Disclosures of self-injurious thoughts and behaviors to parents in the context of adolescent therapy: A qualitative investigation.

Self-injurious thoughts and behaviors (SITBs), including suicidal thoughts, suicide attempts, and nonsuicidal self-injury, are highly prevalent among adolescents. Identifying adolescents at risk for SITBs relies on their disclosure, and these disclosures commonly occur in therapy context. Moreover, therapists often breach confidentiality to inform adolescents' parent or guardian when they disclose SITBs. Research has explored rates of and barriers to disclosure among adolescents, yet no studies have examined adolescents' experiences of disclosure in the therapy context. Further, no studies have examined adolescents' experiences when their parents are then informed. In this study, we examined qualitative responses from 1495 adolescents who had experienced a SITB disclosure in the therapy context. Qualitative questions included asking adolescents to describe how the SITB disclosure occurred, how their parents were informed, and their parents' reactions. Using open and axial coding, several themes emerged. Adolescents described therapist breaches of confidentiality as collaborative, noncollaborative, or unclear. Adolescents described their parents' affective responses, communication about SITBs, validating and invalidating responses, treatment-oriented responses, and ways that parents restricted their access to people, places, and activities. Findings have implications for the development of clinical guidelines when adolescents disclose SITBs in therapy and highlight areas for future research in adolescent SITB disclosure.

Evaluating a treatment selection approach for online single-session interventions for adolescent depression.

BACKGROUND: The question 'what works for whom' is essential to mental health research, as matching individuals to the treatment best suited to their needs has the potential to maximize the effectiveness of existing approaches. Digitally administered single-session interventions (SSIs) are effective means of reducing depressive symptoms in adolescence, with potential for rapid, large-scale implementation. However, little is known about which SSIs work best for different adolescents. OBJECTIVE: We created and tested a treatment selection algorithm for use with two SSIs targeting depression in high-symptom adolescents from across the United States. METHODS: Using data from a large-scale RCT comparing two evidence-based SSIs (N = 996; ClinicalTrials.gov: NCT04634903), we utilized a Personalized Advantage Index approach to create and evaluate a treatment-matching algorithm for these interventions. The two interventions were Project Personality (PP; N = 482), an intervention teaching that traits and symptoms are malleable (a 'growth mindset'), and the Action Brings Change Project (ABC; N = 514), a behavioral activation intervention. RESULTS: Results indicated no significant difference in 3-month depression outcomes between participants assigned to their matched intervention and those assigned to their nonmatched intervention. The relationship between predicted response to intervention (RTI) and observed RTI was weak for both interventions (r = .39 for PP, r = .24 for ABC). Moreover, the correlation between a participants' predicted RTI for PP and their predicted RTI for ABC was very high (r = .79). CONCLUSIONS: The utility of treatment selection approaches for SSIs targeting adolescent depression appears limited. Results suggest that both (a) predicting RTI for SSIs is relatively challenging, and (b) the factors that predict RTI for SSIs are similar regardless of the content of the intervention. Given their overall effectiveness and their low-intensity, low-cost nature, increasing youths' access to both digital SSIs may carry more public health utility than additional treatment-matching efforts.

Optimizing Flow Cytometric Analysis of Immune Cells in Samples Requiring Cryopreservation from Tumor-Bearing Mice.

Most shared resource flow cytometry facilities do not permit analysis of radioactive samples. We are investigating low-dose molecular targeted radionuclide therapy (MTRT) as an immunomodulator in combination with in situ tumor vaccines and need to analyze radioactive samples from MTRT-treated mice using flow cytometry. Further, the sudden shutdown of core facilities in response to the COVID-19 pandemic has created an unprecedented work stoppage. In these and other research settings, a robust and reliable means of cryopreservation of immune samples is required. We evaluated different fixation and cryopreservation protocols of disaggregated tumor cells with the aim of identifying a protocol for subsequent flow cytometry of the thawed sample, which most accurately reflects the flow cytometric analysis of the tumor immune microenvironment of a freshly disaggregated and analyzed sample. Cohorts of C57BL/6 mice bearing B78 melanoma tumors were evaluated using dual lymphoid and myeloid immunophenotyping panels involving fixation and cryopreservation at three distinct points during the workflow. Results demonstrate that freezing samples after all staining and fixation are completed most accurately matches the results from noncryopreserved equivalent samples. We observed that cryopreservation of living, unfixed cells introduces a nonuniform alteration to PD1 expression. We confirm the utility of our cryopreservation protocol by comparing tumors treated with in situ tumor vaccines, analyzing both fresh and cryopreserved tumor samples with similar results. Last, we use this cryopreservation protocol with radioactive specimens to demonstrate potentially beneficial effector cell changes to the tumor immune microenvironment following administration of a novel MTRT in a dose- and time-dependent manner.

Comparing self-harming intentions underlying eating disordered behaviors and nonsuicidal self-injury: Replication and extension in adolescents.

OBJECTIVE: Eating disorder (ED) behaviors are often characterized as indirect forms of self-harm. However, recent research has found less clear demarcations between direct self-harming behaviors (e.g., nonsuicidal self-injury [NSSI], suicidal behaviors) than previously assumed. The aim of this study was to replicate findings of this prior research on adult populations in adolescents with a history of restrictive eating. METHOD: A total of 117 adolescents between ages 12-14 were included in the study. Participants reported the presence and frequency of binge eating, compensatory, restrictive eating, and NSSI. Participants also reported thoughts of and intentions to hurt and kill themselves when engaging in each behavior on average. The t-tests and linear effects models were conducted to compare self-harming thoughts and intentions across behaviors. RESULTS: Participants reported at least some intent to hurt themselves physically in the moment and in the long-term when engaging in all ED behaviors and NSSI, and reported engaging in these behaviors while thinking about suicide. Direct self-harming knowledge and intentions were most frequently reported with NSSI and longer-term knowledge and intentions via NSSI and restrictive eating. Additionally, participants reported some suicidal thoughts and intentions across behaviors. DISCUSSION: This study replicates prior research, suggesting that adolescents engage in ED behaviors and NSSI with non-zero self-harming and suicidal thoughts and intentions. ED behaviors and NSSI may better be explained on a continuum. Implications include the recommendation of safety planning during ED treatment. PUBLIC SIGNIFICANCE STATEMENT: This study highlights the overlap between eating disorder (ED) behaviors, nonsuicidal self-injury (NSSI), and suicide. Though clear distinctions typically exist for motives of self-harming behavior between ED behaviors (i.e., indirect, in the long run) and NSSI (i.e., direct, in the moment), this research suggests that intentions for self-harming and suicide may exist on a continuum. Clinical ED treatment should consider safety planning as part of routine interventions.

Timing of childhood adversities and self-injurious thoughts and behaviors in adolescence.

Greater childhood adversity predicts a higher likelihood of later self-injurious thoughts and behaviors (SITB). There is little research focused on whether the timing of childhood adversity predicts SITB. The current research examined whether the timing of childhood adversity predicted parent- and youth-reported SITB at age 12 and 16 years in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) cohort (n = 970). We found that greater adversity at age 11-12 years consistently predicted SITB at age 12 years, while greater adversity at age 13-14 years consistently predicted SITB at age 16 years. These findings suggest there may be sensitive periods during which adversity may be more likely to lead to adolescent SITB, which can inform prevention and treatment.

Structural Correlates of Mental Health Support Access among Sexual Minority Youth of Color during COVID-19.

Many youth with mental health needs cannot access treatment, with multiply-marginalized youth, such as sexual minority youth of Color (SMYoC), experiencing both structural and identity-related barriers to care. The COVID-19 pandemic threatens to exacerbate multi-level treatment access barriers facing SMYoC youth nationwide. However, little large-scale research has examined access to mental health care among SMYoC across the United States, either during or prior to the pandemic. Such work is critical to understanding and ameliorating barriers in this domain. Using data from adolescents who self-identified as SMYoC and who endorsed a desire for mental health support during the COVID-19 pandemic (N = 470, ages 13-16, from 43 U.S. states), we examined associations between state-level, structural factors (income inequality; mental health-care provider shortage; anti-Black racism; homophobia; and the interaction between anti-Black racism and homophobia) and SMYoC mental health treatment access. Multinomial logistic regressions revealed state-level mental health-care provider shortage as the only significant predictor of SMYoC reporting they never (versus always) accessed mental health support during the COVID-19 pandemic. SMYoC living in areas with both lower homophobia and lower anti-Black racism were more likely to report always (versus sometimes) accessing mental health treatment. Results highlight the critical importance of considering diverse structural factors and applying an intersectional lens when exploring barriers to mental health treatment among multiply-marginalized youth. In locations where provider shortages are less severe, cultural stigma - including anti-Black racism and homophobia - may still pose challenges for SMYoC in need of mental health care.

Ecological-Systems Contributors to Internalizing Symptoms in a US Sample of Adolescents During the COVID-19 Pandemic.

OBJECTIVE: Internalizing problems are common in adolescence and increased substantially during the COVID-19 pandemic. Although rates of anxiety and depression have since improved, the general increase in the prevalence of mental health problems and disruptions to mental health services during the COVID-19 pandemic has resulted in huge gaps in care. Although research has primarily focused on proximal correlates of internalizing problems, a growing literature suggests that factors outside youths' immediate microsystems are equally crucial for their mental well-being. Thus, it is important to investigate multisystemic correlates of internalizing problems to inform individual and community-based interventions to address the current mental health burden. METHOD: Leveraging secondary data from a nationally diverse U.S. sample of 2,954 adolescents (ages 13-16), we examined the associations between factors at multiple levels of youths' ecologies - spanning indicators of threat and deprivation - and their depression and anxiety symptoms during the COVID-19 pandemic. Furthermore, in follow-up exploratory analyses, we examined if these associations differed by adolescents' racial/ethnic groups. RESULTS: Consistent with socioecological models, we found that indicators of threat and deprivation in the adolescents' immediate home and more distal neighborhood environments were associated with depression and anxiety symptoms. The patterns of associations were similar across racial/ethnic groups in multigroup structural equation models. Additionally, we found that mean levels of internalizing symptoms and socioecological predictors significantly differed across racial/ethnic groups. CONCLUSION: These findings have important implications for understanding multi-level contributors to adolescent mental health, which may inform research, practice, and policy.

Key Challenges and Potential Strategies for Engaging Youth with Lived Experience in Clinical Science.

Centering the perspectives of youth with lived experience (YWLE) in psychopathology is critical to engaging in impactful clinical research to improve youth mental health outcomes. Over the past decade there has been a greater push in clinical science to include community members, and especially community members with lived experience, in all aspects of the research process. The goal of this editorial is to highlight the need for and importance of integrating YWLE into every stage of clinical science research, from idea generation to interpretation and dissemination of research findings. We identify five key problems associated with pursuing research on adolescent mental health without involvement of YWLE and propose strategies to overcome barriers to youth engagement in clinical science research. We conclude with a call to action, providing guidance to clinical scientists, institutions, and funding agencies in conducting research on youth psychopathology with YWLE.

Using National Survey Data: A Cross-Sectional Analysis of Surveys with Questions on Chronic Diseases and Social Determinants of Health.

Surveys are a common tool utilized by organizations and researchers to collect data and evaluate various populations. This project aimed to consolidate a list of national health surveys to make the data source identification process easier when utilizing survey data. A cross-sectional analysis of currently available national survey data was conducted using information from the Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services website. Surveys were assessed for inclusion criteria, and then data on diagnosis of chronic diseases and social determinants of health (SDoH) were extracted from included surveys. A total of 39 data sources were identified. After screening, 16 surveys met inclusion criteria and were included in the extraction process. This project identified 16 national health surveys containing questions related to chronic disease(s) and SDoH, which can be used to answer clinical, educational, and research questions. National surveys presented cover a broad range of topics, and these surveys may meet a variety of user needs.

How does a move towards a coaching approach impact the delivery of written feedback in undergraduate clinical education?

Feedback uptake relies on interactions between learners and educators Winstone (Educ Psychol 52: 17-37, 2017). Feedback that coaches using a feedforward approach, is considered to be more personal and emotionally literate Bussey (Bull R Coll Surg Engl 99: 180-182, 2017), Hattie (Rev Educ Res 77: 81-112, 2007). Many modes of feedback are employed in clinical teaching environments, however, written feedback is particularly important, as a component of feedback discourse, as significant time may elapse before a similar clinical situation is encountered. In practice, time constraints often result in brief or descriptive written feedback rather than longer coaching feedback. This study aimed to explore whether a change in ethos and staff development would encourage clinical dental tutors to utilise a coaching approach in their written feedback. Across two time-points, written feedback was categorised into either descriptive, evaluative or coaching approaches. Cross-sections of data from 2017 to 2019 were examined to determine whether changes in practice were noted and whether there were any alterations in the affective nature of the language used. Feedback moved significantly towards coaching and away from a descriptive approach. A shift towards the use of more positive language was seen overall, although this was solely driven by a change in the evaluative feedback category. Descriptive feedback generally used neutral language with coaching feedback using marginally more positive language. Both categories employed significantly lower levels of affective language than evaluative feedback. These data indicate a move towards feedback approaches and language that may support increased uptake and utilisation of feedback.

Online Methods in Adolescent Self-Injury Research: Challenges and Recommendations.

Online methods hold promise as effective research tools for adolescent psychopathology research. Such methods may be the most effective way to reach large, representative samples of adolescents and harder-to-reach populations. They also may increase adolescent disclosure of risky behaviors, reduce recruitment costs, and increase the cost and time efficiency of recruitment. Despite these advantages, researchers may be concerned about including measures assessing risky behaviors, like suicidal thoughts and behaviors and nonsuicidal self-injury, in online studies of youth. In addition, parental consent in online studies is impractical and difficult to obtain. Concerns also include potential iatrogenic effects, sample bias, and data quality issues. This review discusses the benefits and challenges for online adolescent self-injury research, proposes strategies to overcome barriers, and provides examples and recommendations for future research.

Self-Injurious Thoughts and Behaviors Interview-Revised (SITBI-R): Reliability, Validity, and Inter-Informant Agreement in an Adolescent Sample.

OBJECTIVE: The present study sought to evaluate the psychometric properties and inter-informant agreement of the Self-Injurious Thoughts and Behaviors Interview-Revised (SITBI-R) in adolescents and their parents. METHOD: Suicidal and nonsuicidal adolescents from the community (N = 206), ages 12-19 years, were administered the SITBI-R during a lab visit. Approximately half of the adolescents' parents opted to complete a parent assessment, including the SITBI-R, on behalf of their child. Inter-rater reliability, convergent validity, and inter-informant agreement were assessed. RESULTS: The SITBI-R exhibited overall excellent inter-rater reliability and good convergent validity in adolescents. Parent-adolescent agreement ranged from fair to poor across most outcomes, with parents tending not to report past self-injurious thoughts and behaviors endorsed by their children. CONCLUSIONS: The present study suggests that the SITBI-R can be extended for use with adolescents. Future research should evaluate moderators and implications of parent-adolescent disagreement, particularly with regard to suicide risk.

The transitional care pathway following traumatic dental injuries: Patient perspectives.

BACKGROUND AND AIM: The nature of complex traumatic dental injuries (TDIs) often means that management continues through paediatric to adult dental services. Evidence suggests that failure in transitional care can have detrimental impacts on health. There is limited evidence regarding patients' experiences of transitional care pathways (TCPs) in dentistry. The aim of this study was to investigate the views and experiences of the TCP from paediatric to adult care for individuals who have experienced TDIs. MATERIALS AND METHODS: Semi-structured interviews were undertaken. Ethical approval was granted by the Health Research Authority and sponsored by the University of Liverpool. Inclusion criteria included individuals aged 16 to 21 years old who had received care in both paediatric and adult restorative dentistry departments at Liverpool University Dental Hospital following a TDI. Five purposively sampled patients were interviewed. Thematic analysis was undertaken using NVivo. RESULTS: Thematic analysis identified 5 main themes with regard to transitional care experience: patient-clinician communication, impact of dental trauma, feelings of uncertainty, patient personal development and transitional care planning. Feelings of uncertainty with regard to the long-term prognosis of traumatized teeth were highlighted. Clear communication and involvement of young people in decision-making was identified as a vital factor to facilitate a successful TCP experience. CONCLUSION: The involvement of young people in decision-making is essential for a successful TCP. Consideration should be given to development of TCP guidance, to allow for the provision of timely and consistent information regarding the process. Despite this, there needs to be adaptivity within the TCP to create a successful TCP for every young person.

Improving dental student confidence through the use of simulated patient cases.

INTRODUCTION: This study investigates whether student confidence could be improved through the use of simulated patient case-based scenarios. MATERIALS AND METHODS: Students in their 4th and 5th year of undergraduate study completed an online e-portfolio workbook consisting of activities related to five simulated patient cases. Following completion of the relevant learning activities within the e-portfolio, students then viewed a tutor case presentation video and attended simulated clinic sessions to complete corresponding exercises involving 3D-printed teeth related to the case. Subsequently, students undertook online self-reflection and goal-setting activities to aid their development. An anonymous questionnaire was distributed to all participants to gain insight into the themes of student confidence and learning support. The Cronbach's Alpha coefficient was calculated for both sections of the student questionnaire. The values for "student confidence" and "learning support" were α = 0.91 and α = 0.87, respectively. RESULTS: There was a total of 89 valid student responses to the questionnaire (65%). A Spearman's correlation of rs  = 0.50 (p < .001) suggests a tentative causative correlation between the learning support offered through the simulated patient cases and student confidence. There was a positive directional relationship between engagement with the learning support of the simulated patient cases and student confidence scores. CONCLUSION: Student confidence increased following the completion of simulated patient cases and students found the learning support offered beneficial to their development. This learning intervention has the potential to improve student self-efficacy, develop contextual competency and facilitate reflective practice. Simulated patient cases may be a useful precursor or adjunct to traditional patient clinics.

The impact of COVID-19 on U.S. adolescents: loss of basic needs and engagement in health risk behaviors.

Across the United States, the COVID-19 pandemic created myriad challenges for youth and families, including losses of basic needs which may be associated with increased use of maladaptive coping behaviors. In a sample of 2491 U.S. youth (ages 13-16), demographic differences in loss of basic needs and maladaptive coping were assessed using regression models. More than 21% of adolescents endorsed losing one or more basic needs (e.g., loss of access to food or shelter) and 83% endorsed use of maladaptive coping strategies (e.g., using drugs or alcohol; self-harming behaviors) during the COVID-19 pandemic. Although adolescents with both majority and minority identities reported losing basic needs and engaging in maladaptive coping behaviors, minoritized youth reported more basic needs losses (ps < 0.05) and greater reliance on maladaptive coping strategies (ps < .05) than their non-minoritized peers. Furthermore, adolescents who endorsed losing basic needs were more likely to also endorse engaging in maladaptive coping behaviors (p < .05). Healthcare providers and teachers must consider basic need losses while structuring emotional and behavioral supports for youth during and beyond the COVID-19 pandemic.

The Transdiagnostic Origins of Anxiety and Depression During the Pediatric Period: Linking NIMH Research Domain Criteria (RDoC) Constructs to Ecological Systems.

In the last decade, an abundance of research has utilized the NIMH Research Domain Criteria (RDoC) framework to examine mechanisms underlying anxiety and depression in youth. However, relatively little work has examined how these mechanistic intrapersonal processes intersect with context during childhood and adolescence. The current paper covers reviews and meta-analyses that have linked RDoC-relevant constructs to ecological systems in internalizing problems in youth. Specifically, cognitive, biological, and affective factors within the RDoC framework were examined. Based on these reviews and some of the original empirical research they cover, we highlight the integral role of ecological factors to the RDoC framework in predicting onset and maintenance of internalizing problems in youth. Specific recommendations are provided for researchers using the RDoC framework to inform future research integrating ecological systems and development. We advocate for future research and research funding to focus on better integration of the environment and development into the RDoC framework.

Comparing self-harming intentions underlying eating disordered behaviors and NSSI: Evidence that distinctions are less clear than assumed.

OBJECTIVE: Eating disordered (ED) behaviors (i.e., binge eating, compensatory behaviors, restrictive eating) and nonsuicidal self-injury (NSSI; intentional and nonsuicidal self-harm) are highly comorbid and share several similarities, including consequent pain and physical damage. However, whereas NSSI is considered direct self-harm, ED behaviors are considered indirect self-harm. These distinctions stem from theoretical understanding that NSSI is enacted to cause physical harm in the moment, whereas ED behaviors are enacted for other reasons, with consequent physical harm occurring downstream of the behaviors. We sought to build on these theoretically informed classifications by assessing a range of self-harming intentions across NSSI and ED behaviors. METHOD: Study recruitment was conducted via online forums. After screening for inclusion criteria, 151 adults reported on their intent to and knowledge of causing physical harm in the short- and long-term and suicide and death related cognitions and intentions when engaging in NSSI and specific ED behaviors. RESULTS: Participants reported engaging in ED and NSSI behaviors with intent to hurt themselves physically in the moment and long-term, alongside thoughts of suicide, and with some hope and knowledge of dying sooner due to these behaviors. Distinctions across behaviors also emerged. Participants reported greater intent to cause physical harm in the moment via NSSI and in the long-run via restrictive eating. NSSI and restrictive eating were associated with stronger endorsement of most suicide and death-related intentions than binge eating or compensatory behaviors. CONCLUSIONS: Findings shed light on classification of self-harming behaviors, casting doubt that firm boundaries differentiate direct and indirectly self-harming behaviors.

Depression and hopelessness as risk factors for suicide ideation, attempts and death: meta-analysis of longitudinal studies.

BACKGROUND: Many studies have documented robust relationships between depression and hopelessness and subsequent suicidal thoughts and behaviours; however, much weaker and non-significant effects have also been reported. These inconsistencies raise questions about whether and to what degree these factors confer risk for suicidal thoughts and behaviours.AimsThis study aimed to evaluate the magnitude and clinical utility of depression and hopelessness as risk factors for suicide ideation, attempts and death. METHOD: We conducted a meta-analysis of published studies from 1971 to 31 December 2014 that included at least one longitudinal analysis predicting suicide ideation, attempt or death using any depression or hopelessness variable. RESULTS: Overall prediction was weaker than anticipated, with weighted mean odds ratios of 1.96 (1.81-2.13) for ideation, 1.63 (1.55-1.72) for attempt and 1.33 (1.18-1.49) for death. Adjusting for publication bias further reduced estimates. Effects generally persisted regardless of sample severity, sample age or follow-up length. CONCLUSIONS: Several methodological constraints were prominent across studies; addressing these issues would likely be fruitful moving forward.Declaration of interestNone.

Novel online daily diary interventions for nonsuicidal self-injury: a randomized controlled trial.

BACKGROUND: Nonsuicidal self-injury (NSSI), which involves self-damaging behavior (e.g., cutting) causes tissue damage and places people at elevated risk for future suicidal behaviors. Yet few specific treatments for NSSI currently exist. Extreme self-criticism is implicated in the development and maintenance of NSSI. We conducted a randomized controlled trial to evaluate Autobiographical Self-Enhancement Training (ASET), a novel, cognitive intervention for NSSI focused on reducing self-criticism and enhancing positive self-worth. We also examined whether Expressive Writing (EW) was a helpful treatment for NSSI. METHOD: Participants (N = 144) who had engaged in NSSI at least twice in the past month were recruited online and then randomly assigned via Qualtrics to receive the ASET intervention (N = 49), the EW intervention (N = 49), or Daily Journaling [JNL; N = 46]), an active comparison condition. Treatments were designed as month-long daily diaries. Participants in ASET wrote about something that made them feel good about themselves that day, participants in EW described something that had been on their mind that day, and participants in JNL reported on the events of the day in a factually descriptive manner without emotional content. RESULTS: Intent-to-treat analyses revealed that, regardless of treatment group, participants showed significant reductions in self-criticism, NSSI episodes, depression, and suicide ideation from baseline to the end of active treatment. Relative to the JNL group, the ASET group reported significantly less self-criticism at post-treatment; this was not maintained at follow-up. There was also a trend toward ASET being associated with less suicide ideation at the end of treatment compared to EW. This difference was significant at the 3-month follow-up. Unexpectedly, the JNL group reported significantly less suicide ideation than the EW group at post-treatment; this was maintained at 3-month follow-up. No significant treatment effects were detected for suicide plans, suicidal behaviors, desire to discontinue NSSI, or likelihood of future NSSI. CONCLUSION: Self-criticism is an important treatment target in NSSI, but changing self-criticism in people with an established history of NSSI presents challenges. Nonetheless, all approaches provided benefits. This study also established the feasibility of inexpensive and easily disseminated treatments for NSSI. TRIAL REGISTRATION NUMBER: ISRCTN12276176 (retrospectively registered, March 13, 2018).

How to Implement Therapeutic Evaluative Conditioning in a Clinical Setting.

Self-injurious behaviors (SIBs), including both suicidal and nonsuicidal self-injury, are major public health problems that have been on the rise in recent decades. There are few effective SIB interventions, and those that are effective cannot reach most people who are in need of help-that is, these interventions are not scalable. To address this need, we recently developed a scalable, app-based treatment called Therapeutic Evaluative Conditioning (TEC) that preliminary studies have shown causes reductions in SIBs (Franklin et al., 2016). Although TEC was developed and evaluated as a standalone, self-administered intervention, it may also be a valuable therapeutic tool within traditional clinical settings. Here we provide a case illustration of a young adult female who presented at an outpatient clinic with a long history of self-injurious behaviors and multiple failed treatment attempts. In discussing this case, we describe how to implement TEC within such a setting and what might be expected as a result.