Trauma-related self-inflicted Violence: A critical Review

TABLE OF CONTENTS

CHAPTER I INTRODUCTION
Statement of the Problem
Purpose of the Study
Significance of the Study
Scope of the Study
Definition of Terms

CHAPTER II METHODOLOGY
Search Strategy
Procedures

CHAPTER III REVIEW OF LITERATURE
Historical perspective
Epidemiology
Risk Factors
Neurobiological Theories
Childhood maltreatment
Methods for SIV
Motivations for and Functions of SIV
Emotion regulation/tension reduction
Control/punishment
Communication/expression
Concomitant Factors
Cultural Considerations
Suicide versus SIV
Treatment Approaches
Psychodynamic Perspective
Cognitive Behavioral Perspective
Feminist Theory Perspective
Pharmacotherapy
Assessment Measurements
Summary

CHAPTER IV CONCLUSION AND DISCUSSION
Implications for Practice

REFERENCES

APPENDICES

CHAPTER I
INTRODUCTION

The complexities of motivation and behavior in those who inflict violence upon themselves are challenging for both helping professionals and those they treat, yet we are fortunate as clinicians to have an abundance of theoretical literature and empirical data on the topic of self-inflicted violence (SIV). This study critically reviews extant literature of trauma-related SIV behavior and the interventions currently employed by those who work with individuals who engage in this pervasive and perplexing clinical phenomenon.

Empirical research has consistently linked childhood maltreatment with the adult sequelae of SIV; the nature of this relationship however, is complicated. This review focuses on several questions: (a) whether SIV behavior is universally defined in terms of function and meaning; (b) whether literature and research have adequately studied differences in those who engage in SIV in terms of age, gender, ethnicity, socioeconomic status, education, and sexual orientation; and (c) whether contemporary interventions adequately treat and prevent SIV behavior.

This paper seeks to condense selected literature in order to raise awareness of the multiple ways of understanding SIV. Gathering and fostering awareness of all aspects of the SIV phenomenon may help to continue the commitment toward understanding, prevention, and treatment of this behavior. Chapter 1 includes five sections that provide the reader with a broad overview of this project, which comprise the following:

(a) Statement of the Problem; (b) Purpose of the Study; (c) Significance of the Study; (d) Scope of the Study; and (e) Definition of Terms.

Statement of the Problem

Approximately 4% of general population and 21% of clinical samples report engaging in socially unsanctioned SIV behavior, which involves a predictive increase among clinical and general populations as social stressors mount (Favazza & Conterio, 1988; Walsh & Rosen, 1988; Briere & Gil, 1998). Although research suggests SIV is predominately a female phenomenon, it trends toward a narrowing prevalence among males and females (Briere & Gil, 1998). Many authors describe the typical individual who engages in SIV behavior as White, female, adolescent or young adult, single, middle to upper class, intelligent, and attractive (Darche, 1990; Favazza & Conterio, 1988); this unfortunate stereotypical description may be a reason why research has focused more on women than on men. Empirical research with male samples remains scarce and qualitative research and case studies appear nonexistent. Additionally and unfortunately, a review of available research revealed few published studies that investigate prevalence, meaning, and function of SIV among diverse ethnicities and geriatric populations. Despite the widespread use of SIV as a means of coping with stressors, many professionals and laypeople lack understanding regarding the functions and meanings behind the behavior and continue to mistake SIV for suicide attempts. The two behaviors, however, serve very different end functions.

Purpose of the Study

The purpose of the present study was to (a) conduct a critical review of SIV literature and research; (b) integrate existing and relevant literature into a written analysis; (c) review theoretical approaches that focus on prevention and treatment of SIV behavior, including individual and group modalities; and (d) provides recommendations for intervention, integration, and research needs.

Significance of the Study

The present study has significance for psychological practice because of the long-term physical and mental consequences to those who engage in SIV and the need for psychotherapists to better understand and respond to this behavior in their clients. By reviewing SIV literature, the results of this paper will (a) increase understanding of SIV behavior; (b) promote a multidimensional approach to the treatment and prevention of SIV; (c) advance knowledge of the current and future impact of this increasingly prevalent phenomenon on the mental health care system; and (d) explore areas of needed research. By evaluating documented approaches that focus on the treatment and prevention of SIV, the hope is to provide more effective interventions, preventions, and measurements for SIV behavior.

The present study integrates SIV into a larger conceptual framework that can be utilized in various fields, such as medicine, mental health, social services, education, and the criminal justice system. An integrated multidimensional concept of SIV can provide a comprehensive understanding of and effective assessment tools and interventions for SIV behavior.

Scope of the Study

The present study evaluates the findings of SIV research and literature that met the following criteria: (a) is an English language publication; (b) relates to people who practice SIV; (c) identifies meanings, predictors, measurements, and/or effective interventions for SIV behavior; and (d) identifies epidemiology, etiology, motivations, and functions of SIV behavior.

Definition of Terms

Amygdala

The amygdala is a primitive area of the brain located in the core and composed of a collection of nuclei that controls the fear response. It is involved in the fear response as well as the non-verbal and unconscious memory of fear.

Childhood Emotional Abuse

Emotional abuse (psychological abuse and verbal abuse) includes acts or omissions by the parents or other caregivers that have caused, or could cause, serious behavioral, cognitive, emotional, or mental disorders (Fromm, 2001).

Childhood Emotional and Physical Neglect

Childhood neglect is characterized by failure to provide for the child’s basic needs. Neglect can be physical, educational, or emotional. It can include refusal or delay in seeking health care, inattention to the child’s needs for affection, failure to provide needed psychological care, and spousal abuse in the child’s presence (Fromm, 2001).

Childhood Physical Abuse

Physical abuse was defined by Briere & Gil (1998) as reports of “parental actions committed before the subject was 17 years old that were either a) intentional and resulted in bruises, scratches, broken bones, or broken teeth; or b) involved punching, kicking, or biting” (p. 611).

Childhood Sexual Abuse (CSA)

Briere & Gil (1998) defined CSA as “sexual contact ranging from fondling to intercourse between a child in mid adolescence or younger and a person at least five years older” (p. 611). The definition can be expanded to include incest, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials.

Complex Trauma

Complex trauma is a phenomenon referring to the resulting intrapersonal and interpersonal consequences of emotional trauma experienced by individuals who endure severe and repetitive childhood maltreatment and invalidation and who remain vulnerable to continuing emotional traumatization (Brown & Bryan, in press; Herman, 1992).

Cortisol

Cortisol is a bodily hormone regulated by the hypothalamic-pituitary-adrenal (HPA) axis . It is designed to allow humans and animals to respond appropriately to stressful, dangerous, or threatening situations.

Dissociation

Dissociation is a complex and creative psychological defense mechanism wherein specific anxiety-provoking thoughts, emotions, physical sensations, memories, and experiences are separated from the rest of the psyche. The function of dissociation in trauma is to disengage from stimuli in the external world and attend to the internal psychic world (van der Kolk, 1994).

Hippocampus

The hippocampus is an area of the brain composed of a collection of nuclei and is responsible for the mediation of conscious memory.

Hypothalamic-pituitary-adrenal (HPA) axis

By regulating the stress hormone cortisol, the HPA axis mediates the brain’s network that controls the body’s physiological response to stress.

Motivation

Motivation is defined for the purpose of this study as a broad range of inner feelings or perceptions that lead to the act of SIV.

Posttraumatic Stress Disorder (PTSD)

As outlined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000) PTSD is a normal human response to a traumatic event that lies outside the range of usual human experience and is characterized by symptoms such as reliving the event, reduced involvement with others, and manifestations of autonomic arousal such as hyper-alertness and exaggerated startle response.

Risk Factor

The term risk factor indicates a non-random association between characteristics and the outcome, with the added requirement that the characteristics precede the outcome.

Self-Inflicted Violence (SIV)

The term self-inflicted violence will be used in this study to refer to a class of socially unacceptable and unsanctioned deliberate actions of violence inflicted upon the self that hurt or harm the body, including but not limited to cutting, burning, scratching, gouging, interfering with healing wounds, and head banging. It is an adaptive coping mechanism, where the intent of the SIV is not about annihilation of the self, but rather it is a means of continuing to live (Babiker & Arnold, 1997; Himber, 1994). In the reviewed literature deliberate SIV was called a range of names: self-harm, self-inflicted violence (as cited in Brown & Bryan, in press), parasuicidal behavior (Linehan, 1987), self-mutilation (Walsh & Rosen, 1988), self-destructive behavior (Figueroa, 1988), self-damaging behavior (Courtois, 1988), and self-injurious behavior (de Young, 1982; Winchel & Stanley, 1991).

The author chose to use the term self-inflicted violence because it is the less pejorative option and best describes this particular presentation of trauma as a continuing cycle of interpersonal and intrapersonal violence perpetrated against the body and psyche.

Suicide

Suicide is defined as the intentional taking of one’s own life, in which there is little if any communication with others about the action.

Traumatic Stress

The term traumatic stress refers to a combination of physiological and psychological reactions that include muscle tension and unpleasant emotions in response to challenging events or situations. The most common sources of stress are conflicts, failures, changes, situational or interpersonal demands, threats, or danger.

CHAPTER II
METHODOLOGY

The focus of this paper is a critical evaluation of SIV literature mainly produced within the framework of Euro American and Western culture. The findings of SIV studies reviewed in this paper are reported in order to analyze and integrate the research of individual studies and books. This paper aims to accomplish the goal of an integrative research review, which is a type of literature review where the goal is “to summarize the accumulated state of knowledge concerning the relation(s) of interest and to highlight important issues that research has left unresolved” (Cooper, 1984, p. 11).

Search Strategy

This critical review focuses on American, Canadian, Australian, New Zealand, and British literature of SIV behavior, and includes published reports and studies in conjunction with seminal books as the sources of data. Reports and studies for this paper were located using several electronic databases: PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, SocINDEX, LIRN, OCLC FirstSearch, and Proquest. A wide range of keywords was used to locate and assemble existing literature of SIV and related subjects (see Appendix A). The literature was organized and coded based on the population group participating in the study (see Appendix B) and by the type of behavior studied such as SIV, suicide, and/or SIV and suicide combined (see Appendix C). The literature was organized by type of study (i.e. qualitative vs. quantitative) and assembled in the appendix section (see Appendices D-H).

Research books for this review were obtained through purchases from Amazon.com and from Internet subject searches through the Argosy University library, University of Washington library, and Jones e-global library (see Appendix H). Some reports were gathered through the following Internet Web sites: Prevent Child Abuse (http://www.preventchildabuse.org), and Journal for Indian Association for Child and Adolescent Mental Health (http://openmed.nic.in). Literature was also located by referencing the bibliography of peer-reviewed articles.

Procedures

Literature was reviewed if it directly addressed trauma-related SIV or synonyms of SIV as described in chapter 1: Definition of Terms. Literature searches were conducted using the term self-harm and its synonyms. Further searches used the Boolean ‘and’ command with the term self-harm and the various synonyms of self-harm. Studies exploring characteristics that may have preceded SIV such as childhood maltreatment or rape, and consequences resulting from SIV, were included for review and analysis. Articles about and studies of SIV that were quantitative, qualitative, case study, meta-analysis, and review were further examined using the following steps:

1. Examined article titles that contained the term SIV or a synonym of SIV.
2. Reviewed the abstract to assure relevancy to the topic of SIV.
3. Scanned the article to further assess the applicability to a critical review and analysis.
4. Thoroughly read and outlined selected articles for possible use in the final written analysis.

Books were reviewed if the topic of SIV was suggested by the title. The following steps were implemented for possible book inclusion in the final written analysis:

1. Checked title for specific SIV terminology.
2. Assessed table of contents for relevancy to topic.
3. Reviewed and outlined selected books.

Literature was excluded from further review and use in the final analysis if it addressed SIV that was only intended for cultural, non-symbolic, or body enhancement expression and did not address trauma-related SIV.

Literature was organized and outlined in table form based on the type of study, author(s) of study, date of study, location of study, and description of study (See Appendixes D-H). Selected literature was further organized and coded based upon the study’s participant population and participant behavior studied (e.g. SIV behavior, suicide behavior, or SIV and suicide behavior combined).

This review provides not only a summary of studies but also an actual critique of the strengths and weaknesses of the methods used in selected studies, which is then integrated into the process of analysis. The author’s analysis is influenced by a hermeneutic approach wherein the author’s biases are openly acknowledged as forming part of the final analysis. This approach allows the author to place more emphasis on the description of the literature and signifies an ongoing process of understanding.

CHAPTER III
REVIEW OF LITERATURE

Historical perspective

Theories of SIV originated in the psychological literature in 1913 when Emerson provided the first contribution to the clinical literature on repetitive SIV with a case study of Miss A (as cited in Walsh & Rosen, 1988). His account revealed an approach to understanding SIV that was grounded in Miss A’s subjective experience: She articulated that her practice of SIV was related to her need to relieve both her headaches and the nightmares of sexual abuse she experienced. Emerson presented an empathic explanation for Miss A’s cutting by suggesting it represented the tension between her difficulty in bearing the psychological pain and anger as a result of the abuse she incurred and her unconscious desire to live a rewarding life (as cited in Walsh & Rosen).

The first major advance in the modern understanding of SIV was made by Karl Menninger in his highly influential and widely cited book, Man Against Himself (1938). Menninger argued against the then-prevalent notion that attempts to harm the self were incomplete attempts at suicide. He suggested that individuals who engage in SIV were searching for a means of self-preservation and self-healing, and he believed that SIV was a compromise between aggressive impulses and the survival instinct that represents a sacrifice of one part of the body in preservation of the whole. He noted that “mutilation is an attempt at self healing … local self destruction being a form of partial suicide so as to avert total suicide” (p. 271).

While Freud conceptualized suicide as an expression of the unconscious mind, he did not comment specifically on SIV (though it is believed that he referred to the idea of SIV). In his early work, he characterized the unconscious mind as composed of two psychic drives: eros and thanatos (Jacobs, 2007). Eros represents the drive for love and life and is directed toward other persons, as well as toward the self. The psyche develops and internalizes symbolic representations for the deep attachment that is felt for the other person (object). The destructive drive of thanatos creates a tug-of-war with eros. Hopefully, thanatos coexists in equilibrium with eros in the unconscious mind (Jacobs). Freud’s theory of the ambivalent need for homeostasis between the opposing forces of eros and thanatos may be parlayed to SIV behavior.

It was not until the 1960s that mental health professionals began studying SIV in earnest. In the early ’70s, more articles began appearing in peer-reviewed psychology journals as professionals devoted a steadily increasing amount of research time to this phenomenon, and so by the mid-’70s researchers had proposed a profile of the typical individual who self-inflicts violence as a young female (adolescent to just-post-adolescent) who was usually attractive (Ross & McKay, 1979). Having insisted that SIV “is not a phenomenon which is to be found only in girls, or only in institutions, or only among disturbed delinquents” (p. 9), researchers Ross and McKay sought to dispel the myth of the typical SIV-utilizing individual within the scientific discourse, yet their quantitative study contributes to continued stereotyping of the SIV-utilizing individual by focusing on 71 adolescent females in a Canadian training school.

In the 1970s, the feminist movement challenged contemporary social constructs by revealing that the most common trauma experiences are not those of men in war but is those of women (and girls) in civilian life. In turn, consciousness-raising for the public increased. A 1986 epidemiological study by Diana Russell (as cited in Briere, 1992) was at the forefront of the challenge. Of 930 women in the general population who were interviewed regarding their experiences of domestic violence and sexual exploitation, 1 in 4 had been raped, and 1 in 3 had been sexually abused as a child. Furthermore, 78% of the women reported resulting negative and long-lasting psychological problems. Russell helped redefine sexual abuse and rape as acts of violence rather than acts of sex. Such violence against women was conceptualized as a method of political control through the enforcement of the subordination of women through terror.

Feminist theorists have opposed traditional definitions and pathologizing of the female body and female behavior in relation to the body; instead, they have sought to expose the mechanisms of social control and medicalization that attempt to constrict and define representations of the female body by redefining the female body as a site of political struggle. Despite feminist efforts to change the nature of research, including conceptual and definitional issues of SIV, the model developed by psychiatric studies decades ago, and one created from a particular social bias that pathologizes and objectifies the female body, continues to predominate in both scientific and popular discourse today.

Continuing work in the feminist realm, specifically on the connection between physical and sexual violence against women and men and the long-term effects of emotional trauma presenting as SIV, has been slowly emerging. An example of this ongoing contemporary work is a case-study article in which Brown & Bryan (in press) articulate a client’s personal experiences and struggle with SIV resulting from childhood maltreatment. Employing feminist praxis, they describe the client’s therapy progression and favorable outcome.

Favazza (1987) and Walsh and Rosen (1988) greatly expanded our understanding of SIV when they suggested the behavior be understood as a survival strategy that has both psychological and biological underpinnings. In the early ’90s, Favazza and Rosenthal (1993) further contributed to the SIV literature when they proposed a conceptual organization for a behavior that encompasses a broad range of situations. They suggested that SIV behavior be divided into three typological classifications: (a) ‘Major or Psychotic Self-Mutilation,’ which is the most extreme form of SIV and includes eye enucleation and self-castration to atone for sins; (b) ‘Stereotypic Self-Mutilation,’ which is seen in autistic and developmentally disabled populations and is typically a habitual and rhythmic action that lacks symbolic value; and (c) ‘Superficial or Moderate Self-Mutilation,’ in which the ultimate intent for the individual is to feel better, and the behavior typically holds symbolic value. Trauma-related ‘Superficial/Moderate Self-Mutilation’ is the type of SIV that is the focus of this dissertation. Favazza later diffused some of the myths and mysteries surrounding SIV with the publication of his seminal work Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry (1996).

Researchers and authors (Briere & Gil, 1998; Brown & Bryan, in press; Courtois & Lader, 1998, Gratz, 2006, 2007; Hawton & Harriss, 2005; Straker, 2006) continue to contribute to this large body of literature with concern and compassion in a pursuit to further understand and find effective resolutions for this challenging yet important issue.

Epidemiology

Research from Brickman and Mintz (2003) revealed that the prevalence of SIV behavior across the developmental spectrum is astounding; in addition, the numbers of individuals engaging in SIV are growing. While more women than men report the use of SIV as a coping strategy (Hyman, 1999), the margin of difference is narrowing (Briere & Gil, 1998; Gratz & Chapman, 2007). Of note: Historically more studies have been conducted on women than on men, which may explain why women appear to engage in SIV more than men do.

In epidemiological studies, the prevalence of individuals who SIV varies depending upon the population group being studied. Briere and Gil (1998) estimated that 1 to 4% of the general adult population and 21% of adult psychiatric inpatients practice SIV. Darche (1990) found approximately 40% of adolescents in psychiatric inpatient settings use SIV, and among incarcerated adult populations as many as 30% engage in this behavior (Jelic, Vanderhoff, & Donovick, 2005). A year-to-year increase in the number of older people presenting to emergency departments with SIV has been found, especially in men (Hawton & Harriss, 2006; Lamprecht, Pakrasi, Gash, & Swan, 2005). Although exact prevalence and incidence is difficult to ascertain due to definitional variance among authors and the conflation of SIV and suicide ideation, the use of this behavior, predominately as a coping strategy, is clearly on the rise (Hawton & Harriss; Lamprecht et al.).

SIV most commonly begins in adolescence and peaks between the ages of 16 to 25 years of age (Favazza & Conterio, 1988), but there are cases in which the behavior begins in adulthood, for example, following rape (Greenspan & Samuel, 1989) and following combat exposure (Brown, 1986). Although there are many forms of SIV, cutting has been found to be the most common (Babiker & Arnold, 1997; Favazza & Conterio), and damage is typically minimal but in some instances may require medical attention.

Many researchers (e.g. Briere & Gil, 1998; Favazza, 1998; Suyemoto, 1998) agree that the statistics on the incidence and prevalence of SIV may be unreliable for several reasons. First, multiple definitions of the same phenomenon create inconsistencies and replication difficulties in epidemiological research studies. Determination of accurate prevalence is difficult; thus, rates should be interpreted within the scope of the definition as stated in chapter 1. Next, some authors discussing SIV conflate SIV behavior and suicide intent as the same phenomenon (Linehan, 1987, 1993; Romans, Martin, Anderson, Herbison, & Mullen, 1995) making research comparisons and replication meaningless with regard to SIV alone. In addition, SIV may be underreported because it remains socially unacceptable and is typically practiced in secrecy (Briere & Gil; Favazza, 1996; Linehan, 1993), and the guilt and shame as consequences of SIV may increase the likelihood of isolation (Favazza; Herman, 1992). Therefore, many SIV incidents that may require medical attention will instead be treated by the individual in private and will not reach the awareness of helping professionals and researchers (Mazelis, 2003). Finally, in spite of the rise in numbers of those who SIV, the behavior continues to be highly stigmatized by laypersons and professionals (Foucault,). Service providers’ unfortunate misunderstandings about the motivations for and functions and meanings of SIV behavior help maintain the negative connotation of SIV and the belief that those who practice SIV use it as pathological manipulation of others.

Often individuals who SIV are pathologized and unfairly labeled as borderline or personality disordered by the very professionals who mean to help them (Linehan, 1987, 1993; Soloff, Lynch, & Kelly, 2002). Many professionals lack a clear understanding of how to intervene effectively with this growing concern (Crowe & Bunclark, 2000; Favazza & Rosenthal, 1993; Jeffery & Warm, 2002); consequently, these stereotyping labels exacerbate the perceived need for the individual who engages in this behavior to maintain a shroud of secrecy.

Despite the likely inaccurate estimations of prevalence rates of individuals who practice SIV, clinicians and researchers agree that the behavior is increasing rapidly and it is likely stretching care-giving resources to the limit (Conterio & Lader, 1998; Strong, 1998; Suyemoto, 1998; Suyemoto & MacDonald, 1995). While extensive literature exists on the physical and psychological aspects of SIV, this author discovered no research or information on the actual resource costs of the physical and psychological care associated with SIV behavior. However, Walsh and Rosen (1988) suggested that SIV behaviors are likely to increase in repetitiveness and level of risk or lethality over time, leading to more severe behaviors and an increase in the cost of attending to the medical concerns of these behaviors. In addition, the increasing prevalence of individuals in Western cultures—and likely worldwide—who engage in SIV, coupled with the emergence of managed care systems in which clinicians are expected to provide more service with increasingly limited resources are all indicators of why research about SIV is urgently needed (Favazza & Conterio, 1988).

Risk Factors

Proposed theories of the etiology and function of SIV typically involve biological and psychological explanations. The literature suggests a number of conditions that might predispose an individual to SIV including loss of a parent, childhood illness or surgery, childhood sexual or physical abuse, alcoholism in the family, witnessing family violence, peer conflict, intimacy problems, body alienation, and impulse-control disorders (Walsh & Rosen, 1988). Of these potential etiologic factors, recent research has focused on childhood sexual and physical abuse and the subsequent posttraumatic sequelae as being associated most powerfully with the development of SIV behavior.

Biological theories of the etiology of SIV include the ideas that people have biological vulnerabilities or chemical imbalances effecting brain structure and function predisposing them to SIV behaviors (Bremner, 2005; Canli, Zhao, Brewer, Gabrieli, & Cahill, 2000; Carrion, Weems, & Reiss, 2007; Herman, 1992; LeDoux, 1996; Pies & Popli, 1995; Sachsse, von der Heyde, & Huether, 2002; van der Kolk, Perry, & Herman, 1991). Animal models of traumatic stress have guided our understandings of the psychophysiological effects of prolonged exposure to trauma, and more recently functional brain imaging focused on individuals, especially children, who have been exposed to chronic traumatic experiences has wielded important information as well (Bremner, 2005, Carrion, 2007).

The majority of empirical research on the risk factors for SIV has focused on the childhood experiences associated with risk for SIV in adulthood. In particular, most research has centered on the role of childhood sexual abuse. The preponderance of evidence suggests that there is a strong relationship between childhood maltreatment and SIV in adulthood (Boudewyn & Liem, 1995; Briere & Gil, 1998; van der Kolk et al., 1991). In van der Kolk et al.’s longitudinal study with 39 women and 35 men (N =74), childhood trauma and disrupted attachment appeared to be associated with SIV behavior. The participants were administered the Traumatic Antecedents Questionnaire, which inquires about primary caretakers and other important relationships. The researchers found that childhood sexual abuse, and emotional neglect and abuse were powerful predictors of subsequent adult SIV, the functions and meanings of which are discussed in a later section.

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