Non-fatal suicidal behaviour in young women: links to self-mutilation Dr Cate Curtis email@example.com
Introduction:Although there is an increasing body of researchinto youth suicide in New Zealand, much of it iswith clinical populations and quantitative in nature. My research was with a community sample ofwomen and focused on finding out about theirperceptions and understandings of events. It alsoincluded interviews with service providers/keyinformants.
Areas of discussion will include:• The relationship between self-mutilation and suicidal behaviour• Survivors’ perceptions of the services they have encountered and the recovery process (if time allows)Other key findings included the importance of sexual abuse as a risk factor, alongside issues of powerlessness
Key features of the study• Who: 25 women and 25 key informants• Where: throughout New Zealand• How: The women were invited to discuss their experiences of becoming and being suicidal and recovering from suicidality. The narratives were collated and thematic analysis undertaken.
Method: I• Recruitment: class presentations, newspaper & magazine articles, word of mouth.• Participants: 25 women who had engaged in suicidal behaviour while aged under 25. Ages ranged between 21 and 46 at the time of the interview.• Procedure: Mostly unstructured interviews, in person (19). Some by phone (2), email (3), letter (1). Thematic analysis using Nu*Dist.
Literature – self-mutilation• Little risk of death, goal of short-term alleviation through alteration of consciousness. Some overlap with suicide attempters (Walsh & Rosen, 1988)• Counter-suicidal (Ross & McKay, 1978)• Secret, most common among adolescent females. Sense of relief through endorphin release: self-reinforcing (Alderman, 1997).• Abuse history very common (Dieter, Nicholls & Pearlman, 2000).
•Cognitive distinction between suicide and self-mutilation,though linked to other self-destructive behaviour, e.g.eating disorder (Favazza, 1986, 1996).•Differing levels of depression and suicidal ideation,attitudes to life (Muehlenkamp, Gutierrez, 2004).•Dunedin study – most self-harm not suicidal (Shyamala-Rada et al., 2004).Overall: part of the self-harm continuum, quite distinctfrom suicidal behaviour, although some self-mutilatorsmay go on to attempt suicide. Links to psychosis,dissociation. Manipulative, attention-seeking (older lit.).
Results18 of the 25 had self-mutilated*• Most common forms:• Cutting (14)• Burning (4)• Hitting/kicking (2)• Abrasions (1)• Frequency & duration varied: several times a day for several years, to three times in total. Usually several times a month.* These results are provided for interest’s sake only.
Different from suicide:• “Cutting is playing with dying – it’s not consciously wanting to die…It’s a means of self-expression, stress and tension- relief. It made me sane when I was going crazy. It’s not really any different from smoking or drinking except that it’s not socially acceptable.”• “Cutting wasn’t a suicide thing, it was a release of emotion. It does hurt, but it doesn’t matter because you feel like you deserve to hurt. The internal pain is far worse than the physical. Sometimes cutting could be a way of dealing with feeling suicidal, releasing the pain instead of making a suicidal act.”• “I tried cutting myself on my arm to see what it would be like to cut my wrists, because I didn’t want to fail at a suicide attempt … cutting gave me a sense of release of tension, it changed my state.”
Expression of emotions:• “…an expression of anger, punishment for eating [when anorexic]… pressure release, a way of relieving suicidal feelings.”• “Cutting made me feel better for a while – it hurt so it felt like a strong thing to do, although I knew it was kind of stupid… It was a clear decision to do it, when I felt kind of powerless”
Fourteen of the 18 women who had self-mutilatedlink their behaviour to sexual abuse:“I was unable to express myself, the [emotional]pain was like a physical ache. I felt raw, as if I’dbeen peeled. Cutting provided a release oftension…[the focus on] physical pain made theemotional pain easier to bear.”
“It was because of anger, frustration, inability to express myemotions. I had no-one safe to talk to, no-one wouldunderstand, I was ashamed, and I just wouldn’t have beenable to bring myself to talk. I hadn’t even acknowledged it[sexual abuse] to myself - I kept a very tight lid on mythoughts – so how could I talk to anyone about it anyway?It was also about proving that I was tough, strong, leave mealone, don’t fuck with me, no-one can hurt me. Which ofcourse was bullshit. I didn’t hurt because I didn’t allowmyself to feel… at the time I wouldn’t have been able to saywhy I did it. Some-times it was quite public…I guess I wasalso wanting some-one to notice and help me, or just giveme some attention, but at the time if any-one had askedwhat was wrong I probably would have said ‘nothing’.”
Power and controlA key issue, frequently emphasised• “I felt absolutely powerless, I was absolutely powerless. My depression took a turn I couldn’t control, and I was over the edge…. I felt that nothing was in my control except this aspect of my body and my life.”• “I felt mesmerised by the knife and the blood, and felt like I was getting a slice of power back.”
Abuse sense of externally-targeted attempts successful powerlessness to regain sense of control no further fail action self-mutilation to regain sense of control temporarily successful sense of powerlessness returns suicide attempt / further mutilation
Differences between the behaviours• self-mutilation began before the first suicide attempt, and nearly half continued after the last suicide attempt;• means used for self-mutilation usually different from those used for suicidal behaviour;• participants typically interspersed suicide attempts with self-mutilation;• self-mutilation usually occurred more frequently, with several episodes increasing in frequency before culminating in a suicide attempt;• a period of respite from self-harming behaviours often followed. However, for most participants this respite was temporary.
Key Findings• Definite relationship, although quite distinct behaviours:• Goal of self-mutilation: short-term release, to feel better cf not feel at all• Change focus of pain to physical• Punishment• Reclaim control of the body• Statement of strength• For most it is physically painful
• However, participants brought up the topic of self-mutilation without prompting and made clear links between self-mutilation and suicide attempts, particularly discussing self-mutilation as a way of dealing with suicidal ideation.• Although many self-mutilators may not be or become suicidal, it seems many female suicide attempters also self-mutilate.• In contrast to a self-harm continuum, this research suggests a repetitive, wave-like pattern
Implications for treatment• Importance of partnership• Awareness of power dynamics• Realisation that abuse likely, but may be too painful to deal with• Assistance to find other ways of recovering a sense of power e.g. support to leave a destructive relationship, prosecute an abuser• Non-reinforcement (by medical staff) – matter of fact attitude
Key features of successful counselling/therapy:•an empathetic counsellor•a sense of control/partnership in the counselling process•feeling listened to•not feeling like a burden (cf to talking to family/friends)•feeling the counsellor could relate– similar demographics•feeling that the counsellor genuinely cared•feeling the counsellor could be trusted –particularlyimportant issue for women who felt betrayed by othersincluding parents and previous counsellors.
Implications for treatment:• Importance of partnership in the therapeutic process• Awareness of power dynamics• Realisation that abuse likely, but may be too painful to deal with immediately• Assistance to find other ways of recovering a sense of power e.g. support to leave a destructive relationship, prosecute an abuser• Non-reinforcement (by medical staff) – matter of fact attitude
Conclusion:• Although distinct behaviours in terms of intent and lethality, there are clear links, in particular, using self-mutilation as a way of dealing with potential suicidality.