Examination of the indicators of emotion dysregulation suggested that limited access to emotional regulation strategies might be of particular importance in the prediction of NSSI. In contrast, lack of emotional awareness performed particularly poorly as a reliable indicator of regulation difficulties, which might suggest that this factor plays less of a role in NSSI behaviours. Therefore, the full model was modified by removing the lack of emotional
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awareness subscale and re-tested. The results demonstrated that this modified model was a significant improvement over the original. Previous research has also found different levels of support for the domains of emotion dysregulation, as measured by the DERS. The findings of Gratz and Roemer (2008) highlight the importance of limited access to emotion regulation strategies, as this was the only subscale of the DERS that was found to predict, as well as partially mediate, the relation between childhood maltreatment and NSSI. Lack of emotional clarity was also demonstrated to predict NSSI, but the mediational relationship was not found. Likewise, Heath and colleagues (2008) also found limited access to strategies especially relevant to engagement in NSSI, followed by difficulties controlling impulsive behaviours and difficulties engaging in goal-directed behaviour when experiencing negative emotions. The latter study further found that lack of emotional awareness was not significantly different between participants with and without a NSSI history.
The particular relevance of limited emotion regulation strategies is consistent with the conceptualization of NSSI as a maladaptive coping strategy used to decrease intolerable emotions in the absence of more healthy strategies. Limited access to alternative coping strategies might assist in distinguishing between individuals with deregulated emotional experiences who self-injure and those who do not. This finding also has implications for treatment of NSSI, such that interventions targeted at strengthening an individual's coping strategy repertoire might be particularly effective, although additional research is also needed to explore the salience of this domain of emotion regulation. Preliminary results obtained through a re-validation of the DERS do support the importance of access to strategies, as this was the only subscale to remain significantly associated with NSSI after controlling for the other domains of emotion regulation, gender, and psychopathology (Perez, Venta, Garnaat & Sharp, 2012).
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The results regarding emotional awareness in this research and the aforementioned studies reporting null results are surprising given the theoretical association between these factors (e.g., Gratz, 2007). Further, prior research has demonstrated an association between NSSI and alexithymia, specifically greater difficulty in identifying emotions (Borrill, Fox, Flynn & Roger, 2009). It might be that difficulty identifying emotions is more aligned with the lack of emotional clarity subscale of the DERS (versus emotional awareness), which did not perform as poorly as an indicator of emotion dysregulation in the current study. An alternative hypothesis for this finding across studies is that it is not the lack of emotional awareness per se that confers risk for NSSI, but that the individual is intolerant of the negative emotions of which he/she is aware, with the greater risk for self-injury lying in such non-acceptance of emotional experience. In contrast, Sim and colleagues (2009) did find a relationship between lack of emotional
awareness and NSSI, indicating additional research is needed to clarify the role of this domain of emotion regulation. Future research could employ a more comprehensive assessment of
emotional awareness, such as through utilization of the Level of Emotional Awareness Scale (LEAS; e.g., Ciarrochi, Caputi & Mayer, 2003), which assesses emotional awareness in both self and others.
As the results indicated that the original full model provided an adequate, although not strong fit, a final reduced model was also tested. In the reduced model, both emotional reactivity and emotional dysregulation were conceptualized to be indicators of an underlying factor
reflecting emotional vulnerability as risk for NSSI. Such a conceptualization was drawn from Linehan's biosocial model (Crowell, Beauchaine, & Linehan, 2009; Linehan, 1993). In her model, emotional difficulties/dysregulation are described under a broad construct which includes: 1) heightened emotional sensitivity; 2) inability to regulate intense emotional
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responses; and 3) a slow return to baseline (Crowell et al., 2009). Applying this aspect of the biosocial model to the variables examined in the current study, emotion dysregulation, as measured by the DERS, maps on to Linehan's second factor. Further, emotional
sensitivity/intensity and persistence, assessed by the ERS, are reflective of Linehan's first and third factors, respectively. The results indicated that overall the reduced model was an improvement compared to the original full model in the prediction of NSSI. Furthermore, the reduced model demonstrated the same pattern of relationships among emotional vulnerability and the interpersonal factors. Specifically, in the reduced model parental and peer relationships significantly predicted greater emotional difficulties that, in turn, predicted engagement in NSSI. The direct paths from parent and peer relationships to NSSI were not significant, again indicating support for the mediational impact of interpersonal relationships via emotional difficulties. Finally, the results demonstrated that the DERS performed as a more reliable indicator of the underlying emotional vulnerability construct.
The results of the reduced model suggest that it might be the combined influence of both high emotional reactivity and emotion dysregulation, rather than their influence when considered more in isolation, that confers the greatest risk for NSSI. Indeed, as discussed by Gratz (2007), although emotional reactivity is a risk factor for difficulties in emotion regulation, the relation between these factors is not direct, and most research indicates that emotional reactivity on its own is not associated with more pathological outcomes. Furthermore, preliminary research also suggests that emotional reactivity is not a direct risk for NSSI, but rather increases risk when considered in combination with other factors such as emotional inexpressivity and experiences of maltreatment during childhood (Gratz, 2006). Such a hypothesis is consistent with the
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the context of invalidating interpersonal relationships that interfere with the continued fine- tuning of emotion regulation skills, are at greatest risk for turning to NSSI as a coping strategy. In addition, these results suggest that emotional reactivity may be a necessary but not sufficient risk factor for NSSI, and that emotion dysregulation, particularly the lack of healthy strategies to deal with such reactivity, is the more salient, specific risk factor. This hypothesis is also
supported by the current findings in that composite emotion regulation factors emerged as a more reliable indicator of the latent emotional vulnerability factor than did the emotional reactivity measure. The overall findings of the current study are clear in indicating that NSSI is a multiply determined behaviour that involves dynamic and complex interactions among factors. Although factors such as emotional reactivity or negative interpersonal relationships might not, in and of themselves, directly contribute to NSSI, the greater risk appears to lie in the reciprocal
associations among the examined variables and the contribution of such factors to increased emotional dysregulation.
4.4.6 Conclusions.
The results of the current study provide an important contribution to the NSSI research base. The results demonstrate both a replication and extension of a number of findings in the current literature, and provide additional information regarding important etiological and/or maintenance factors that contribute to NSSI. Further, the current study provides a more comprehensive examination of both intrapersonal and interpersonal factors, using statistical model tests that are relatively recent and novel within the NSSI literature.
The current study provides additional support for the important role of emotion regulation as a function of self-injury. Specifically, individuals with greater difficulties regulating their emotional experiences were found to be more likely to engage in NSSI. Support was also
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demonstrated for the particular relevance of a limited access to emotion regulation strategies subcomponent of emotion regulation. Such a pattern is consistent with the notion that NSSI is used as a maladaptive coping strategy in the face of intolerable emotions and when the individual does not have access to healthy coping skills.
This study also advances the literature by examining the role of emotional reactivity within the broader model. As hypothesized, greater emotional activity was associated with greater difficulties in emotion regulation. Consistent with preliminary evidence that emotional reactivity is not, in itself, associated with more pathological outcomes, the association between reactivity and the interpersonal variables was weaker or non-significant compared to emotion regulation. Further, the results of a modified model suggested that the combination of both emotional risk factors might be particularly relevant in the understanding of NSSI behaviours.
In regard to interpersonal factors, the current results suggest that negative parental and peer relationships might not directly impact engagement in NSSI. Rather, the influence of interpersonal relationships appears to be indirect, acting on NSSI via the impact of relationships on emotion regulation. Such a pattern replicates findings regarding the mediational role of relationships in the existing literature, which to date has largely focussed on experience of abuse, neglect, or victimization. The aforementioned patterns among the emotional and relational variables have been previously demonstrated in a sample of adolescent girls (Adrian et al., 2010). The current study represents the first to include measures of emotional reactivity, emotion regulation, and general measures of parent and peer relationships in regard to NSSI among a sample of primarily young adults. Thus, the results extend existing literature by demonstrating that such variables remain important considerations following adolescence. As the onset of NSSI is most commonly reported to be during adolescence, such results appear to suggest that
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emotional and interpersonal factors contribute both to the initiation of NSSI, as well as its maintenance into adulthood.
Finally, the current study significantly contributes to the literature by providing the first examination of how current and past identification with various subcultural groups might be associated with engagement in NSSI. Although response rate concerns precluded any fine-tuned examination of the subcultural variables, the results do provide preliminary evidence and point to the need for further investigation. More specifically, the results suggest that identification with more deviant groups, or those departing from the mainstream peer group, might represent a risk factor for NSSI. Such a hypothesis is consistent with a preliminary empirical study and anecdotal evidence. The nature of the potential association between NSSI and subculture is likely to be complex and involve many additional factors which go beyond those assessed in the current study.
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Chapter 5. Study 3 Results and Discussion