The role of women's self‐injury support‐groups: a grounded theory

Research evidence suggests that services are struggling to adequately address the increasing incidence of self‐injury and the needs of women who self‐injure, while national self‐injury support‐groups across the UK appear to be growing in number. Despite their reported value, evidence regarding the role of self‐injury support‐groups in women's management of their self‐injury is lacking although government policy and official guidelines are advocating the incorporation of support‐groups into self‐injury services. Seven semi‐structured interviews were conducted and analysed using Grounded Theory to investigate the role of three UK self‐injury support‐groups in women's management of self‐injury and associated difficulties. Empowerment‐as‐process emerged as the core theme of self‐injury support‐groups, mediated through experiences of belonging, sharing, autonomy, positive feeling and change. Findings are discussed in relation to relevant theory and research, followed by critical evaluation and implications of the study. Copyright © 2006 John Wiley & Sons, Ltd.     

Motivations for Self‐Injury,Affect, and Impulsivity: A Comparison of Individuals with Current Self‐Injury to Individuals with a History of Self‐Injury

Individuals who report nonsuicidal self‐injury (NSSI) are characterized by the tendency to act rashly while experiencing distress (negative urgency), the tendency to act without thinking, and endorsement of both social and affect regulation motives for the behavior. However, very little research has identified characteristics that distinguish current self‐injurers from those with a history of the behavior. The purpose of this study was to compare individuals with current self‐injury to a history of self‐injury on impulsivity‐related personality traits, motives for self‐injury, and distress. Among a sample of 429 undergraduates, 120 reported self‐injury. Among these 120 individuals, 33 endorsed self‐injury within the past month, with a mean frequency of 4.77 acts of NSSI. Within the self‐injury group, current self‐injurers reported higher endorsement of affect regulation motives for NSSI, and higher levels of current negative affect than individuals with a history of self‐injury. There were no differences between current and former self‐injurers on measures of impulsivity, endorsement of social motives for NSSI, or positive affect. We propose that individuals who use NSSI to regulate negative affect may be more likely to repeatedly engage in this behavior over time.     

The Effect of Shame‐Proneness,Guilt‐Proneness,and Internalizing Tendencies on Nonsuicidal Self‐Injury

Nonsuicidal self‐injury is especially common in adolescents and young adults. Self‐injury may be related to shame or guilt—two moral emotions—as these differentially predict other maladaptive behaviors. Using a college sample, we examined not only how shame‐proneness, guilt‐proneness, and internalizing emotional tendencies related to self‐injury, but also whether these moral emotions moderate the relation between internalizing tendencies and self‐injury. High shame‐proneness was associated with higher frequencies of self‐injury. High guilt‐proneness was associated with less self‐injury, although this effect was mitigated at higher levels of internalizing tendencies. These results suggest shame‐proneness is a risk factor for self‐injury, while guilt‐proneness is protective.     

Risk factors for nonsuicidal self‐injury in Japanese college students: The moderating role of mood regulation expectancies

Self‐injurious behavior is increasing among college students, and is common in both psychiatric and nonclinical populations. People's engaging in self‐injury is associated with childhood maltreatment, poor negative mood regulation expectancies, and depression. During times of distress, maltreated children without healthy coping strategies tend to have impairment in mood regulation, which contributes to engaging in self‐injury. This study investigated differences between nonsuicidal self‐injury (NSSI) and non‐self‐injury groups in history of childhood maltreatment, negative mood regulation expectancies, and depression in a sample of Japanese college students. We also assessed risk factors for self‐injurious behavior, including mood regulation expectancies as a moderator of the relationship between childhood maltreatment and NSSI. Participants were 313 undergraduate students, who completed anonymous self‐report questionnaires—Deliberate Self‐Harm Inventory, Child Abuse and Trauma Scale, Negative Mood Regulation Scale, and short version of the Center for Epidemiological Studies–Depression Scale. Ten percent (n = 31) of all participants had injured themselves. Consistent with past literature, participants with self‐injury history reported more severe childhood maltreatment, poorer mood regulation expectancies, and more depression, compared to non‐self‐injurers. Frequency of NSSI positively correlated with childhood maltreatment and depression, and negatively correlated with negative mood regulation expectancies. Regression analysis revealed that stronger expectancies for negative mood regulation interacted with maltreatment to predict self‐injury: More maltreatment was associated with more self‐injury, particularly among those with weaker expectancies. Results suggested childhood maltreatment, low expectancies for negative mood regulation, and depression predicted self‐injury. Consistent with our moderation hypothesis, strong expectancies for negative mood regulation buffered the effects of childhood maltreatment, reducing the risk for self‐injury.     

Evaluation of an arm‐splint belt to reduce self‐injury

After a functional analysis yielded undifferentiated results, a subsequent assessment suggested self‐injury exhibited by a young boy with autism was sensitive to physical restraint. Canvas arm splints with metal stays were initially effective to reduce self‐injury. Although we successfully faded the number of stays in each sleeve to 3, self‐injury reemerged. We then used a withdrawal design to evaluate a behind‐the‐back belt connected to the arm splints. When the belt and splints were on, self‐injury did not occur. When the belt was removed, self‐injury increased, even though the splints remained intact. Finally, we faded the length of the belt to allow increased range of motion, and rates of self‐injury remained low.     

Suicidal Intent and Method of Self‐Harm: A Large‐scale Study of Self‐Harm Patients Presenting to a General Hospital

Data from the Oxford Monitoring System for Attempted Suicide (2004–2011) were used to study hospital presentations for self‐harm in which Suicidal Intent Scale (SIS) scores were obtained (N = 4,840). Regression of medians was used to control for the confounding effect of age and gender. Higher estimated median SIS scores were associated with increasing age, male gender, self‐poisoning versus self‐injury, multiple methods of self‐harm versus self‐injury alone, use of gas (mainly carbon monoxide), dangerous methods of self‐injury (including hanging, gunshot), and use of alcohol as part of the act. For self‐poisoning patients, there was a correlation between the number of tablets taken and the total SIS score. Compared with self‐poisoning with paracetamol and paracetamol‐containing compounds, self‐poisoning with antipsychotics was associated with a lower median SIS score while antidepressants had the same estimated median as paracetamol. Use of alcohol within 6 hours of self‐harm was associated with lower SIS scores. In conclusion, certain methods of self‐harm, particularly dangerous methods of self‐injury and self‐poisoning with gas, were associated with high intent and should alert clinicians to potential higher risk of suicide. However, apart from use of gas, suicidal intent cannot be inferred from type of drugs used for self‐poisoning.     

Working With Clients Who Self‐Injure: A Grounded Theory Approach

This article presents the findings of a qualitative study examining the experiences of counselors in their work with clients who self‐injure. Using grounded theory methodology, the authors established 6 categories to explain the counselors’ conceptualization of self‐injury and their process of working with these clients: (a) external factors to self‐injury, (b) defining self‐injury, (c) potential for harm, (d) conditions for treatment, (e) counselors’ reactions to working with clients who self‐injure, and (f) clients’ response to treatment.     

You still feel different: the experience and meaning of women's self‐injury in the context of a lesbian or bisexual identity

This article reports an intensive qualitative study of the subjective experience and meaning of self‐injury for 16 women who identified as lesbian or bisexual and who had deliberately self‐injured on repeated occasions. In individual interviews, the women talked about their experiences of self‐injury and the role it played in their lives as lesbian or bisexual women. Interpretative Phenomenological Analysis (IPA) was used to elicit themes arising within their accounts. These highlighted a number of ways in which social and contextual factors contributed to the development of self‐injury. Although many of these factors seemed applicable to any woman who self‐injures, there were some aspects that were specific to the experience of lesbian and bisexual women. In addition, the women's accounts raised a number of important issues about the way in which mental health services respond to lesbian and bisexual women who self‐injure. It is argued that self‐injury can be understood as a coping response that arises within a social context characterized by abuse, invalidation, and the experience of being regarded as different or in some way unacceptable. These factors are especially salient in the lives of women, and they emerge particularly strongly as part of the experience of women who are developing a lesbian or bisexual identity. Copyright © 2004 John Wiley & Sons, Ltd.     

The Impact of Cannabis Use Disorder on Suicidal and Nonsuicidal Self‐Injury in Iraq/Afghanistan‐Era Veterans with and without Mental Health Disorders

The objective of this study was to assess the association between cannabis use disorder (CUD ) and self‐injury among veterans. As expected, after adjusting for sex, age, sexual orientation, combat exposure, traumatic life events, traumatic brain injury, posttraumatic stress disorder, depression, alcohol use disorder, and noncannabis drug use disorder, CUD was significantly associated with both suicidal (OR = 3.10, p  = .045) and nonsuicidal (OR = 5.12, p  = .009) self‐injury. CUD was the only variable significantly associated with self‐injury in all three models examined. These findings are consistent with prior research among civilians and suggest that CUD may also increase veterans’ risk for self‐injurious behavior.     

Measuring Fear of Movement/(Re)injury in Chronic Low Back Pain Using Implicit Measures

Fear of movement/(re)injury is assumed to contribute to the development and maintenance of chronic low back pain (CLBP) in a subgroup of patients. Studying fear of movement/(re)injury with implicit attitude measures, without the awareness of the patient, might be a valuable addition to self‐report questionnaires. The aims of the current study were to investigate whether CLBP patients demonstrate more implicit fear of movement/(re)injury than healthy controls, and whether 2 implicit measures are related to each other, and to an explicit self‐report measure of fear of movement/(re)injury. A group of 66 CLBP patients and 30 healthy controls took part in this study. In addition to self‐report questionnaires, fear of movement/(re)injury was implicitly assessed by the Extrinsic Affective Simon Task (EAST) and the Go‐No‐Go‐Association Task (GNAT) that aimed to determine the association between back‐stressing movements and the evaluation “threatening”. On both implicit tasks it was found that neither CLBP patients nor healthy controls demonstrated implicit fear of movement/(re)injury, and that CLBP patients did not differ from healthy controls in their level of implicit fear of movement/(re)injury. In general, no associations were found between the EAST and the GNAT, or between implicitly measured and self‐reported fear of movement/(re)injury. One major caveat in drawing inferences from these findings is the poor reliability of these implicit measures. Research towards the psychometric properties of these measures should first be expanded before modifying, and applying, them to more complex domains such as fear of movement/(re)injury.     

An analysis of the selective effects of NCR with punishment targeting problem behavior associated with positive affect

Among individuals with developmental disabilities and behavioral problems, self‐injury and aggression are often associated with negative affect such as crying. In the current report, we present data on two children who displayed problem behaviors (screaming and self‐injury) that were often associated with positive affect. In contrast to their other problem behaviors that were socially mediated, these behaviors were maintained independent of social consequences. One concern about treating problem behavior associated with positive affect is that the treatment may produce generalized reductions in positive affect. In both cases presented in the current study, the reductive effects of a treatment targeting these behaviors were highly selective, producing decreases in screaming and self‐injury, while minimally affecting affect. Copyright © 2001 John Wiley & Sons, Ltd.     

Extended analysis and treatment of self‐injurious behavior

In experiment 1, an extended functional analysis of self‐injury was conducted with a 21‐year‐old male diagnosed with autism and profound mental retardation. The multielement phase yielded undifferentiated results. Subsequent blocking of conditions plus the addition of a component allowing access to multiple sensory stimuli suggested that self‐injury was unrelated to programmed positive or negative reinforcement contingencies. The behavior appeared to be automatically reinforced; its occurrence decreased when access to alternative sensory stimuli was provided. Experiment 2 evaluated a treatment condition in which response‐independent access to these sensory stimuli was provided within the participant's everyday environment. Baseline and treatment frequencies of self‐injury were compared in a combined, multiple‐baseline‐across‐settings and ABAB design. The level of self‐injury decreased substantially during treatment. These results support the use of extended analog analyses of aberrant behavior in instances in which undifferentiated responding occurs in the initial analogue analysis. Additionally, a procedure is described for generalizing the intervention derived from the experimental analysis into the participant's everyday environment. Copyright © 2001 John Wiley & Sons, Ltd.     

Victimization and Exposure to Pro‐Self‐Harm and Pro‐Suicide Websites: A Cross‐National Study

The study of websites displaying methods of both physical self‐harm and suicide has become an important aspect of deliberate self‐injury and suicide research. However, little is known about contextual factors related to entering such sites. Using data from 3,567 respondents aged 15–30 in the US, UK, Germany, and Finland, we found that experiences of victimization are associated with entering pro‐self‐harm sites and pro‐suicide sites. Also, the victimization context had relevance, as online victimization was particularly related to pro‐self‐harm behavior. The findings suggest a need to organize more specific online support for the victims of violence and online aggression.     

Exploring Self‐Injury Through a Relational Cultural Lens

In this article, self‐injurious behaviors are examined through the conceptual framework of relational cultural theory (RCT). As an emerging theoretical approach that takes into account the importance of relationships and relational goals, it is suggested that RCT be used in conjunction with mainstream approaches to treat self‐injury.     

A Meta‐Analysis of Self‐Attributions Following Three Types of Trauma: Sexual Victimization,Illness, and Injury1

Victim self‐attributions (e.g., that one caused an event or was responsible for its occurrence) have been discussed frequently in the trauma literature. However, little empirical work has sought to test the extant theoretical models conceptualizing why self‐attributions occur. We investigated by meta‐analysis the prevalence and predictors of self‐attributions following 3 traumatic events—sexual victimization, illness, and severe injury—in an attempt to identify predictors of self‐attributions and to examine extant theoretical models. The results supported that self‐attribution is not the modal response to trauma. In addition, partial support was found for the extant theoretical models, but no one model could explain the entire pattern of findings. Implications of these results for future empirical and theoretical work are discussed.     

Injury Representations,Coping, Emotions,and Functional Outcomes in Athletes With Sports‐Related Injuries: A Test of Self‐Regulation Theory1

This study examined the influence of injury representations on emotions and outcomes of athletes with sports‐related musculoskeletal injuries using self‐regulation theory. Participants were athletes (N= 220; M age = 23.44 years, SD= 8.42) with a current sports‐related musculoskeletal injury. Participants self‐reported their cognitive and emotional injury representations, emotions coping procedures, physical and sports functioning, attendance at treatment centers, and 3‐week follow‐up attendance. Participants’ negative and positive affect were influenced by emotional representations. Identity, causal attributions, and emotional representations influenced physical functioning; and identity, serious consequences, causal attributions, and emotional representations predicted sports functioning. Injury severity, identity, and personal control predicted attendance at treatment centers, but the effect of personal control was mediated by problem‐focused coping. Problem‐focused coping predicted 3‐week follow‐up attendance. Results support self‐regulation theory for examining injury representations in athletes.     

Increasing therapeutic exercise participation by individuals with acquired brain injury using self‐recording and reinforcement

The purpose of this study was to evaluate the effects of self‐recording and contingent reinforcement on exercise participation by four adults with acquired brain injury. The results indicate that self‐recording and contingent reinforcement increased participation in stretching, aerobic, and weight‐lifting activities for each participant. The results also indicate that each participant was able to accurately self‐record his or her exercise participation. Possible operant conceptualizations for the observed behavior change, as well as limitations to the results, are briefly discussed. Copyright © 2008 John Wiley & Sons, Ltd.     

Self‐Criticism as a Transdiagnostic Process in Nonsuicidal Self‐Injury and Disordered Eating: Systematic Review and Meta‐Analysis

Nonsuicidal self‐injury (NSSI) and disordered eating (DE) are highly comorbid and may be regarded as belonging to a spectrum of self‐harm behaviors. We investigated self‐criticism as a transdiagnostic correlate of these behaviors, in keeping with etiological theories of both NSSI and DE. We reviewed the literature and meta‐analyzed the relation of self‐criticism to both NSSI (15 studies; 17 effect sizes) and DE (24 studies; 29 effect sizes). Results showed equivalent, moderate‐to‐large effects for the relation of self‐criticism to NSSI (r = .38; CI: .29–.46) and DE (r = .40; CI: .34–.45). The relation of NSSI to self‐criticism generalized across multiple potential moderators. DE behavior type moderated the relation of self‐criticism to DE, with a stronger relation emerging for purging than restriction. Findings support self‐criticism as a possible candidate for transdiagnostic pathways to self‐harm.     

A Hobbesian Theory of Shame

On most accounts present in the literature, the complex experience of shame has the injury to self‐esteem as its main component. A major objection to this idea is that it fails to differentiate between shame and disappointment in oneself. I argue that previous attempts to respond to the objection are unsatisfactory. I argue further that the distinction should refer to the different ways the subject's self‐esteem is formed. A necessary requirement for shame is that the standards and values by which the subject judges himself are borrowed from a canon of values the subject accepts as a given. The proper focus of shame is the fact of conformity to that canon. Those agents who have a different conception of self‐esteem and who freely set and alter their own values are prone to self‐disappointment, but not to shame.     

Empirically Derived Subgroups of Self‐Injurious Thoughts and Behavior: Application of Latent Class Analysis

Latent class analysis was applied to the sample data to identify homogenous subtypes or classes of self‐injurious thoughts and behavior (SITB) based on indicators indexing suicide ideation, suicide gesture, suicide attempt, thoughts of nonsuicidal self‐injury (NSSI), and NSSI behavior. Analyses were based on a sample of 1,809 healthy adults. Associations between the emergent latent classes and demographic, psychological, and clinical characteristics were assessed. Two clinically relevant subtypes were identified, in addition to a class who reported few SITBs, and were labeled as follows: low SITBs (25.8%), NSSI and ideation (25%), and suicidal behavior (29.2%). Several unique differences between the latent classes and external measures emerged. For instance, those belonging to the NSSI and ideation class compared with the suicidal behavior class reported lower levels of entrapment, burdensomeness, fearlessness about death, exposure to the attempted suicide or self‐injury of family members and close friends, and higher levels of goal disengagement and acute agitation. SITBs are best explained by three homogenous subgroups that display quantitative and qualitative differences. Profiling the behavioral and cognitive components of suicidal and nonsuicidal self‐injury is potentially useful as a first step in developing tailored intervention and treatment programs.