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Minimizing social contagion in adolescents who self-injure: considerations for group work, residential treatment, and the internet.

Social contagion Contagion

The likelihood of significant economic changes in one country spreading to other countries. This can refer to either economic booms or economic crises.

Notes:
An infamous example is the "Asian Contagion" that occurred in 1997 and started in Thailand.
 among adolescents is a growing concern as the numbers of youth who selfinjure increases. Mental health counselors face challenges in treating self-injurers in settings that are prone to social contagion. This article describes social contagion as one factor motivating self-harm in group settings, residential facilities, and audiences for social and electronic media. It reviews possible benefits and pitfalls of self-injury treatment in these environments and presents approaches to minimize social contagion. Responses to self-injury and social contagion are explored.

**********

The prevalence of nonsuicidal self-injury (NSSI NSSI National Security Space Institute (formerly the Air Force Space Operations School)
NSSI North Slope Science Initiative (Alaska)
NSSI Navrátil Software System Information
NSSI No Significant Schedule Impact
) among adolescents and young adults has been rising rapidly and significantly (Kerr, Muehlenkamp, & Turner, 2010; Prinstein, Guerry, Browne, & Rancourt, 2009); it has even been described as epidemic (e.g., Plante, 2007; Whitlock, Purington, & Gershkovich, 2009). In one recent study of a community adolescent population, at least 27% had engaged in one or more types of NSSI (Baetens, Claes, Willem, Muehlenkamp, & Bijttebier, 2011). In studying adolescent clinical populations, Jacobson, Muehlenkamp, Miller, and Turner (2008) found that only 52% of patients reported not having engaged in any form of self-injury, and in a different population Nock nock  
n.
1. The groove at either end of a bow for holding the bowstring.

2. The notch in the end of an arrow that fits on the bowstring.

tr.v. nocked, nock·ing, nocks
1.
 & Prinstein (2004) found that 82.4% had engaged in at least one NSSI incident. These statistics suggest the importance mental health professionals must place on helping prevent self-injury. It is imperative that counselors working with youth recognize the prevalence of NSSI and understand how certain environments present higher risks.

By definition, intent to die is not a factor in NSSI (Wilkinson & Goodyear, 2011; Yaryura-Tobias, Neziroglu, & Kaplan, 1995). Researchers describe it as a deliberate, adaptive strategy to manage physiological stimulation and emotional distress, without the intention of ending life (Deiter-Sands & Pearlman, 2009; Hyldabl & Richardson, 2011; Plante 2007; Walsh 2006). Most often individuals engage in NSSI to regulate or express affect, relieve tensions, manage dissociative dissociative /dis·so·ci·a·tive/ (-so´se-a´tiv) pertaining to or tending to produce dissociation.  and depersonalization depersonalization /de·per·son·al·iza·tion/ (de-per?sun-al-i-za´shun) alteration in the perception of self so that the usual sense of one's own reality is temporarily lost or changed; it may be a manifestation of a neurosis or another  symptoms, gain a sense of control, and influence others (Klonsky, 2009). Consequently, NSSI can become a repetitive, addictive coping strategy that may result in significant scarring, infection, life-threatening injury, and accidental death (Nafisi & Stanley, 2007; Plante, 2007). Understanding the unintended consequences For the "Law of unintended consequences", see Unintended consequence

Unintended Consequences is a novel by author John Ross, first published in 1996 by Accurate Press.
 of NSSI is important to preventing it.

With a significant proportion of teens engaging in NSSI, there is growing evidence that self-injury "is a behavior subject to peer influence, perhaps particularly among adolescents ... [which] presents a large public health concern" (Prinstein et al., 2009, p. 89). Self-injury contagion has been defined as when (a) acts of self-injury occur in two or more persons within the same group within 24 hours, or (b) acts of self-injury occur within a group of statistically significant clusters (Walsh & Rosen, 1985). The primary focus of this article is to identify environments that present a high risk of contagion and suggest ways counselors working with adolescents can minimize and prevent it.

CROUP croup (krp), acute obstructive laryngitis in young children, usually between the ages of three and six.  WORK FOR TREATING SELF-INJURY

Many programs designed to treat adolescents who self-injure consider group therapy to be an essential treatment ingredient. Self Abuse Finally Ends (SAFE), founded in 1985 by Karen Conterio and Wendy Lader, was the first treatment facility designed specifically for people who self-injure. Since its inception, clinicians at SAFE have used group therapy as a central feature of their treatment programs (Conterio, Lader, & Bloom, 1998). Dialectical di·a·lec·tic  
n.
1. The art or practice of arriving at the truth by the exchange of logical arguments.

2.
a.
 behavior therapy behavior therapy or behavior modification, in psychology, treatment of human behavioral disorders through the reinforcement of acceptable behavior and suppression of undesirable behavior.  (DBT DBT Department of Biotechnology (India)
DBT Dibenzothiophene
DBT Drive-By Truckers (band)
DBT Design Basis Threat
DBT Deutscher Bundestag (German Parliament) 
), which combines individual therapy, group skills training, and family education, has emerged as one of the most effective treatments for adolescents who are suicidal or self-injurers (Katz, Cox, Gunasekara, & Miller, 2004; Muehlenkamp, 2006; Rathus & Miller, 2002). Many of the skills needed to reduce self-injurious behaviors (e.g., emotional regulation, distress tolerance, or interpersonal communication Interpersonal communication is the process of sending and receiving information between two or more people. Types of Interpersonal Communication
This kind of communication is subdivided into dyadic communication, Public speaking, and small-group communication.
 skills) are learned and practiced in group therapy. Matthew Selekman (2009) has written extensively on using strengths-based, solution-focused strategies to meet the therapeutic needs of distressed adolescents. He has recently developed a nine-session Stress Buster's Leadership Croup for adolescents in both school and community settings who engage in self-destructive behaviors. While these group approaches may differ, they all tend to be didactic di·dac·tic
adj.
Of or relating to medical teaching by lectures or textbooks as distinguished from clinical demonstration with patients.
, highly structured, and skill-based.

For logistical and developmental reasons, group homes, residential facilities, and hospitals typically use group work as the primary mode of treatment. Groups are more efficient and cost-effective than individual approaches because they enable counselors to work with more youth (Corey & Corey, 2006; Rose, 1998). Also, since much social learning occurs within groups, both formal and informal (e.g., families, classrooms, social groups, gangs, sports teams), adolescents often prefer group work because it tends to be a better developmental fit for them than individual therapy (Richardson, 2001; Towberman, 1993). For example, youth care more about what their peers think of them than how adults may perceive them (Hollander, 2008). Plante (2007) stressed that affirmation and encouragement to try positive coping strategies The German Freudian psychoanalyst Karen Horney defined four so-called coping strategies to define interpersonal relations, one describing psychologically healthy individuals, the others describing neurotic states.  is more effective in gaining the attention of adolescent self-injurers.

Youth who self-injure tend to feel isolated and disconnected. Among therapeutic factors youth most value hope, universality, and relationship climate (Chase, 1991; Shechtman & Cluck, 2005). While individual counselors can inform youth that they are not alone, the group allows them to experience a sense of universality with their peers (Richardson, 2001; Selekman, 2009; Yalom, 1986) and learn from others at different stages in the recovery process. Adolescent group members can also support and model healthy behaviors and challenge unhealthy choices (Conterio et al., 1998). By assisting others, members can begin to see themselves in a different light. Gladding (2007) noted that one of the most effective ways to boost the self-esteem and self-confidence of youths is to structure situations in which they can help others and feel altruistic al·tru·ism  
n.
1. Unselfish concern for the welfare of others; selflessness.

2. Zoology Instinctive cooperative behavior that is detrimental to the individual but contributes to the survival of the species.
.

However, despite the potential benefits of using groups in treating those who self-injure, there are pitfalls that could disrupt the process or even increase NSSI. Walsh (2006) recommended that counselors always be mindful of the risk of contagion whenever persons who self-injure are treated in groups. He also warned that groups that are largely cathartic--where members are encouraged to openly express their emotions and share traumatic experiences--are often counterproductive coun·ter·pro·duc·tive  
adj.
Tending to hinder rather than serve one's purpose: "Violation of the court order would be counterproductive" Philip H. Lee.
 for young people: Open discussion of self-injury antecedents, behaviors, and consequences can be exceptionally triggering (Walsh, 2006). Many clinicians and researchers assert that group leaders should structure activities to focus on empowerment and replacement or coping skills training and prohibit detailed discussion of self-injury (Conterio et al., 1998; Hollander, 2008; Lieberman, Toste, & Heath, 2009; Selekman, 2009; Walsh, 2006).

It can be very difficult for counselors to maintain this focus because sharing details about self-injury can be alluring. Walsh (2006) recommended acknowledging that although discussing self-injury in detail is important, it should be shared in individual therapy rather than with group members. Conterio et al. (1998) also cautioned that group therapy may at first be seen as an opportunity to compare wounds, so such disclosures should be prohibited from the outset, and mental health counselors should be aware that sharing the graphic detail of self-harm stories can trigger NSSI after the session.

School counselors in particular should be cautious about organizing "cutter-specific" groups because students may view cutting as a criterion for membership (Lieberman et al., 2009). For example, one school social worker who started a cutter-specific group was approached by a girl who asked what severity of self-injury was required to join (Walsh, 2006). Both school and community counselors need to be aware of ways groups can backfire.

NSSI groups are thus most likely to be effective if:

1. Group leaders have significant training and understanding of treating self-injury and managing contagion.

2. Membership is closed to enhance cohesion and trust.

3. The group is governed by rules that strictly prohibit discussion of details of self-injury and the sharing of wounds or scars.

4. Like DBT groups, the sessions are highly structured, didactic, and dedicated to teaching new skills and behaviors (e.g., emotional regulation, mindfulness, self-soothing, distress tolerance, exercise) to help reduce further incidents of self-injury.

SELF-INJURY WEBSITES AND MESSAGE BOARDS

While the Internet can be a valuable source of support and information for self-injurers, it can also be a breeding ground for contagion. Some 93% of American youth aged 12 to 17 use the Internet, nearly two-thirds of them daily, and 73% of American teens now use social networking See social networking site.

social networking - social network
 sites (Lenhart, Purcell, Smith, & Zickuhr, 2010). In the past decade there has been an increase in the number of websites for and about people who self-injure (D'Onofrio, 2007). Whitlock, Lader, and Conterio (2007) documented over 500 NSSI-focused message boards, and the numbers rise each year. These researchers also observed the parallel between the increase in self-injury information on the Internet and the growth in self-injury awareness in society. Whitlock, Powers, and Eckenrode (2006) recognized the Interact as a transformational mechanism, influencing the communication, support, and social reality of adolescents. Many Internet message boards are populated pop·u·late  
tr.v. pop·u·lat·ed, pop·u·lat·ing, pop·u·lates
1. To supply with inhabitants, as by colonization; people.

2.
 by adolescent females (Whitlock et al., 2006).

Self-injury websites and message boards may have particular appeal for adolescents who are socially avoidant or feel marginalized (McKenna, Green, & Gleason, 2002). These youth may feel deep relief at being able to make meaningful connections with individuals who share similar concerns and experiences. Also, the anonymity of these sites may encourage more, and more truthful, disclosures about feelings and behaviors (D'Onofrio, 2007). Another potential benefit is positive peer pressure. Just as in group counseling, these adolescents may more readily accept feedback from peers that encourages them to practice safer, more productive ways to express their emotions.

It is important not to minimize the perceived value these sites have for young clients. While social scientists and mental health professionals often focus on the potential for harm, adolescents who use these sites tend to report positive experiences. For example, in a survey of self-harm discussion group members, most said they had reduced the frequency and severity of their NSSI, which they attributed largely to the support and guidance they found online (Murray & Fox, 2006). Baker and Fortune (2008) interviewed 10 members of online self-harm support groups, who consistently reported '"feeling understood', 'feeling part of a community', or 'coping with psychological distress'" (p. 121).

Whitlock et al. (2006) were among the first researchers to study the content of self-injury message boards to better understand their role in sharing information about self-injurious practices and influencing help-seeking behaviors. Focusing on active but lightly moderated boards where the content is less likely to be censored, they analyzed over 3,000 posts over a two-month period. The most common type of exchange they found was informal support to other posters through comments such as "'We're glad you've come here' and 'Just relax and try to breathe deeply and slowly'" (p. 412). There was also considerable discussion about ways to conceal scars and maintain secrecy.

While 44% of all help-seeking posts showed favorable attitudes toward seeking mental health treatment, about 20% discouraged individuals from seeking treatment or voiced negative views about therapy. Self-injury message boards can also expose vulnerable youth to encouragement for self-injury, with potential for fueling social contagion. On several sites, Whitlock et al. (2006) found that members shared new and often more dangerous cutting techniques and instruments and even offered links to sites where self-injury paraphernalia PARAPHERNALIA. The name given to all such things as a woman has a right to retain as her own property, after her husband's death; they consist generally of her clothing, jewels, and ornaments suitable to her condition, which she used personally during his life.  could be purchased. Again, while many adolescents find comfort and solace in these communities, "the adolescent drive to belong and the satisfaction that comes with associating with a community of similar others may inadvertently feed fundamentally self-destructive behavior for some participants" (p. 415).

Some posters shared that posting videos, artwork, and poetry serves a cathartic cathartic (kəthär`tĭk): see laxative.  function that was helpful in their healing process. A recent study by Lewis, Heath, St. Denis Denis, king of Portugal: see Diniz.  and Noble (2011) studied NSSI videos posted online. Their analysis of videos posted on YouTube found that the top 100 NSSI videos were viewed over two million times and included graphic images. Uploaders had a mean age of 25.39, which the authors suggested is misleading due to young viewers who would otherwise be prohibited falsifying fal·si·fy  
v. fal·si·fied, fal·si·fy·ing, fal·si·fies

v.tr.
1. To state untruthfully; misrepresent.

2.
a.
 their age. Again, Whitlock et al. (2007) warned that sites that feature graphic depictions of self-injury can be highly suggestive and triggering to others who self-injure.

D'Onofrio (2007) voiced concerns that persons who self-injure and seek support and encouragement may be negatively influenced by anonymous but forceful "friends" they meet online. Worrisomely, those who self-injure can become better at self-injury by learning from people they meet online. Walsh (2006) observed that some posters use chat rooms to coerce others, model self-destructive behaviors, compete with others, and discourage others from stopping the injuring or seeking help: "Pecking orders also emerge in chat rooms whereby those who self-injure with the greatest conviction have the highest status.... Most claim to have developed the websites to provide support and help others, but the content ... is often more triggering than therapeutic" (p. 242).

Analyzing several websites, however, Murray and Osborne (2009) found that conversation was frequently geared to understanding and justifying the self-injurious behaviors. Posters explained their behavior as addictive, uncontrollable, and an understandable response to traumatic life events. Both posters and responders provided justifications; this seemed to be an important function of the group, but the justifications were typically not used to encourage self-injury. Rather, most members attempted to discourage continued NSSI. Baker and Fortune (2008) also asserted that participants' experiences with self-harm and suicidal websites are strikingly different from those found in the professional literature and wider media. They postulated pos·tu·late  
tr.v. pos·tu·lat·ed, pos·tu·lat·ing, pos·tu·lates
1. To make claim for; demand.

2. To assume or assert the truth, reality, or necessity of, especially as a basis of an argument.

3.
 that professional criticism and warnings about online message boards may stem more from their "antipsychiatric attitudes" rather than scientific evidence that they are harmful.

In conclusion, self-injury websites and message boards are helpful for some and counterproductive for others, which suggests they should be an area of therapeutic inquiry. In fact, the omnipresence Omnipresence
See also Ubiquity.

Allah

supreme being and pervasive spirit of the universe. [Islam: Leach, 36]

Big Brother

all-seeing leader watches every move. [Br. Lit.: 1984]

eye

God sees all things in all places.
 of Interact use among adolescents presents a crucial argument for both assessment of Internet use in general and specific assessment of Internet exposure to self-injury (Whitlock et al., 2007). Mental health professionals should therefore educate themselves about various websites for self-injurers. Whitlock et al. (2007) offered suggestions for follow-up questions if adolescent clients acknowledge visiting NSSI-related sites, and recommended that clinicians maintain a curious, neutral, nonjudgmental non·judg·men·tal  
adj.
Refraining from judgment, especially one based on personal ethical standards.

Adj. 1. nonjudgmental
 tone when asking questions like these:

* How comfortable do you feel hearing stories from others who self-injure?

* Have you shared your own story? How did you feel?

* What do you like most about having friends that you only really know through the Internet?

* How honest are you when you share information on the Web? (Do you minimize or tend to embellish?)

* Do you ever take advice from Interact friends? If so, can you provide examples of advice you got ... that you used? (p. 1141)

Assessing the mechanisms that influence clients will help counselors determine appropriate interventions and Internet-use recommendations (Whitlock et al., 2009). Whitlock et al. (2007) expressed concern that some sites have minimal or no monitoring for potentially dangerous content, and where there are moderators, they typically have minimal or no training in mental health. With some clients, counselors might assess that it is best to be direct in encouraging or discouraging particular sites or interactive behaviors, clarifying concerns about why some sites might be traumatic or triggering and therefore countertherapeutic. These direct suggestions will likely be more fruitful with adolescents who have entered counseling voluntarily, begun to develop a therapeutic relationship, and voiced a desire to stop or reduce self-injury.

TREATING YOUTH IN RESIDENTIAL FACILITIES

As with group therapy and the Internet, residential treatment offers both benefits and pitfalls. NSSI reportedly occurs in significant clusters in residential settings (Taiminen, Kallio-Soukainen, Nokso-Koivisto, Kaljonen, & Helenius, 1998; Walsh & Doerfler, 2009; Walsh & Rosen, 1985). Residential here refers to community-based group homes, special education boarding schools, juvenile detention facilities, and psychiatric inpatient settings. Many NSSI experts suggest a need for further research into the residential contagion effect, but few studies have been published (e.g., Lofthouse & Katz, 2009). This population is likely at higher risk of contagion due to peer influence and the prevalence of more severe psychopathology psychopathology /psy·cho·pa·thol·o·gy/ (-pah-thol´ah-je)
1. the branch of medicine dealing with the causes and processes of mental disorders.

2. abnormal, maladaptive behavior or mental activity.
, such as eating disorders eating disorders, in psychology, disorders in eating patterns that comprise four categories: anorexia nervosa, bulimia, rumination disorder, and pica. Anorexia nervosa is characterized by self-starvation to avoid obesity.  and affective regulation issues (Nixon & Heath, 2009; Prinstein et al., 2010; Walsh & Doerfler, 2009). Recognizing the potential for contagion makes it possible to take precautions case by case in determining the benefits of residential treatment and can help in choosing appropriate responses to NSSI in a residential population.

Lofthouse and Katz (2009) cited three studies illustrating the longitudinal phenomenon of NSSI by adolescent inpatients. The first, published in 1999 by Lipschitz et al., reported that 39% of adolescents admitted to an American hospital had incidents of NSSI. In 2002, Nixon, Cloutier, and Aggarwal reported 29.7% of adolescent inpatients at a Canadian facility were engaging in NSSI, with 80% of these injuring at least once per week. Finally, in 2004 Makikyro et al. reported that 67.7% of adolescents in an inpatient unit in Finland occasionally or frequently engaged in NSSI. Data reported by Boxer (2010) suggested a comparable increase in NSSI in a Midwestern inpatient facility. His analysis of 476 adolescent patients explored the relationship between reported history of self-harm and length of stay at the first critical incident of NSSI. Specifically, 33% patients with no history of self-harm had a critical incident of self-harm, at an average of 60.3 days after their stay began. Similarly, 39% of patients with a history of self-harm had a critical incident, at an average of 61.5 days into their stay. These comparable data suggest not only the increase in NSSI among adolescent inpatients both with and without self-harm histories but also the increase in exposure to NSSI in the residential environment. This raises the question of whether the benefits of inpatient care inpatient care Managed care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital  are worth the risks associated with the contagion effect.

Several arguments can be made for residential treatment despite concern about social contagion. In specific clinical cases, when the need for structured, intensive treatment is the primary goal of patient care, placement in a residential facility may be preferable to nonresidential options, such as partial hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.

2. the term of confinement in a hospital.
 or outpatient care. For example, best clinical practices require mandatory hospitalization of an eating-disordered client because the primary treatment goal is sustaining life (Maxmen, Ward, & Kilgus, 2009). For these clients, although they may be at higher risk of NSSI due to contagion, inpatient treatment is optimal because the principal concern is adequate nutrition.

Furthermore, social contagion is just one variable affecting the likelihood of NSSI onset; intrapersonal in·tra·per·son·al  
adj.
Existing or occurring within the individual self or mind.



intra·per
 reinforcement, such as relief from negative emotions, is more highly correlated to NSSI, Nock and Prinstein (2004) have suggested. In their analysis of adolescent inpatient NSSI, they found that most adolescents hurt themselves for automatic reinforcement: the increase or decrease (regulation) of physiological or emotional experience. For these patients, the function of their self-harm would be to feel a sense of relief. Fewer patients, although a significant number, endorsed the function of social reinforcement. For them, their decision to engage in NSSI would be to convey a message to others, such as "I want you to know how unhappy I am." Recognizing the function of a patient's self-harm behavior is thus a beneficial aspect of inpatient care. If a patient does begin to engage in NSSI, staff are prepared to determine the clinical significance and have unlimited access to the patient, which is arguably ar·gu·a·ble  
adj.
1. Open to argument: an arguable question, still unresolved.

2. That can be argued plausibly; defensible in argument: three arguable points of law.
 more structured than outpatient care or attention to the injury by less trained individuals, such as family members or school staff.

But although residential care staff are trained in working with NSSI, adolescents in residential settings are also more likely to have contact with emotionally disturbed youth, who may influence them to consider or increase self-harm (Boxer, 2010; Lofthouse & Katz, 2009; Plante, 2007). Walsh and Doerfler (2009) cautioned that social contagion is one example of residential treatment risks; people who exhibit emotional dysregulation living together can aggravate dysfunctional behaviors like NSSI. Plante (2007) addressed such concerns as the increased risk of peer influence due to underlying personality and impulse control disorders Impulse Control Disorders Definition

Impulse control disorders are characterized by an inability to resist the impulse to perform an action that is harmful to one's self or others.
. She suggested that a sense of inclusion with these peers often involves NSSI as an act of initiation. Beyond the influence of the affective symptomology, often observed in residential populations, peer socialization socialization /so·cial·iza·tion/ (so?shal-i-za´shun) the process by which society integrates the individual and the individual learns to behave in socially acceptable ways.

so·cial·i·za·tion
n.
 effects also prompt adolescent NSSI (Prinstein et al., 2010).

Residential staff can work to avoid the risks by understanding the role of peer influence and social contagion in eliciting NSSI in an adolescent community. The first step is making an appropriate referral for residential care. Because ethical treatment recognizes the client's right to the least restrictive service, counselors are not to encourage unnecessary hospitalization (White Kress, McKormick, & Kelly, 2003). After referral to a residential program, however, precautions and suggestions guide clinicians toward the appropriate response to NSSI, such as educating the patient, confronting what triggers social contagion, and encouraging youth to build and share healthy coping skills (e.g., Walsh, 2006). The use of empirically supported responses to residential NSSI will create a consistent level of standard care (Muehlenkamp, 2006; Walsh & Doerfler, 2009). For example, McDonell et al. (2010) found that adolescent inpatients receiving DBT experienced a decrease in NSSI, an increase in global functioning, and a reduction in psychotropic medications List of medications which are used to treat psychiatric conditions on the market in the United States. A
  • Abilify - antipsychotic used to treat schizophrenia, bipolar disorder, and agitation
. This is consistent with Walsh's treatment guide (2006), which suggests emphasizing healthy coping skills and communication. Although communicating with peers in a communal environment is beneficial for those who feel isolated and may benefit from peer support, counselors are advised, however, to educate residents on the negative effects of sharing stories of self-injury and instruct them instead to share stories of healing and healthy coping behaviors.

SUMMARY AND FUTURE RESEARCH

This article has identified several environments as being at high risk for social contagion of NSSI, namely group treatment, social media, and residential facilities. It also identified methods of preventing social contagion, such as (a) building a clinical understanding through training and research in how social contagion may affect adolescents; (b) working with clients who engage in NSSI to help them become aware of appropriate venues to discuss self-injury, such as individual therapy sessions; (c) asking clients who self-injure to cover up scars, wounds, and bandages, which can be triggering; (d) prohibiting graphic detail about NSSI when group therapy begins; (e) incorporating strengths-based strategies into treatment to encourage healthy coping behaviors; (f) assessing client Internet use, especially exposure to self-injury imagery; (g) determining the appropriate level of treatment and avoiding unnecessary hospitalizations that may trigger NSSI in vulnerable clients; and (h) instructing group members to share stories of healing and healthy coping behaviors to both decrease the opportunity for contagion and inspire altruistic motives.

Further investigation of the differences between the environments analyzed here would help to refine understanding of social contagion and lead to more effective ways of preventing contagion among adolescents. Allocating resources and clinical attention to this population would therefore be more economically efficient as clinicians face limitations in balancing clinical treatment and prevention programs. Another opportunity for research is further understanding of social contagion and NSSI within groups not mentioned here. Atmospheres like foster care and the home may also be at high risk for contagion if one member is engaging in NSSI. Recognizing the implications of peer influence and family dynamics may bring insight into the contagion effect.

Moreover, the role of mental health counselors working with youth engaging in NSSI extends past the therapeutic relationship to the client's family system and school setting. Providing referrals for information to individuals concerned with the adolescent, such as parents and other caretakers, is useful in attending to NSSI and contagion among peers. The following websites provide information grounded in clinical research and professional standards:

* S.A.F.E Alternatives: http://www.selfinjury.com

* American Self-Harm Information Cleaninghouse: http://selfiniury.org

* First Signs Support Network: http://www.firrtsigns.org.uk

* Mayo Foundation: www.mayoclinic.com/health/self-injury/DS00775 (Mayo Foundation for Medical Education and Research, 2010)

* Helpguide: www.helpfuide.org/mental/self_iniury.htm (Smith & Segal, 2011)

Empowering members of the client's family and care system to understand self-injury will help them to comprehend the messages the client is sending and be alert to counteract opportunities for contagion. It is crucial that the counselor as a provider of information is clear about what is appropriate Internet material, such as empirically validated information for families, and about possible misinformation mis·in·form  
tr.v. mis·in·formed, mis·in·form·ing, mis·in·forms
To provide with incorrect information.



mis
 on sites containing blogs and graphic imagery. Prevention of contagion begins with both understanding NSSI in youth and empowering the people in their lives who have opportunity to preclude self-injury.

REFERENCES

Baetens, I., Claes, L., Willem, L., Muehlenkamp, J., & Bijttebier P. (2011). The relationship between non-suicidal self-injury and temperament in male and female adolescents based on child and parent report. Personality and Individual Differences, 50, 527-530. doi:10.1016/i.paid.2010.11.015

Baker, D., & Fortune, S. (2008). Understanding self-harm and suicide websites. Crisis, 29, 118-122. doi:10.1027/0227-5910.29.3.118

Boxer, P. (2010). Variations in risk and treatment factors among adolescents engaging in different types of deliberate self-harm in an inpatient sample. Journal of Clinical Child (7 Adolescent Psychology Adolescent Psychology addresses the specific issues of adolescents. Adolescence
Adolescence, the transitional stage of development between childhood and adulthood, represents the period of time during which a person experiences a variety of biological changes and
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Chase, J. L. (1991). Inpatient adolescent and latency-age children's perspectives on the curative curative /cur·a·tive/ (kur´ah-tiv) tending to overcome disease and promote recovery.

cu·ra·tive
adj.
1. Serving or tending to cure.

2.
 factors in group psychotherapy group psychotherapy, a means of changing behavior and emotional patterns, based on the premise that much of human behavior and feeling involves the individual's adaptation and response to other people. . Groups, 15, 85-108. doi:10.1007/BF01456792

Conterio, K., Lader, W., & Bloom, J. K. (1998). Bodily harm The medical idea of (grievous) bodily harm is more specific than legal ideas of assault or violence in general, and distinct from property damage.

It refers to lasting harm done to the body, human or otherwise, although in its legal sense it is exclusively defined as lasting
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New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
, NY: Hyperion.

Corey, M. S., & Corey, G. (2006). Groups: Process and practice (7th ed.). Pacific Crove, CA: Brooks/Cole.

Deiter-Sands, P. J., & Pearlman, L. A. (2009). Self-injury: Treatment of a complex adaptation. In P.M. Kleespies (Ed.), Behavioral emergencies: An evidence-based resource for evaluating and

managing risk of suicide, violence, and victimization victimization Social medicine The abuse of the disenfranchised–eg, those underage, elderly, ♀, mentally retarded, illegal aliens, or other, by coercing them into illegal activities–eg, drug trade, pornography, prostitution.  (pp. 211-234). Washington, DC: American Psychological Association.

D'Onofrio, A. A. (2007). Adolescent self-injury: A comprehensive guide for counselors and health care professionals. New York, NY: Springer.

Gladding, S. (2007). Groups: A counseling specialty. Upper Saddle River Saddle River may refer to:
  • Saddle River, New Jersey, a borough in Bergen County, New Jersey
  • Saddle River (New Jersey), a tributary of the Passaic River in New Jersey
, NJ: Prentice Hall Prentice Hall is a leading educational publisher. It is an imprint of Pearson Education, Inc., based in Upper Saddle River, New Jersey, USA. Prentice Hall publishes print and digital content for the 6-12 and higher education market. History
In 1913, law professor Dr.
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An important antecedent to the specialty of child psychiatry was the social recognition of childhood as a special phase of life with its own developmental stages, starting with
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anorexia nervo´sa
, and dysmenorrhea dysmenorrhea

Pain or cramps before or during menstruation. In primary dysmenorrhea, caused by endocrine imbalances, severity varies widely. Irritability, fatigue, backache, or nausea may also occur.
 in obsessive compulsive disorder. International Journal of Eating Disorders, 17, 33-38.

Brent G. Richardson and Rebecca S. Hyldahl are affiliated with Xavier University For other educational institutions using the name Xavier, see .
Xavier University may refer to:

In the United States:
  • Xavier University (Cincinnati), Ohio
  • Xavier University of Louisiana at New Orleans
  • St.
; Kendra Surmitis is affiliated with The College of William and Mary Noun 1. William and Mary - joint monarchs of England; William III and Mary II . Correspondence concerning this article should be addressed to Dr Brent G. Richardson, Department of Counseling, Xavier University, 3800 Victory Parkway, Cincinnati, Ohio “Cincinnati” redirects here. For other uses, see Cincinnati (disambiguation).
Cincinnati is a city in the U.S. state of Ohio and the county seat of Hamilton County.
 45207-3226. Email: richardb@xavier.edu
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Title Annotation:PRACTICE
Author:Richardson, Brent G.; Surmitis, Kendra A.; Hyldahl, Rebecca S.
Publication:Journal of Mental Health Counseling
Geographic Code:1U2NY
Date:Apr 1, 2012
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