There are several reported methods used by individuals who engage in SIV behaviors; however for this study, teasing out ways in which individuals practice SIV was difficult due to the various authors’ inconsistencies in the operational definition of SIV. For example, some researchers use terminology that does not distinguish between SIV and suicide attempts (e. g. Linehan, 1993). In a survey of the different methods of SIV, Favazza et al.
(1988) identified cutting the skin with a sharp object as the most common practice (72%), followed by drug overdose (57%), burning (35%), and interfering with wound healing (22%), as well as using multiple methods (78%). The majority of survey respondents reported an average of 50 harmful acts since beginning their SIV behavior and had been hospitalized at least once for this behavior. While cutting is the most common method of inflicting violence on oneself, drug overdose and poisoning are the most lethal forms of this behavior (Hawton, Fagg, Simkin, Bale, & Bond, 1997).
A more recent quantitative study by Laye-Gindhu and Schonert-Reichl (2005) involved 424 high-school adolescents (236 girls, 188 boys) and revealed that cutting was the most frequent method (43%) adopted, followed by hitting or biting (26%) and overdose (16%). Of the many participants, 28% of the girls and 13% of the boys reported they engaged in multiple methods of SIV. Most individuals who practice SIV begin by cutting themselves with sharp objects (Conterio & Lader, 1998; Favazza & Conterio, 1988). Typically, SIV then moves from cutting to a trial of various other forms of violence to the self.
Methods of SIV and regions of the body that are harmed can be associated with types of previous abuse and may tell a story about the past and present circumstances surrounding an individual’s behavior (Favazza & Conterio). Although the lines between SIV behavior and suicidal ideation are often blurred, it is important to note that many who practice the various forms of SIV are doing so to help manage and make sense of a chaotic intrapsychic environment; it is a method of keeping themselves alive. Motivations for and Functions of SIV
The preponderance of evidence gleaned from the literature supports the notion that SIV serves more than one function; indeed, it may serve several simultaneous functions. Many influential researchers and clinicians have illuminated possible motivations for SIV behavior (Abrams & Gordon, 2003; Briere & Gil, 1998; Brown & Bryan, in press; Brown, Comtois, & Linehan, 2002; Connors, 1996; Favazza, 1996; Favazza & Conterio, 1988; Jelic et al. , 2005; McAllister, 2003; Ousch, Noll, & Putnam 1999; Straker, 2006; Suyemoto, 1998).
For example, Briere and Gil examined the function of SIV among a group of individuals with a history of SIV who were asked to select the reasons for their ‘self-mutilation’ from a list of reasons commonly provided by ‘self-mutilating’ clients for their behavior. The participants reported a wide variety of purposes for SIV, including self-punishment, distraction, relief from painful feelings, management of stress, reduction of tension, release of anger, and enhancement of feelings of control. Each participant endorsed 70% of the functions and each endorsed multiple functions for SIV (Briere & Gil, 1998). Similarly, Brown et al.
(2002) studied the reasons for both SIV and suicidal behaviors among women with BPD and revealed that the majority of participants (96%) endorsed reasons for SIV related to emotional relief, anger expression (63%), and self-punishment (63%). A more recent study of SIV among adolescents reported similar findings: Rodham, Hawton, and Evans (2004) found that among a sample of adolescents (N =220) in the United Kingdom, the most frequently endorsed reason (72%) for SIV was to find relief from a “terrible” state of mind; 51% wanted to punish themselves. Based on these findings and related qualitative studies (e.
g. Abrams, 2003), case studies (e. g. Brown & Bryan, in press) and reviews (e. g. Santa Mina & Gallop, 1998; Suyemoto, 1998), this author concluded that the functions and motivations for SIV can be grouped into three broad categories: 1) Emotion regulation/ tension reduction, 2) Control/punishment, and 3) Communication/expression. Emotion regulation/tension reduction Psychological theories that consider the motivations for and functions of SIV typically emphasize the potential for SIV to regulate strong emotional responses and reduce unbearable tension in individuals who practice it.
SIV is an accessible and effective coping strategy that provides constancy for those who SIV (Babiker & Arnold, 1997; Haines, Williams, Brain, & Wilson, 1995; Suyemoto & MacDonald, 1995). SIV as a motivation for emotion regulation and tension reduction involves the attempt to bring the body back to a state of equilibrium in the midst of overpowering feelings (Ross & McKay, 1979). This includes calming the body in times of high emotional and physiological arousal, validating internal pain with an external expression, and avoiding suicide because of unbearable feelings (Walsh & Rosenthal, 1988).
In a widely cited study of 240 women who self-identified as having engaged in SIV, Favazza and Conterio (1989) reported that two thirds of the participants experienced a significant decrease in negative symptoms lasting several hours following an act of SIV. Of this group, one third reported feeling relief that continued for several days, while another third reported feeling relief for several weeks. Those who undertake SIV reports that while it fails to eradicate painful feelings completely, it does provide powerful and effective short-term relief.
Support for the hypothesis that SIV relates to emotional regulation comes from several qualitative investigations and case studies in which people who engage in SIV have been asked about or have subjectively expressed their reasons for SIV (Brown & Bryan, in press; Himber, 1994; Strong, 1998). For example, Hyman (1999) presented 15 case narratives of women varying in age from 26-51 years. While each participant reported numerous reasons for SIV, they endorsed ‘release of turbulent and frightening emotions’ as their primary motivation.
Individuals who engage in SIV often report that their actions help to relieve psychological pain, decrease physical tension, and keep traumatic memories from recurring. Furthermore, some report that SIV helps them to better express their emotions and allows them to release anger, depression, and anxiety. Thus, SIV helps individuals experience a sense of control over their lives and emotions (Mazelis, 2003). Control/punishment SIV is understood as a means for individuals to gain control over their emotions and other areas of their lives when they seem to have little or no control of such things (Suyemoto, 1998).
In an analysis of power relations, Brown (1994) hypothesized that a lack of control and powerlessness is linked to broader systems of gender, class, and racial-based oppression. Powerlessness is a contributing factor in the emergence of SIV as an individual attempts to regain a position of power (power meaning a sense of agency); additionally, for individuals who have experienced trauma, SIV may induce a sense of efficacy and relieve feelings of victimization (Brown, 1992; Himber, 1994). Control and punishment can include trauma re-enactment, and in this respect, control overlaps somewhat with emotion regulation.
For many trauma survivors, SIV behaviors represent attempts to master previously unmanageable situations and are often fundamentally connected to the survivors’ efforts to regain their sense of power following a traumatic experience—a person may engage in SIV in a purposeful effort to control and thereby claim power over punishment that had at one time been doled out by the perpetrator (e. g. hitting, rape, incest) (Brown & Bryan, in press; Brown, 2000; Himber, 1994). Additionally, SIV may function to direct negative feelings toward the self that may interact with a need for self-punishment.
The felt need to punish oneself may be connected to body betrayal and the discomfort of having feelings of pleasure, longing, or sadness toward the abuser. Hence, SIV can serve to express as well as punish any feelings of arousal and shame that may arise (Chu, 1998; Favazza, 1996). Communication/expression Some people may use SIV as a way to express overwhelming feelings such as shame, guilt, and rage for which they cannot find language; to communicate about the trauma, to find a way to tell others what happened is a powerful function of SIV (Brown & Bryan, in press; Herman, 1992).
For example, Brown recalled a conversation with a woman who engaged in SIV: When people see my blood and the wounds they start to have some idea—not the whole idea, but at least some idea—of how bloody and wounded it feels inside of me. I don’t know if they can believe how much I hurt inside if they don’t see how hurt I am outside. (p. 9) In addition, because trauma is generally stored in nonverbal modes such as sensations and visual images (Bremner, 2005; Herman; van der Kolk, 1994), SIV behavior may function to unconsciously act out the traumatic event on the survivor’s body.
When the communication of SIV is directed at others such as family members and helping professionals, the behavior is often seen as a manipulative action to control environment and others. However, the word manipulation is a pejorative term. Instead, SIV behavior can be reframed as the client’s indirect attempts to ask for help (Brown & Bryan, in press; Himber, 1994). If a person learns that her direct requests will be listened to and addressed, then her need for indirect attempts to influence others’ behavior may decrease.
Thus, understanding what an individual is trying to communicate through an act of SIV can be crucial to dealing with the behavior in an effective and constructive way. Not all individuals who intentionally injure themselves are survivors of trauma, and for these individuals, SIV may serve other functions entirely. Although this sub-population in the realm of SIV is outside the scope of this review, it is nonetheless an important area of SIV meriting attention and investigation by clinicians and researchers. Concomitant Factors
Numerous studies have underscored the link between SIV and other clinical disorders as outlined by the DSM-IV-TR (APA, 2000), including borderline personality disorder (BPD) (Herman et al. , 1994; Linehan, 1987; van der Kolk et al. , 1991; Walsh & Rosen, 1988), posttraumatic stress disorder (PTSD) (Favazza, 1996; Gold, 2002; Herman, 1992; van der Kolk, 1994; Walsh & Rosen), dissociative disorders (Chu, 1998; Briere & Gil, 1998; Saxe, Chawla, & van der Kolk, 2002), depressive disorders (Briere & Gil, 1998; Parker et al. , 2005), and eating disorders (Favazza, DeRosear, & Conterio, 1989).
In addition, women who practice SIV are commonly diagnosed with personality disorders (Walsh & Rosen, 1988; Zweig-Frank et al. , 1994a). The personality disorder most associated with SIV is BPD (Linehan, 1993; Walsh & Rosen, 1988) with self-injury being essential criterion for the diagnosis as per the DSM-IV-TR (APA, 2000). Controversy surrounds the diagnosis of BPD—whether it exists as it is defined or whether it is a manifestation of chronic exposure to traumatic experiences and therefore perhaps better and less-pejoratively explained via posttraumatic stress criteria.
That clinical symptoms of PTSD may become chronic or integrated into the developing personality (Herman, 1992; van der Kolk, 1994) perhaps contributes to the diagnosis of BPD in those who practice SIV. The pathologizing label attributed to BPD diagnosis, with symptom criteria that might be better attributed to PTSD, further stigmatizes an individual who utilizes an already highly stigmatized and often misunderstood self-preserving SIV behavior.
Dissociation is among the constellation of symptoms associated with the presentation of emotional and physical trauma (Chu, 1998). Typical dissociative symptoms include depersonalization, derealization, amnesia, identity confusion, and identity alteration (APA, 2000), with individuals who dissociate reporting feelings of going to a “different place,” a sense of “floating,” or a sense of “watching a movie that I was in” (Chu, 1998).
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); as such, dissociation is primarily a protective response, an adaptive defense mechanism that aids in survival of the body and mind, commonly in response to perceived or actual horrific threatening environmental situations (i. e. childhood sexual abuse) (Chu; Herman, 1992; van der Kolk).