5. Point-of-Care Device for Molecular Diagnosis
5.5 Summary
literature?
The review highlighted a number of functions of self-harm which Suyemoto (1998) and Klonsky (2007a) do not describe in the theoretical literature, such as self-harm serving to: help gain control over oneself, act as a distraction, give pleasure, enable
experimentation, create a sense of belonging, protect, cleanse, show strength, help focus, communicate, escape, transfer pain and finally, self-harm was reported to serve as a way of remembering significant events. These functions were found in a large number of studies adopting different research approaches, examining different methods of harm.
Although this review has found a number of functions of self-harm that Suyemoto (1998) and Klonsky (2007a) do not describe, some earlier theoretical literature does go some way to describe some of the those functional themes. For example, Bennum (1984) wrote about psychological models of self-mutilation and described functions related to communication. He describes a social psychological model of appeal; the act of mutilation is an appeal to the social network surrounding the individual and resembles a strong and desperate message which they are unable to communicate.
Surprisingly, although cited by Suyemoto (1998), this type of function is excluded from her review and Klonsky’s (2007a). They both describe how people use self-harm as a way of interacting with their environment. Suyemoto (1998) refers to this as the environmental model, describing how self-harm behaviour is initiated through familial modelling or learning about the effects of such a behaviour through vicarious
reinforcement, which is then maintained through reinforcement from those in their environment (family, friends, caregivers). Klonsky (2007a) on the other hand referred to this sort of function as ‘interpersonal influence’. He described how people use self-harm to influence or manipulate people in their environment. Arguably there is some similarity in what they describe and what this review and Bennum (1984) termed
‘communication’, however there would also appear to be some distinctions. This particular function doesn’t appear to be associated with behavioural and systemic traditions as Suyemoto (1998) described or to manipulate as Klonsky (2007a) described. As some of the respondent statements describe they do it as a way of visually showing their pain, not necessarily to get action but perhaps to seek validation / acknowledgement of their pain. ‘That was how I was feeling, the things I was doing, it would describe my battles and all sorts of things. It was all very pictorially displayed on my body and sometimes I wanted to share it with other people’.
The communicative function was also found and described by Bancroft et al (1979) as
‘where the goal or purpose was to communicate a feeling of state of mind combining both instrumental and expressive functions’ (p.356), for example, to show love, to show desperation. Moreover, Bancroft et al (1979) separated this function from ‘to influence someone’ which they grouped as an instrumental function. Given Bancroft’s study is considered to be one of the key studies of functions of self-harm it seems unusual that the communication function has not been incorporated into subsequent theoretical explanations other than Bennum’s (1984).
Bennum (1984) also referred to the function of control. He describes the ‘hostility model’ and briefly referred to how hostility, in the form of aggression against the self, can be used as a function of gaining control over oneself and others, which bears some similarities with how Osuch (1999), and Haas & Popp (2006) described the function of control, as noted earlier (p.40). Again this type of function was excluded from the reviews of both Suyemoto (1998) and Klonsky (2007a).
Carr (1977) also wrote a review of some motivational hypotheses in relation to self-injury. He referred to the ‘negative reinforcement hypothesis’ which described how people self-injure to terminate or avoid something adverse, although the negative hypothesis is not considered a function per se, it does help describe the process underlying the function of escape. For example, ‘to escape from life’; ‘wanted to sleep for a while’; ‘to get away from my problems’, the act of self-harm is serving to put a stop, albeit temporary, to a difficult experience(s), and so the behaviour is maintained through negative reinforcement.
The functional processes underlying self-harm behaviours was also a particular focus point for Nock & Prinstein (2004). They developed the four function model (FFM) in which they classified functions of self-harm into four theoretical models; automatic positive reinforcement – to create desirable states, automatic negative reinforcement – to reduce negative states, social positive reinforcement – attention from others, and social negative reinforcement – escape from interpersonal task. Although this
assessment of functions doesn’t explain the detail of particular functions it does give us some indication of the processes that might maintain the behaviour.
Notably, throughout the process of synthesising the evidence of the different functions and considering whether different functions mapped onto the thematic framework or not, it was difficult at times to ascertain the meaning behind some research led items and respondent statements. For example, a number of studies used instruments which included the functional item ‘to make body unattractive’ (Briere and Gill, 1998, Claes et al., 2010), ‘to change my body image and / or appearance’ (Holly, 2007); this particular
theme was also openly reported by a participant ‘to make myself ugly or disgusting, I’ve been cutting myself so that if someone does try anything they’ll see my body and think what a freak, she’s disgusting, she’s ugly’ (Parfitt, 2005). The latter response seems to indicate how self-harm was being used to ward off unwanted attention from others.
However, this same item has also been used in research led items to describe how people use self-harm as a way of disfiguring their body as punishment (Briere and Gill, 1998) and self-destruction (Claes and Vandereycken, 2007b). Holly (2007) on the other hand used the FASM and although she doesn’t describe the meaning of this particular item she does report how people who endorsed this item also endorsed items such as
‘to show others how strong or tough I am’, ‘to prove to myself how much I can take’ and
‘to replace unbearable pain with physical pain’. This grouping of items seemed to share the functional theme of self-harm serving as way to protect oneself. As discussed earlier (p.35), showing others how tough you are to perhaps ward them off, and to change unbearable emotional pain into something more bearable.
Similarly, Osuch (1999) described six motivational factors that make up the SIMS, the item ‘to show others how hurt / angry I am’ was under the factor ‘influencing others’
which might relate to the function of communication. The item ‘to remind myself that I’m alive when I otherwise feel dead’ was under the factor ‘punitive duality’ when instead it would appear related to the function of dissociation; and ‘to do something only I have control of and no one else can control’ was under the factor desolation which might relate to the function of control.
Other statements / items such as, ‘I wanted to take the pain away from my heart and put it somewhere else (Laye-Gindhu and Schonert-Reichl, 2005)’, ‘feel inside body’,
‘ownership of body’, ‘facilitate / hinder switching from one personality to another’ (Briere and Gill, 1998)’, ‘to feel concrete pain when the other pain is so overwhelming and confusing that I can’t grasp it’ (Shearer, 1994), ‘uniqueness’ (Haas and Popp, 2006) also proved difficult to code.
As discussed earlier in relation to the function of communication and punishment of others, a number of functions also overlap or are very closely related and so it can be difficult to ascertain whether endorsement of certain statements are providing evidence to support one function or another. Another example of this is where participants indicate functions such as, ‘self-harm helps me to concentrate’ (Kleindienst et al., 2008)’, ‘to take my mind off my problems’, ‘to have something else to think about’
(Rodham et al., 2004 p.83) , ‘to regain focus’ (Klonsky, 2009) this seems to be describing cognitive regulation as opposed to affect regulation, which might be considered two distinct functions (Franklin et al., 2010) yet they are coded as one,
which might of course have an impact on the interpretation and application of the evidence.
The difficulty in attributing meaning / interpretation was also noted with the boundaries function described by Suyemoto (1998). In her article she used an excerpt from Leibenluft’s (1987) study who explored the self-harm experience of people who met the criteria for borderline personality disorder. Suyemoto (1998) used one of the participants experiences to exemplify the boundaries model and how people use self-harm to reaffirm the boundaries between the self and others, Liebenluft (1987)
however, using the same excerpt, reported how this person used self-harm as a way of terminating the feeling of dsyphoria, to stop the extreme emotional pain, which is perhaps more aptly described as affect regulation.
Again, the disparity in interpretation was also noted when closely screening some of the studies included in Klonsky’s (2007a) review. For each of the 18 studies included in his review the functions studied and supported were listed. The study carried out by Shearer (1994) reportedly studied and supported the following functions: affect
regulation, self-punishment, interpersonal influence, interpersonal boundaries, anti-suicide, anti-dissociation, and sensation seeking - seven out of the eight functions from the thematic framework. This review also reported support for seven functions however the functions reported differ. For example, Klonsky (2007a) included interpersonal boundaries in his review of Shearer’s (1994) study and it is possible that he reported support for this from the item ‘to do something only I have control over and no one else can control’. This review however grouped this item under the theme of control. In addition, Klonsky (2007a) failed to report how Shearer’s (1994) study found support for the sexual function; 5% of participants endorsed the item ‘to provide a sense of relief that feels much like sexual release’. It is possible that Klonsky (2007a) categorised this item as sensation seeking.
Similarly, the study carried out by Wilkens and Coid (1991) was reported as having studied and supported the functions of affect regulation and anti-dissociation. This review however found evidence for both those functions in addition to interpersonal boundaries and interpersonal influence. Wilkens & Coid (1991) reported how women had ‘done it to attract attention to themselves’, ‘to copy others’, and 5% of the women reported how ‘it reassured them of their existence’. This study also reported a number of functions such as deriving pleasure, warmth and comfort which Klonsky (2007a) does not mention.
It would seem then that functions of self-harm, other than those described by
Suyemoto (1998) and Klonsky (2007a), have been reported in the empirical literature
and some (not all) have been referred to in the earlier theoretical literature. However, there would also seem to be a certain amount of disparity amongst researchers in how they attribute meaning to certain items and responses and perhaps this would account for some of the apparent gaps between the empirical evidence and subsequent theory development.
These findings do perhaps suggest the need for a more comprehensive theoretical review of self-harm functions that incorporates these additional functions and distinctions which could be useful for both health professionals and researchers, particularly those aiming to develop new instruments to assess functions of self-harm.
A more comprehensive review might also be helpful to potential participants who are also required to interpret meaning and subsequently endorse relevant functional items.