Why Do People Hurt Themselves?: New Insights Into the Nature and Functions of Self-Injury

ABSTRACT— Nonsuicidal self-injury (NSSI) is a prevalent but perplexing behavior problem in which people deliberately harm themselves without lethal intent. Research reveals that NSSI typically has its onset during early adolescence; most often involves cutting or carving the skin; and appears equally prevalent across sexes, ethnicities, and socioeconomic statuses. Less is known about why people engage in NSSI. This article presents a theoretical model of the development and maintenance of NSSI. Rather than a symptom of mental disorder, NSSI is conceptualized as a harmful behavior that can serve several intrapersonal (e.g., affect regulation) and interpersonal (e.g., help-seeking) functions. Risk of NSSI is increased by general factors that contribute to problems with affect regulation or interpersonal communication (e.g., childhood abuse) and by specific factors that influence the decision to use NSSI rather than some other behavior to serve these functions (e.g., social modeling). This model synthesizes research from several different areas of the literature and points toward several lines of research needed to further advance the understanding of why people hurt themselves.     

青少年自伤网络展示的动机及其影响

自我伤害行为是一种复杂且危险的心理病理行为,它会给个体的身心带来不同程度的损害。自伤是在多种因素的共同作用下产生,且在青少年中发生率最高。随着互联网的普遍使用,网络已经成为青少年生活中不可或缺的部分,近年来研究者开始关注到青少年的自伤网络展示行为。研究显示,许多自伤青少年会在网络上展示自己的自伤行为;个体一般是在多种动机的作用下对自己的自伤行为或经历进行展示;这些展示的内容既可能会让更多的人模仿或强化自伤,也可能会为自伤者提供社会支持,有助于他们减少自伤行为。     

Parental Absence and Non-Suicidal Self-Injury: Social Support,Social Constraints and Sense-Making

Given the rise of non-suicidal self-injury (NSSI) in youth, it is imperative to address understudied correlates that may contribute to NSSI. The primary purpose of the present study was to investigate NSSI in college students (N?=?1703) with or without a history of parental absence. We also examined the relationships between parental absence, interpersonal (i.e., support and social constraint) factors, intrapersonal (i.e., sense-making) factors, and NSSI in our sample of primarily Caucasian/White, heterosexual, single, traditional-aged, female college students. Logistic regression indicated that the odds of reporting NSSI were 5 times higher for participants who had experienced permanent parental absence (e.g., death) compared to those who had not experienced absence. The odds of reporting NSSI were 8.5 and 7.5 times higher for those respondents who had experienced non-permanent parental absence (e.g., parental travel) and both types of parental absence, respectively, when compared to those who experienced permanent parental absence. Social support, social constraint, and sense-making made significant but small contributions to the prediction of NSSI endorsement. Participants who reported experiencing both permanent and non-permanent absence exhibited the highest level (p?<?.001, η²?=?.09) of interpersonal reasons (e.g., to hurt someone) for engaging in NSSI. These findings can serve as a catalyst for future NSSI research (e.g., the potential importance of including parental absence as a background variable). Moreover, the results suggest the possible benefit of continued examination of: (a) the relationship between experiencing both types of parental absence and engagement in NSSI for interpersonal reasons; and (b) social support, sense-making, and social constraint as contributing factors of NSSI endorsement.     

Prevalence and Function of Non-Suicidal Self-Injury (NSSI) in a Community Sample of Adolescents, Using Suggested DSM-5 Criteria for a Potential NSSI Disorder

Previous prevalence rates of non-suicidal self-injury (NSSI) in adolescents have varied considerably. In the present cross-sectional study, prevalence rates, characteristics and functions of NSSI were assessed in a large randomized community sample consisting of 3,060 (50.5 % female) Swedish adolescents aged 15–17 years. The suggested criteria for NSSI disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) were used to assess prevalence rates with the aim of arriving at a more precise estimate. Out of the whole sample, 1,088 (35.6 %) adolescents (56.2 % female) reported at least one episode of NSSI during the last year, of which 205 (6.7 %) met suggested DSM-5 criteria for a potential NSSI disorder diagnosis. The NSSI disorder diagnosis was significantly more common in girls (11.1 % vs. 2.3 %, χ ² (1, N?=?3046) = 94.08, p?<?0.001, cOR?=?5.43, 95 % CI [3.73, 7.90]). The NSSI disorder group consisted of significantly more smokers and drug users compared to adolescents with NSSI that did not meet DSM-5 criteria for NSSI disorder, and also differed concerning demographic variables. A confirmatory factor analysis (CFA) was conducted on reported functions of NSSI, with the aim of validating Nock and Prinstein’s (Journal of Consulting and Clinical Psychology 72:885–890, 2004, Journal of Abnormal Psychology 114:140–146, 2005) four-factor model on a Swedish community sample, resulting in a close to acceptable fit. A two-factor model (social and automatic reinforcement) resulted in a slightly better fit. The most frequently reported factors were positive and negative automatic reinforcement. A majority of functions were significantly more often reported by girls than boys. The implications of the suggested DSM-5 criteria and reported functions are discussed.     

Thought suppression and self-injurious thoughts and behaviors

This study proposes and tests a theoretical model suggesting that the propensity to suppress unwanted thoughts is associated with an increased presence and frequency of self-injurious thoughts and behaviors (SITB). In the model, propensity to suppress unwanted thoughts is hypothesized to be a cognitive mediator of the relationship between emotional reactivity and SITB, and is expected to be related to the extent to which SITB is initiated to escape from aversive emotions. Results of this cross-sectional study of adolescents (N=87) revealed that the self-reported propensity to suppress unwanted thoughts is associated with the presence and frequency of non-suicidal self-injury (NSSI), suicidal ideation, and suicide attempts. Furthermore, thought suppression partially mediates the relationship between emotional reactivity and the frequency of NSSI and suicidal ideation. Finally, adolescents with a higher tendency to suppress unwanted thoughts report engaging in NSSI in order to reduce aversive emotions rather than for social communication. Results are discussed within the framework of the negative reinforcement function of SITB.     

The evaluation and treatment of aggression maintained by attention and automatic reinforcement.

In the current investigation, we used direct and indirect methods to assess and treat several topographies of aggression that were hypothesized to have separate operant functions in a young boy with severe mental retardation and pervasive developmental disorder. First, a functional analysis of aggression, using the methods described by Iwata, Dorsey, Slifer, Bauman, and Richman (1982/1994), was conducted and produced inconclusive results. Next, indirect methods were used to develop a second functional analysis, which showed that chin grinding (firmly pressing and grinding his chin against the skin and bones of others) persisted independent of social contingencies and that the other topographies of aggression (e.g., hitting, kicking) were maintained by social positive reinforcement (attention). A treatment designed to decrease aggression maintained by attention—functional communication training with extinction—reduced all forms of aggression except chin grinding. This latter topography of aggression, which we hypothesized was maintained by automatic reinforcement, was reduced when the response-reinforcer relation was interrupted through response blocking and the child was provided with an alternative form of chin stimulation.     

Functions of Nonsuicidal Self‐Injury Are Differentially Associated with Suicide Ideation and Past Attempts among Childhood Trauma Survivors

Research into factors for suicide has revealed relations between trauma exposure and suicidality (e.g., Bridge, Goldstein, & Brent, 2006 ; Joiner, Sachs‐Ericson, Wingate, Brown, Anestis, & Selby, 2007 ) wherein painful and provocative experiences (e.g., nonsuicidal self‐injury [NSSI]) are an important link (e.g., Van Orden, Witte, Cukrowicz, Braithwaite, Selby, & Joiner, 2010 ; Smith, 2013 ). No prior research has assessed the relationship between functions of NSSI and suicidality among childhood trauma survivors. Participants who endorsed childhood trauma exposure (N = 121; M_age = 18.69, range 18–22) completed measures of posttraumatic stress disorder (PTSD) symptoms, NSSI, and suicidality. Multiple regressions assessing whether the four functions of NSSI predicted suicide ideation and past attempts after controlling for PTSD symptom severity found that only social negative reinforcement was associated with SI ( = .304, SE = .243, t = 2.23, p = .028), while only automatic negative reinforcement was associated with past attempts ( = .470, SE = .066, t = 2.25, p = .028). Findings highlight the importance of assessing NSSI functions when assessing suicidality among trauma survivors.     

Recent advances in the modification of establishing operations to reduce aberrant behavior

The term establishing operation (EO) refers to an event that alters the reinforcement effects of a particular stimulus. Although EOs have received more attention in the basic, non-human literature, reports of EO manipulations in the treatment of aberrant behavior are increasingly appearing. We discuss EO interventions for behaviors maintained by social positive reinforcement (e.g., noncontingent reinforcement), social negative reinforcement (e.g., noncontingent escape, curricular revision, demand fading), and automatic reinforcement (e.g., environmental enrichment, noncontingent stimulation, reduced aversive stimulation). Suggestions for future research concerning both specific EO interventions and the general manipulation of EOs as a behavior-change technique are provided. © 1998 John Wiley & Sons, Ltd.     

Implementing a differential reinforcement of low rates schedule to alter vocal stereotypy and task engagement in two adolescents with autism spectrum disorder

Vocal stereotypy (VS) is often observed in individuals with autism spectrum disorder (ASD) which at high rates can interfere with socialization or functioning in structured settings. There are multiple effective interventions available; yet, many procedures target the complete omission of the behavior or are only assessed at short intervals, making it unclear how they will generalize in applied settings. One intervention yet to be assessed as an individual intervention for automatically reinforced VS is differential reinforcement of low rates of behavior (DRL). In the present study, a functional analysis determined that the VS of two female adolescents with ASD was maintained by automatic reinforcement. A DRL procedure was implemented which incorporated: (a) a specified interval for reinforcement; (b) the behavioral expectations; (c) the permissible instances of VS within the interval; (d) learner feedback; and (e) the reset/non-reset aspect of the schedule. As the targeted behavior decreased across sessions, the DRL interval was systematically increased in order to thin out the schedule of reinforcement. The intervention reduced VS and increased untargeted task engagement for both participants. Applied and theoretical implications of the study as well as social validity, limitations, and future research are discussed.     

Assessing the Functions of Non-suicidal Self-injury: Psychometric Properties of the Inventory of Statements About Self-injury (ISAS)

The present study reports the psychometric properties of the Inventory of Statements About Self-injury (ISAS), a measure designed to comprehensively assess the functions of non-suicidal self-injury (NSSI). The ISAS assesses 13 functions of NSSI, as well as the frequency of 12 NSSI behaviors. The ISAS was administered to 235 young adults from a college population who had performed at least one NSSI behavior. Consistent with previous research, ISAS functions comprised two factors representing interpersonal and intrapersonal functions. In addition, the ISAS factors exhibited excellent internal consistency and expected correlations with both clinical constructs (e.g., borderline personality disorder, suicidality, depression, anxiety) and contextual variables (e.g., tendency to self-injure alone). Findings support the reliability and validity of the ISAS. The ISAS may be useful in research and treatment contexts as a comprehensive measure of NSSI functions.     

TREATMENT OF PICA THROUGH MULTIPLE ANALYSES OF ITS REINFORCING FUNCTIONS

We conducted functional analyses of the pica of 3 participants. The pica of 1 participant appeared to be maintained by automatic reinforcement; that of the other 2 participants appeared to be multiply controlled by social and automatic reinforcement. Subsequent preference and treatment analyses were used to identify stimuli that would compete with the automatic function of pica for the 3 participants. These analyses also identified the specific aspect of oral stimulation that served as automatic reinforcement for 2 of the participants. In addition, functional analysis-based treatments were used to address the socially motivated components of 2 of the participants' pica. Results are discussed in terms of (a) the importance of using the results of functional analyses to develop treatments for pica and (b) the advantages of developing indirect analyses to identify specific sources of reinforcement for automatically reinforced behavior.     

Interpersonal Features and Functions of Nonsuicidal Self‐injury

Etiological models of nonsuicidal self‐injury (NSSI) suggest interpersonal features may be important to understand this behavior, but social functions and correlates have not been extensively studied. This study addresses existing limitations by examining interpersonal correlates and functions of NSSI within a stratified random sample of 1,243 predominantly Caucasian college students (mean age = 21.52, SD = 4.15 years). Participants completed an anonymous online survey assessing NSSI features, perceived social support, and disclosure experiences. Approximately 15% of the students endorsed NSSI. Interpersonal reasons were endorsed proportionally more often for initiating rather than repeating the behavior. Individuals with repetitive NSSI reported significantly lower perceived social support from family members and fewer individuals to seek advice from than single‐act and control participants. Fifty‐nine percent had disclosed their NSSI, but rarely to mental health professionals. Conversations with others about NSSI were rated as being mostly unhelpful. These results emphasize the importance of interpersonal features and functions of NSSI, suggesting treatments should focus on strengthening interpersonal bonds alongside emotion regulation. Improving responses to disclosures of NSSI is needed to promote communication about this behavior and perceived helpfulness of such conversations.     

ANALYSIS OF SOCIAL VARIABLES WHEN AN INITIAL FUNCTIONAL ANALYSIS INDICATES AUTOMATIC REINFORCEMENT AS THE MAINTAINING VARIABLE FOR SELF‐INJURIOUS BEHAVIOR

Self‐injurious behavior (SIB) that occurs at high rates across all conditions of a functional analysis can suggest automatic or multiple functions. In the current study, we conducted a functional analysis for 1 individual with SIB. Results indicated that SIB was, at least in part, maintained by automatic reinforcement. Further analyses using protective equipment (i.e., a helmet with face shield) revealed an attention function for the SIB.     

A FUNCTIONAL ANALYSIS OF HAIR PULLING

We experimentally assessed the functions of hair pulling and hair manipulation of a 19-year-old woman (Kris) with moderate mental retardation and cerebral palsy. In Phase 1 a functional analysis revealed that Kris pulled and manipulated hair for the greatest amount of time in the alone condition, suggesting that the behaviors were maintained by some form of automatic reinforcement (Vaughan & Michael, 1982). In Phase 2 we assessed the nature of the sensory stimulation that maintained hair pulling by providing continuous access to previously pulled or cut hair and, thereafter, by having Kris wear a rubber glove. The results suggested that hair pulling was maintained by digital-tactile stimulation (automatic positive reinforcement). These findings are discussed, and recommendations for further analyses of automatically reinforced habit behaviors are provided.     

Similarities and Differences in the Functions of Nonsuicidal Self‐Injury (NSSI) and Sex as Self‐Injury (SASI)

Differences and similarities were studied in the functions of two different self‐injurious behaviors (SIB): nonsuicidal self‐injury (NSSI) and sex as self‐injury (SASI). Based on type of SIB reported, adolescents were classified in one of three groups: NSSI only (n = 910), SASI only (n = 41), and both NSSI and SASI (n = 76). There was support for functional equivalence in the two forms of SIB, with automatic functions being most commonly endorsed in all three groups. There were also functional differences, with adolescents in the SASI only group reporting more social influence functions than those with NSSI only. Adolescents reporting both NSSI and SASI endorsed the highest number of functions for both behaviors. Clinical implications are discussed, emphasizing the need for emotion regulation skills.     

The effects of variable-time delivery of food items and praise on problem behavior reinforced by escape

Prior research indicates that reinforcement of an appropriate response (e.g., compliance) can produce concomitant reductions in problem behavior reinforced by escape when problem behavior continues to produce negative reinforcement (e.g., Lalli et al., 1999). These effects may be due to a preference for positive over negative reinforcement or to positive reinforcement acting as an abolishing operation, rendering demands less aversive and escape from demands less effective as negative reinforcement. In the current investigation, we delivered a preferred food item and praise on a variable-time 15-s schedule while providing escape for problem behavior on a fixed-ratio 1 schedule in a demand condition for 3 participants with problem behavior maintained by negative reinforcement. Results for all 3 participants showed that variable-time delivery of preferred edible items reduced problem behavior even though escape continued to be available for these responses. These findings are discussed in the context of motivating operations.     

Bringing together humanistic and intergroup perspectives to build a model of internalisation of normative social harmdoing

This article introduces a model of the internalisation of normative social harmdoing: the MINSOH. This model seeks to explain how group members internalise harmful social norms such that they personally endorse their groups' normative actions. To this aim, the MINSOH integrates two divergent yet complementary theoretical perspectives: self-determination theory and the social identity approach. These perspectives differ in their basic assumptions about the possibility for harm to become internalised, yet when integrated, they provide a powerful account of how harmdoing can become internalised. The MINSOH proposes specific conditions under which harmful normative actions become accepted by group members. This article outlines multiple self-determined motivations for harmdoing and discrete group processes that enable harmdoing to be internalised and autonomously enacted, and reviews factors that facilitate (i.e., strong/unique/comparative social identification; endorsement of ideological justifications) and block the internalisation process (presence of multiple identities/diverging norms; inclusive superordinate identity). Directions for future research are then discussed.     

Self-Criticism Impacts Emotional Responses to Pain

Nonsuicidal self-injury (NSSI) is associated with numerous negative outcomes (e.g., suicide attempts), making it a focus of great clinical concern. Yet, mechanisms reinforcing NSSI remain unclear. The benefits and barriers model proposes that NSSI engagement is determined by both benefits of and barriers to NSSI. Benefits include mood improvement, a function reported by most who engage in NSSI; barriers include a desire to avoid pain and bodily harm. Self-criticism is generally understood as a trait lowering desire to avoid pain and bodily harm, thus decreasing that specific barrier. However, recent research demonstrated that self-criticism may also increase NSSI benefits. Highly self-critical people may view NSSI and pain in the context of feeling deserving of pain and punishment—thus, pain may improve mood for self-critical individuals. We tested whether self-criticism impacted emotional responding to pain among adult females with (n = 44) and without (n = 65) NSSI histories. After a negative mood induction, participants rated their moods before, during, and after self-administered pain. In participants with and without NSSI histories, self-criticism was positively correlated with mood improvements during pain. Thus, regardless of NSSI history, self-criticism impacted emotional responses to pain. Together, results suggest that self-criticism may not only decrease an important NSSI barrier but also enhance NSSI benefits, specifically leading to more mood improvement during pain.     

Predicting Persistence of Nonsuicidal Self‐Injury in Suicidal Adolescents

Prospective predictors of persistent nonsuicidal self‐injury (NSSI) were examined in adolescents admitted to an inpatient psychiatric unit for suicidal behaviors and followed naturalistically for 6 months. Seventy‐one (77%) participants reported NSSI at baseline, and 40 (56%) persisted at the 6 month follow‐up. Those who endorsed automatic positive reinforcement (APR) as the predominant reason for NSSI were more likely to persist in NSSI. Depression over follow‐up, but not at baseline, also predicted persistence. These results suggest that helping high‐risk adolescents to identify alternative ways of generating emotion(s) to counter the effects of APR that may accompany NSSI should be a high priority treatment target.     

Importance of Therapist Use of Social Reinforcement with Parents as a Model for Parent-Child Relationships: An Example with Parent-Child Interaction Therapy

ABSTRACT

This paper focuses attention on the therapeutic relationship in parent-child therapy by using social reinforcement with parents and children as it relates to Parent-Child Interaction Therapy (PCIT). As in other therapy contexts, it is argued that having the therapist serve as a mediator of social reinforcement facilitates client change, After discussing different aspects of PCIT, we discuss the therapeutic relationship as viewed through other theoretical frameworks. This is followed by a discussion of the role of social reinforcement in the parent-child relationship. We then discuss at methodological and applied levels, the importance of therapist accuracy and consistency in the delivery of reinforcement as a means of changing the parent-child relationship. Next, this is followed by a discussion of the therapist-to-parent-to-child sequential chain of behaviors involved in PCIT. Finally, suggestions for future empirical studies are considered.