging
behavior and self-damaging behavior occurred relatively more often in women
than in men (Claes et al., 2004).

Self-damaging behavior is more common in people who suffer from psychological
problems, such as depression, anxiety, eating problems and problems with
substance use. However, it also appears that 15-20% of adolescents who harm
themselves do not suffer from a mental disorder. People who damage themselves
are more sensitive to interpersonal stress and conflicts and have more
difficulty regulating their emotions (Andover, MS & Morris, 2014). The DSM-5
mentions self-damaging behavior as a criterion for borderline personality
disorder. It has also been added to section III as "a condition requiring
further investigation".

There are various reasons and motives for self-damaging behavior self-damaging
behavior can have multiple functions. Functions of self-damaging behavior
include stopping difficult feelings and thoughts, punishing oneself, getting
rest, feeling something even if it is pain, expressing despair, breaking
through a dissociation, getting lost, expressing anger, gaining control,
getting relief from overwhelming emotions and getting help (Claes &
Vandereycken, 2007). Self-damaging behavior is a way to deal with unbearable
emotions (Camp, van I., 2014). Self-damaging people often report past abuse.

The rewarding effect of self-damaging behavior ensures that it can become a
habit or an addiction. Self-damaging behavior has short-term benefits, namely a
rapid but short-term decrease in tension, anxiety, sadness and anger. In
addition, some experience the feeling of pain or warm blood on their skin as
pleasant. The feelings of shame, guilt and self-hatred increase in the longer
term, which means that people experience this behavior as a problem (Claes and
Vandereycken, 2006). Self-damaging behavior proceeds through the fixed order of
a prior tension build-up, an irresistible urge to hurt oneself in one way or
another, and feelings of satisfaction afterwards (Van der Linden & van Oppen,
2002).

The so-called behavioral addictions are clinically recognized (Van Rooij et
al., 2014) and research is also being done. There seems to be a similarity in
symptomatology between self-damaging behavior and substance addiction, such as
escalation of use, regular relapse, strong desire, and preoccupation with
behavior. There are similarities in other areas too: they often concern people
with increased impulsivity and psychological or social vulnerabilities (Van
Rooij et al., 2014). In addition, preliminary findings from research with brain
scans regularly draw comparisons between behavioral addictions, food addiction
and substance-related addictions with regard to the impaired functioning of the
brain (Griffiths, 2005; Nijs, Franken & Booij, 2009). In the case of addiction,
the trait is an important factor, where emotional distress is leading in
self-damaging behavior. From a study by Nixon et. aAl., (2002) shows that
self-damaging behavior in adolescents shows addiction characteristics. Patients
with internalized aggression have a greater chance of damaging themselves. The
endorphins released by self-damaging behavior is one of the factors mentioned
as part of the addiction.

There is no specific therapy for the treatment of self-damaging behavior. In
general, therapy pays more attention to the underlying problems, with the
expectation that self-damaging behavior will also decrease. In the treatment
guidelines for, for example, anxiety and depression, suggestions for treating
self-damaging behavior are limited. De Klerk, van Emmerik and van Giezen (2010)
have the opinion that self-damaging behavior requires specific treatment. The
underlying causes can also be investigated on the basis of this.

In the treatment of patients who damage themselves, some therapists use a
non-self-injury contract in which the patient makes an agreement to do not harm
himself during treatment. Research shows that these contracts are often used to
reduce feelings of guilt and / or anxiety in the therapist. Research has not
shown that these contracts are effective in reducing self-damaging behavior.
Also entering into such a contract prevents the issue of self-damaging behavior
from being discussed during the treatment. Patients also do not dare to say
that they have damaged themselves due to shame / guilt (de Klerk, van Emmerik
and van Giezen, 2010). There are therefore arguments against the use of such a
contract. In treatment, it is important that the patient learns skills to
ultimately prevent or reduce self-damaging behavior. A bond between the
therapist and patient in which support, trust and cooperation is central is
important. Research shows that cognitive behavioral therapy, combined with a
number of other techniques from other therapies, is effective in the treatment
of self-damaging behavior (de Klerk, van Emmerik and van Giezen, 2010).

In this study, Doeksen's "protocol imaginary execution of self-damaging
behavior" will be investigated. This protocol is derived from Eye Movement
Desencitizition Reprocessing (EMDR), which is a phased form of psychotherapy
that is controlled from the adaptive information processing model of Shapiro
(1989). This model by Shapiro assumes that psychopathology is based on
dysfunctionally stored memories. With EMDR, the emotional charged memories are
activated and making the load tangible. Next, a task is offered that loads the
working memory. The Working Memory Theory is the theory about the working
mechanism of EMDR that currently enjoys the most empirical support (Ten Broeke,
de Jongh and Oppenheim, 2016). The premise of this theory is that the human
short-term or working memory can perform different tasks simultaneously.
Examples include scheduling tasks, solving problems, but also, for example,
retrieving and re-recording memories. However, the memory has a limited
attention capacity. The consequence of this is that performing one task causes
performance on another task - such as recalling and holding memory images - to
come under pressure and be interrupted. Also the attention that is focused on
judging a memory image is distracted by the eye movements and at the same time
distance is created from the memory image by the instructions given during
EMDR. As a result, "decay" (desensitization) of the memory images takes place
and the memory increasingly loses the emotional component when it is written to
the long-term memory. Research also shows that the bilateral stuimulation in
EMDR automatically leads to physical relaxation. The working memory theory has
also been investigated in the treatment of addiction. Research has shown that
craving for a substance diminishes with a positive flash forward and someone
has to perform a double task. The perceived trait with this positive image
decreases in intensity and frequency if a visuospatial task is offered at the
time of the trek (E. Kemps & M. Tiggemann, 2015).

The "Protocol Imaginary Conduct of Self-Harming Behavior" is based on EMDR and
working memory theory and developed by Doeksen, clinical psychologist (Doeksen,
2018). Imagination is also used in this protocol, but in a different way than
with EMDR. With this protocol, the patient is asked to imagine that he / she is
performing the undesirable behavior. The behavior is performed imaginary and at
the same time a distracting task is offered, with which the working memory is
double burdened. The purpose of this technique is to reduce the patient's
unwanted, harmful behavior. Patients receive the homework assignment to do this
at home and to distract themselves with, for example, a task such as follow a
light balk, tetris or the Stroop task. Doeksen has applied this protocol to
different patients with different serious, harmful habits, whose harmful
behavior had disappeared after 4 weeks of treatment. Due to successful results,
this protocol has also been applied to a patient with self-damaging behavior,
furthermore familiar with ADHD and PTSD with dissociative symptoms. Patient
damaged himself internally vaginal and anal. After 2 sessions with the protocol
there is no longer any question of self-damaging behavior after 10 weeks
(Doeksen & ten Broeke, article in preparation).

The above protocol has similarities with the Feeling State Addiction Protocol
(FSAP), which has been developed to treat (behavioral) addictions. This
protocol is based on the Feeling-State Theory (FST) and this theory assumes
that addictions are created when a positive feeling is steadily linked to a
specific object or behavior. The linked part between feeling and behavior is
called the feeling-state (FS). When the FS is triggered, the entire
psychophysiological path is activated. This activation leads to uncontrollable
behavior (Miller, 2012).

Because of these positive results that are seen as an important contribution in
the treatment of self-damaging behavior, this study will investigate this
"Protocol imaginary performance of self-damaging behavior" in a group of 24
patients. There are a number of reasons why this is a useful and important
study. There is as yet no specific, effective treatment for self-damaging
behavior, but there is a need for this. As long as the self-damaging behavior
persists, the negative self-image continues to be nourished, which often has a
stagnating effect in the treatment. The physical consequences of self-damaging
behavior can be serious, which means that patients regularly end up with first
aid. In addition to the negative feelings that this causes to patients, this
also leads to a high cost for health insurers.

The aim of the research is to investigate whether the "Protocol imaginary
execution of self-damaging behavior" leads to a reduction of self-damaging
behavior and the urge to self-damaging behavior.

This is a single-case experimental design, where the aim is to investigate
whether there is a functional relationship between an independent and dependent
variable (Horner et al., 2005). The impact of a treatment is investigated by
taking many repeated measurements and analyzing this data (Morley, 2018). With
single-case, the data is collected within each participant and each participant
also serves as his own control group. The term single case does not mean that
there is only 1 participant, but it refers to the method of data collection
(Neuman & McCormick, 1995). There must be a dependent variable and that is
usually observable and measurable behavior. Each measurement moment during the
intervention period is compared with an earlier measurement moment (Horner et
al., 2005).
The advantage of a single-case design over randomized controlled trials is that
the outcomes, such as the course and process of the therapy, can be viewed per
participant (Morley, 2018).

This research concerns a non-concurrent multiple baseline design. Multiple
baseline designs can handle the data from multiple datasets within a
single-case experimental design means (Neuman & McCormick, 1995). Within this
design, it is possible to allow participants to enter the study at different
times, which is an advantage for this study, since there is a chance that there
will not be 24 participants present who can participate in the study.
This design starts with a baseline period ranging from 7 to 21 days, with 5
participants randomly starting after the baseline period on day 8, 5
participants on day 11, 5 participants on day 15, 5 participants on day 18 and
4 participants on day 22 with the intervention period. The baseline period is
followed by an intervention period (treatment phase) in which the "protocol
imaginary execution of self-damaging behavior" is applied. The starting point
of Doeken is that 1 or 2 sessions with the protocol are necessary to teach the
patient the technique and to let them experience how the urge can decrease when
imagining self-damaging behavior and at the same time performing a work memory
task. Given the severness of the personality problem in this target group,
which is traumatized and neglected, it is decided in this study to offer a
treatment session with the protocol once a week for 5 weeks, which means a
total of 5 sessions. The participants are expected to experience sufficient
security and support to apply the protocol themselves. The duration of a
session depends on how much urge there is at that moment, but will last a
maximum of 60 minutes. During the intervention period, participants receive the
homework assignment to practice the technique on a daily basis. Every time the
participant feels the urge to hurt himself, the assignment is to apply the
protocol.
After the intervention period there is a follow-up period of 4 weeks during
which registration is done daily.

Throughout the study period (the baseline period, the intervention period and
the follow-up period), patients are asked to record daily (see Annex II) how
often they have damaged themselves and how long and severe this was. Patients
are also asked to register how strong the urge for self-harm was (on a scale of
0-10). They are also asked how long they have practice the protocol at home.

At the start of the baseline period, before and after the intervention period
and after the follow-up period, a self-report questionnaire, the Alexian
Brothers urge to s eleven-injury scale (ABUSI), is taken that asks about the
urge for self-harm. This questionnaire has been translated from English into
Dutch and translated back by a native speaker. The back translation almost
corresponded to the original questionnaire and was adjusted on that point. The
Self-check questionnaire is also taken at the same time to measure whether the
participants experience more self-control after the study than at the start of
the study.

Protocol Imaginary execution of unwanted habits during work memory load.
Version: self-injury

Rational self-injury
*I'm going to teach you a method right away, so that you learn to hurt yourself
in your thoughts and at the same time move your eyes, until you no longer have
the urge to hurt yourself.
We call the eye movements Work Memory Task and ensure that you feel less and
less urge to really hurt yourself. *

Introduction Procedure Imaginary self-harm.
*I'm going to ask you a few questions about your urge to hurt yourself.
I'm going to ask you to close your eyes and go to that place where you feel the
strongest urge to hurt yourself.
I then ask you how strong the urge is to hurt yourself, on a scale of 0 not an
urge at all, up to 10 an urge, as strong as possible.
Then I ask you to go to that place and in your mind to hurt yourself as hard as
you can; at the same time I ask you to follow my fingers or the lights. "

*After about 32 seconds, I stop with the fingers or the lights and ask how
strong the urge to hurt yourself is, on a scale of 0 = no urge at all, up to 10
an urge, as strong as can be ...
Then again I ask you in that place, where the urge is not yet 0, in my mind to
hurt yourself, as hard as you can ... and again to follow my fingers or the
lights *

*After about 32 seconds, I stop with the fingers or the lights and ask how
strong the urge to hurt yourself is, on a scale of 0 = no urge at all, up to 10
an urge, as strong as can be ...
Then again I ask you in that place, where the urge is not yet 0, in my mind to
hurt yourself, as hard as you can ... and again to follow my fingers or the
lights *

*We keep repeating this until the urge to hurt yourself is completely gone in
that place and you can give the urge a 0.
If the urge in that place is 0, I ask you to make that place "white" in your
mind, so that you know that the place is quiet and you're done there. "

*Then I ask you to close your eyes again to see if you want to hurt yourself in
another place*.
We will treat that place in the same way: first request a score of the urge
from 0 to 10 and then again in thought to hurt yourself, until the urge is 0
and then make the spot white. *
*We will continue until you are here in the room, no longer feel the urge to
hurt yourself.
We practice this together in the room so that you can do it exactly the same
way at home.
When you feel the urge to hurt yourself at home, go to that place in your mind
and move your finger in front of your eyes (or tap / play tetris) to hurt
yourself in mind, as hard as you can. Just until the urge is 0, and you can
make the place white.
That's how you finish all the places. Every time you want to hurt yourself in
real life, you start doing it this way.
Know that practicing at home is very important *.

Protocol
Introduce the eye movements. Consider the good distance and fast pace (as soon
as someone can follow) Other forms of Work memory load can of course also.

Step 1: Place of the body to hurt yourself
"I ask you to close your eyes and tell me where you would like to hurt you."
Patient mentions a place in the body

Step 2: Strength of the urge (0-10)
"How strong is the urge to hurt yourself now, in this place, on a scale from 0
to 10, where 0 is no urge to 10, as much as you can."
Patient calls a number above 0.

Step 3: Imaginary pain
Go to that place, hurt yourself (depending on what the patient is doing) ..
cut, squeeze, hit ... etc) as hard as you can, do what your body wants to do
... and follow my fingers or the lights.

After about half a minute

Repeat step 2: Strength of the urge
"How strong is the urge to ... ... yourself (cutting, squeezing, biting,
hitting ...) now, on a scale from 0 to 10, where 0 is not an urge and 10 is the
urge as strong as possible."

Repeat step 3: Imaginary pain
*Go to that place and hurt yourself* ..etc. as hard as you can do what you want
to do ... and look at my fingers / the lights. *

After about half a minute. Repeat 2 and 3 repeatedly until the urge to pull is
0.

Step 4: Make the place white
*Go to the place that is now 0 and make it white in your mind.
Then we know that you are there now cut ... etc. and that that place is now
quiet *.

Repeat from steps 1 to 4 until there is no more place where the patient still
feels the urge to hurt themselves.

Step 5: Positive conclusion
*What is the most positive or valuable that you have experienced this session
...
If useful: what does that say about you? What do you call such a person? "

Step 6: Homework
*We have now calmed your entire body.
Now I ask you to practice this at home.
Every time you feel the urge to hurt yourself, you sit down, you go in your
mind to that place of your body where you want to hurt yourself and do it in
your mind; as hard as you can, you do what your body actually wants to do,
while you move your fingers back and forth in front of your eyes and follow
your fingers with your eyes.*

Let the patient practice eye movements.
If it is inconvenient for the patient, other forms of work memory load can be
practiced; like tapping on the legs, playing Tettris or tables on saying ....
etc.

*You can use this registration form to keep track of how long you have hurt
yourself in real life each day and how long you have hurt yourself (imaginary).
You can take this form with you the next time you come *.
© Do Doeksen version 1-2018

One may ask whether patients will not be given more ideas if the treatment will
explicitly refer to self-damaging behavior. For a long time in the media there
has been a large taboo on self-damaging and suicidal behavior. This dilemma
about whether or not to publish about self-damaging and suicidal behavior goes
back to 1774, when a book The Suffering of Young Werther was published by
Goethe, in which the protagonist robbed himself of life. In response to this
book, a wave of suicides in society followed. This is also referred to as the
Werther effect.
Self-harm is also a theme that has been taboo on in care for many years. When
it came to providing assistance, the motto was: ignore, then it would
eventually pass. An important principle in the book "Dealing with self-harm and
suicidal behavior" by de Klerk, van Emmerik and van Giezen (2010) is the theme
of giving explicit attention to self-damaging behavior instead of ignoring or
trivializing it. Herewith the advice of the National Self-harm Foundation to
talk about self-damaging behavior is consistent with (National Self-harm
Foundation, 2019). The Ivonne van de Ven Foundation also disagrees with the
assumption that when you talk to someone about suicide, you bring the person to
ideas. Talking about suicidal feelings can actually give the room to express
someone's feelings and receive the support that someone needs. The guidelines
for the treatment of suicidal patients state that talking about suicidal
thoughts is an essential part of the treatment and the guidelines emphasize
that talking to a patient about suicide will not lead to a patient being
brought to mind, but that this is often wrongly assumed (A. Kerkhof and B .van
Luyn, 2016).

The participants are instructed to register daily for a maximum period of 12
weeks. This is a short registration assignment. In addition, participants are
expected to participate in 5 sessions with the "Protocol imaginary conduct of
self-damaging behavior". This requires effort from the participants, but this
is estimated to be feasible in addition to the therapy that they are already
receiving. A risk is that the urge for self-damaging behavior will be felt more
strongly, but at the same time the participants will also be taught a skill to
deal with this.