Gene therapy vectors

At first the findings from this review would suggest that the use of particular research approaches does not identify particular functions. The review demonstrated evidence for each of the eight functional models from both a quantitative and qualitative

approach. Essentially, both approaches demonstrated the most support for the function of affect regulation and the least support for the boundaries function.

However, the over reliance of constraining response sets in those studies employing a structured interview method might go some way to explain why the evidence for affect regulation and environmental functions is copious compared with the evidence for the boundaries, sexual, sensation seeking and anti-suicide functions.

Empirical evidence of the different functions of self-harm seems largely dependent upon the tools being used. The review found 17 different questionnaires used to elicit motivations to self-harm, not including Bancroft’s list, those considered ‘ad hoc’ or those under design (3).

Empirical evidence to support the psychometric properties of those questionnaires was only found for eight questionnaires. It would seem then that a number of studies failed to use a validated instrument to elicit motivations and instead developed their own ‘ad hoc list / method’ reported as ‘taken from the literature and clinical experience’

(Shearer, 1994, Wilkens and Coid, 1991); ‘based on the work of Shearer & Herpertz’

(Ross and Heath, 2003); ‘derived from the literature as well as discussion with adolescents and clinicians with expertise in self-harm’ (Laye-Gindhu and Schonert-Reichl, 2005); ‘generated from the literature’ (Oyefeso et al., 2008); ‘in the authors experience are often cited by self-mutilating clients’ (Briere and Gill, 1998); doesn’t state (Kovacs et al., 1975, Nelson and Grunebaum, 1971, Sakelliadis et al., 2010, Young et al., 2007, Scoliers et al., 2009, Meltzer et al., 2002, Dear et al., 2000, Martin et al., 2010, Favazza and Conterio, 1989, Klonsky, 2009); or just asked patient about their reason for self-poisoning (Rygnestad and Hauge, 1991). Several studies used lists based on the work of Bancroft et al (1979, 1976) discussed previously see section 1.1.3.1. For further details please see (Rodham et al., 2004, Williams, 1986, Dennis et al., 2007, Varadaraj et al., 1986, Hawton et al., 1982, Holden and DeLisle, 2006, James and Hawton, 1985, Kienhorst et al., 1995, Loughrey and Kerr, 1989, Tulloch et al., 1994, Madge et al., 2008, Schnyder et al., 1999).

It would seem this list was used in spite of some of the reported limitations. For

the meaning of the act as understood by the patient, and being mindful of using lists which may simply be ‘putting words into subject’s mouths’ (p.353). Consequently a further inquiry was conducted which enabled participants to firstly, give their reasons spontaneously (part 1), secondly, asked participants directly why the overdose was taken (part 2) and thirdly, asked participants to select their motive(s) from a series of printed cards (part 3) taken from their previous study, patients, clinical contacts and the available research.

Content analysis was carried out on the responses from parts 1 & 2 and reasons for acting were described as ‘roles’; the person who wants to die, the person who wants to sleep, the person who wants relief from pain, the direct action person - all of which were described as instrumental reasons, and the person forced to act by

circumstances, which was described as an expressive reason. Responses from part 2 were also coded according to the categories available in the list of motives (part 3) in order to compare reasons across the three parts of the interview.

When giving a spontaneous account for the overdose (part 1) participants reported less suicidal intent and more reasons associated with difficult circumstances, reasons perhaps relating to precipitating events. This has also been noted in other studies which enabled participants to offer a spontaneous account for their reasons for self-harm (Michel et al., 1994, Rodham et al., 2004).

In parts 2 and 3, expressive functions (need to act), instrumental functions (seek help, escape, relief of mind, influence someone; find out if loved, make easier for others);

communicative functions (show love, show desperation, frighten / make sorry) and excuses (loss of control) were reported as reasons for non-suicidal overdose. More importantly, they found the endorsement of functions varied according to the method in which they were elicited; apart from suicidal intent, reasons chosen from the list bore little resemblance to reasons offered earlier in the interview and were therefore of uncertain relevance (Bancroft et al., 1979).

Nevertheless, it is the responses from both these studies that have been taken to form the assessment of motivations for a number of subsequent studies, and the

development of different tools. For example, the Reasons for Attempting Suicide Questionnaire (RASQ), Motives for Parasuicide Questionnaire (MPQ) and the Reasons for Overdose Scale were all based on the work of Bancroft et al (1979, 1976) and only included statements relating to functions of affect regulation, environmental influence, sometimes punishment, and functions other than those described by Suyemoto (1998) and Klonsky (2007a), such as ‘escape’, ‘show love’, ‘show desperation’, and ‘make

easier for others’. Perhaps, it is unsurprising then to find a lack of empirical evidence and theoretical literature to describe functions other than these.

Furthermore, when considering the constrained response sets, only 11 of the 67 studies adopting a quantitative approach reportedly offered the option of indicating

‘other’ i.e. none of the reasons listed, which notably was endorsed by participants in those studies (Rygnestad and Hauge, 1991, Martin et al., 2010, Lloyd-Richardson et al., 2007, Dear et al., 2000, Nock and Cha, 2009, Sakelliadis et al., 2010, Young et al., 2007, Osuch et al., 1999, Boergers et al., 1998, Laye-Gindhu and Schonert-Reichl, 2005, Nixon et al., 2002). Of those, only two described the ‘other’ functions - ‘I like the sight of blood and playing with it’, ‘I self-harm to punish myself for things I have done’

(Dear et al., 2000 p.165), ‘I wanted to send a message about my inner pain’ and ‘I wanted to take the pain away from my heart and put it somewhere else’ (Laye-Gindhu and Schonert-Reichl, 2005 p.452).

Somewhat related, the literature suggests how the experience of self-harm can be difficult to articulate (Spandler, 2001p.10). Given that some of the functions are perhaps less socially desirable, or more conceptual and difficult to describe than others, such as the sexual and boundaries functions, they could be considered particularly difficult for people to talk about and so eliciting these types of functions might depend upon the approach taken. For example, those studies endorsing some of these more rare functions predominantly employed the structured interview method.

Despite people who have personal experience of self-harm describing this type of approach as ‘off putting and disempowering’ (Walsh, 2007 p.1058), and something which blocks their ability to express their meaning of self-harm (Spandler, 2001), this approach does enable people to easily indicate some of the more rare functions associated with self-harm, which subsequently may help to inform researchers and health professionals that functions of self-harm other than affect regulation,

environmental influence, punishment and dissociation do exist.

Similarly, eliciting functions through relying on the participant to openly communicate why they self-harm is also considered problematic. Bancroft (1979) Rodham et al (2004) and Michel et al (1994) all demonstrated how participants were more likely to refer to precipitating events / states when asked to spontaneously report why they harmed themselves. For example, responses included ‘because I was really fed up and depressed’; I had an argument with my sister’ (Rodham et al., 2004 p.83) and work / relationship problems (Michel et al., 1994 p.174). It is possible that participants found it is easier to articulate precipitating events as opposed to motivations which might require more emotion laden language.

Finally, it is possible that people who self-harm do not know what motivates them. The review found a number of studies (22) which enabled participants to indicate that they did not know why they self-harmed / self-injured, in such cases the response

‘unknown’ or 'I don’t know why I do it and it seems to serve no function' were endorsed by a large number of participants (Soderberg et al., 2004, Skogman and Ojehagen, 2003, Michel et al., 1994, Swannell et al., 2008, McAuliffe et al., 2007, Kienhorst et al., 1995, Hjelmeland and Groholt, 2005). This is just an indication of those studies that did enable participants to report ‘unknown’. It is possible that people do not know why they self-harm yet they still complete the question which would suggest perhaps that lists of reasons are ‘putting words into the subjects mouths’ as Bancroft et al suggested (1979 p.353).

2.3.4 Limitations

The findings of this review should be considered in light of several limitations.

First, the review only included articles written in the English language. Although this does present potential bias it should be noted that a number of studies were carried out in non-English speaking countries such as Belgium (Claes et al., 2010), Austria (Haas and Popp, 2006) Nordic regions (Holm and Seveinsson, 2010, Rissanen et al., 2008, Hjelmeland and Groholt, 2005, Hjelmeland et al., 1998, Rygnestad and Hauge, 1991, Skogman and Ojehagen, 2003, Soderberg et al., 2004), Netherlands (Kamphuis et al., 2007, Kienhorst et al., 1995) Germany (Herpertz, 1995, Kleindienst et al., 2008,

Schoppmann et al., 2007), Greece (Sakelliadis et al., 2010), Switzerland (Michel et al., 1994, Schnyder et al., 1999) and Sri Lanka (Hettiarachchi and Kodituwakku, 1989).

Some of the studies included in the review did in fact compare functions of self-harm across countries and reported that functions of self-harm were consistent across countries (Hjelmeland et al., 2002a, Madge et al., 2008, Scoliers et al., 2009).

Also, given the large number of studies that were reviewed and the similarity in findings from studies adopting both a qualitative and quantitative approach, any bias affect due to the language restriction is likely to be minimal.

Second, the eligibility rating and appraisal of articles was carried out by one assessor only. Using additional assessors may have altered the selection and quality ratings of papers. Different quality ratings may have led to a more fruitful discussion of the credibility of the evidence.

Third, the review did not concentrate on / separate out the various populations that were assessed. Different populations may typically endorse certain functions and although this was not the aim of this review it may be an area worth considering for

Fourth, in addition to the various populations included in the review there were also a number of different methods of harm with varying definitions. Synthesising the data from all the studies, irrespective of their method, may have dismissed potential

subtleties associated with those methods. Perhaps separate reviews of each group of behaviours may have been more useful and should be considered for future research.

The aim of this review however was to explore motivations to self-harm, as defined by NICE, which includes all the methods included in this review.

Fifth, the analysis of functions other than those described by Suyemoto (1998) and Klonsky (2007a) reported to have used thematic analysis, however given that some of the functions were questionnaire items it was difficult to fully comprehend their

meaning and so the analysis of functions that did not fit the framework was restricted.

Furthermore the thematic analysis of those functions was conducted by one person only and proved difficult at times, yet agreement ratings were only sought on a few occasions.

Finally, due to funding limitations a number of unpublished theses were not retrieved and screened for eligibility. Based on their abstracts all of them appeared relevant to the review (Medina, 2005, Alexander, 1999, Costosa, 2007, Scheel, 1999, Scharf, 2007, Matter, 2009). Still, given the number of articles included in this review, the addition of a further six is unlikely to greatly alter the findings.