This document provides information about a workshop on self-injury presented by Professor Graham Martin and Sophie Martin. It includes summaries of research on self-injury prevalence, theories of self-injury, and effective therapies. Key findings from the 2009 Australian National Epidemiological Study of Self-Injury are presented, showing a lifetime prevalence of self-injury of 8.1%. Dialectical Behavior Therapy and Voice Movement Therapy are discussed as potentially effective therapies, with evidence presented on improvements in emotion regulation, self-esteem, and distress following Voice Movement Therapy.

1. A MTA Workshop
Self-injury
VMT The Cutting Edge of Therapy
:
Professor Graham Martin
g.martin@uq.edu.au
and Sophie Martin
s.martin@voicematters.com.au
14.9.2012

2. Religious Mortification
Mortification of
the flesh literally
means "putting
the flesh to
death". The term
is primarily used in
religious and
spiritual contexts.

3. Self Injury
 Deliberate destruction of body tissue ‘without suicidal intent’
(Favazza, 1989)
 Majority occurs in community; ie ‘hidden’
 Reliable ‘whole of population’ data lacking
Only one prior study of 928 (Briere &Gill, 1997)
 When it does come to medical attention (eg Emergency
Dept), consumers often treated badly - because ‘selfinflicted’
 More serious the injury, more often admitted
 Costs to society high, but difficult to estimate

4. Theoretical Frame, Klonsky, 2007
 Affect-Regulation (Crouch & Wright, 2004)
 Anti-dissociation (Miller & Bashkin, 1974)
 Anti-Suicide (Messer & Fremouw, 2008)
 Interpersonal Boundaries (Claes & Vandereycken, 2007)
 Interpersonal Influence (Messer & Fremouw, 2008)
 Self-Punishment (Linehan, 1993)
 Sensation-seeking (Klonsky, 2007)

5. Findings from the 2009
Australian National
Epidemiological Study of Selfinjury
Martin, G., Swannell, S., Harrison, J., Hazell, P. & Taylor, A., 2010. The
Australian National Epidemiological Study of Self-Injury (ANESSI). Centre for
Suicide Prevention Studies, Discipline of Psychiatry. The University of
Queensland. Brisbane, Australia. ISBN 978-0-9808207-0-6. Available in Soft
Cover, or downloadable in .pdf format from
http://www.suicidepreventionstudies.com

6. ANESSI Key Findings
Lifetime prevalence 8.1% (978 of 12,006 subjects)
Females 8.74% (530 of 6063)
 Peaked 20-24yrs (110/451, 24.4%), followed by 15-19 age
group (95/574, 16.6%)
Males 7.54% (448 of 5943)
 Peaked 20-24yrs (79/436, 18.1%) followed by 25-34 age
group (119/957, 12.4%)

7. NSSI Lifetime Prevalence
978/12,006
8.1%

8. Four Week Prevalence
Overall 1.1% (n 133)
Females 1.19%, 72 of 6063
Peaked 15-19yrs (23/574, 4%)
followed by 20-24 (16/450, 3.6%)
Males 1.02%, 61 of 5943
Peaked 10-14 yrs (9/388, 2.3%)
followed by 15-19 (14/629, 2.2%)
72% more than once

9. Nature of Self-injury
last 4 weeks
 Males
 Hitting body on hard surface (37.1%), cutting (23.7%),
burning (17.5%)
 14.5% medical treatment; none to ED, none admitted
 Females
 Scratching (48.7%), cutting (48.2%), hitting body on hard
surface (29.2%), burning (8.1%)
 19.4% medical treatment; 3 to ED, and all 3 admitted
 Overall, 26% used two methods, 19% used three, 7% used
four, and 3% used five or more methods (Tot 55%)
 Frequency of self-injury during the month ranged from once to
fifty times (mean 7, mode 1)

10. Motivations
‘To manage emotions’ (41%, 25/61 males, and 58%,
42/72 females)
‘Need to punish self’ (26%, 16/61 males, and 18%,
13/72 females)
‘Communicating to others’ (5%), ‘reminding the self
he/she is alive’ (4%), ‘influencing others’ (4%), ‘getting
a high’ (3%), ‘scarification’ (1.5%), ‘to prevent suicide’
(1.5%) and ‘voices telling them to’ (1%).
Other (24%) - ‘habit’, ‘compulsion’, ‘curiosity’
‘distraction’, ‘for a laugh’, ‘to prove toughness’.

11. Self-injury & Suicidality
Lifetime self-injured (of 978 from 12,006)
32.9% had attempted suicide compared to 2%
non self-injurers (OR 24.1)
Self-injury in last 4 weeks (ie of 133)
48% (64/133) suicidal ideation in the month
compared to 7.7% (915/11826) of non selfinjurers (OR 11.25)
14 (10.5%) reported a suicide attempt in the
previous 12 months, compared to non-self
injurers (33 of 11,873, 0.28%) (OR 41.60)

12. Help-seeking in last month
Most (95/133, 71.4%) told at least one family
member or friend about their self-injury
Only 42/133 (31.6%) asked for help.
Only19/133 (14.3%) received medical treatment
for their injuries
Only three (2.3%) attended an emergency
department; the same three were admitted to
hospital overnight.

13. So, is other other work on
help-seeking which may help
us to help our patients or
clients?

14. Rotolone and Martin (2012)
Archives of Suicide Research. 16:2, 147-158.
 312 participants (97 males, 215 females) 1st Year
Psychology. Mean age 20.8±4.3
 106 students had self-injured (34.0%)
 ‘Past self-injurers’ (68, 21.8%) were very similar to
‘Current self-injurers’ (38, 12.2%) in terms of frequency
and severity of SI
 37 of 68 ‘Past self-injurers’ (54.4%) had sought therapy
or counselling for self-injury, 29 (78.4%) reporting it as
helpful in reducing/discontinuing.

15. What helps ? (Rotolone & Martin 2011)
Table 3: Follow up Planned Contrasts for Significant Findings
Variable
Never vs
Current SI + Previous SI
t
p
Effect Size t
Overall Perceived Social Support
Family Support
Friend Support
Significant Other Support
Social Connectedness
Resilience
Self-Esteem
Satisfaction with Life
-6.95
-6.67
-4.46
-2.60
-5.88
-5.43
-7.04
-6.16
.001
.001
.001
.011
.001
.001
.001
.001
0.50
.57
.38
.24
.36
.50
.38
.33
Current SI vs
Previous SI
p
Effect
Size
2.61 .039 .23
3.32 .016 .23
1.24 .220 0.89 .376 2.73 .008 .31
4.30 .001 .48
3.72 .001 .21
3.89 .001 .33

16. What helps ?
The strongest overall predictor of self-injury
(past + present) was low social support (OR
0.54, CI 0.36-0.79)
Self-esteem was the other significant predictor of
past + present self-injury (OR 0.29, CI 0.110.72)
In a second regression, Resilience was the only
variable to predict current versus past status (OR
0.32, CI 0.13-0.76)

17. In other work we concluded that helpseeking is the key to change.
Martin, G. & Page, A., 2009. National Suicide Prevention Strategies: a Comparison.
Centre for Suicide Prevention Studies, Discipline of Psychiatry. The University of
Queensland. ISBN 978-0-9808207-9-9. Commissioned review, DOHA, Canberra.
Downloadable in pdf format (accessed 24.1.2013)
http://www.livingisforeveryone.com.au/Library-Item.html?id=82
‘Help-seeking’ is:
Recognising & accepting that you have a problem
Knowing there is a possibly successful treatment
Knowing to whom or where to go
Finding the help accessible
Finding the help responsive and knowledgeable

18. Are there Effective Therapies for SI?
Hospitalisation is expensive with poor effectiveness
(Linehan, 2000).
A meta-analysis on PST was inconclusive
(Townsend et. al., 2001).
“Few therapies with a satisfactory research base
are available to guide clinical practice”
(Muehlenkamp, 2006)

19. Effective Therapies for SI?
A Cochrane review on therapies for borderline
personality disorder concludes “all therapies
remain experimental and the studies are too few
and small to inspire full confidence in their
results” (Binks et al., 2006).
Two other recent reviews are equally cautious
(Ost, 2008; Kliem etal., 2010).

20. Effective Therapies for SI?
Hawton et al., Cochrane Review 2009
From results of 23 RCTs, “more evidence is
required to indicate what the most effective care
is for this large patient population”.
Promising results found for PST, a card to allow
emergency contact with services, depot
flupenthixol for recurrent repeaters of self-harm
and long-term psychological therapy for female
patients with borderline personality disorder &
recurrent self-harm.

21. Dialectical Behaviour Therapy
(Marsha Linehan)
 Problem solving
 Behavioral Analysis
 Insight Strategies
 Cognitive Restructuring
 Dialectics
 Contingency Management
 Behavioral Rehearsal
 Exposure therapy
 Mindfulness
Marsha Linehan

22. Dialectical Behaviour Therapy
Evidence is improving. Eg…
Pasieczny N, Connor J. in Behav Res Ther. 2011.
Effectiveness of DBT in routine public mental
health settings: An Australian controlled trial.
“After six months of treatment the DBT group
showed significantly greater reductions in
suicidal/non-suicidal self-injury, emergency
department visits, psychiatric admissions and bed
days.”

23. Dialectical Behaviour Therapy
Evidence for the 12 week Adolescent Version of
DBT is not yet good.
Fleischhaker C et al in Child Adolesc Psychiatry
Ment Health. 2011. DBT-A: a clinical Trial
for Patients with suicidal and selfinjurious Behavior and Borderline
Symptoms with a one-year Follow-up.
12 adolescents were treated. 9 patients fulfilled
five or more DSM-IV criteria for borderline
personality disorder.

24. Voice Movement Therapy
Based on the pioneering methods of vocal
facilitator Alfred Wolfsohn and influenced
by the theatre work of actor and director
Roy Hart; the acoustical analysis of
otolaryngologist Dr Paul Moses; the
characterological bodywork of Wilhelm
Reich; and the psychological principles of
C.G. Jung.

25. The Therapy
Therapist is experienced actor/singer with B. Theatre
Arts USQ plus 6 months training in Martha’s
Vineyard, plus a 2 year Masters
10 week course (2 ½ hrs) + TAU.
Waitlist randomization of two groups of 5-7 subjects
Each session begins with Voice work and Body
movement and finishes with group voice.
By week 10 they sing in 3-part harmony.

26. Voice Movement Therapy
VMT is not teaching or coaching. While initial
sessions may be scary from their novelty and
sharing experience with previously unknown
peers, it is overall a non-threatening, acceptable
and fun therapy. We explicitly acknowledge that
small group process, and shared experience of
having been traumatised, and/or a self-injurer, is
a powerful change agent with its impact on the
sense of emptiness and isolation.

27. Voice Movement Therapy
Through working with voice, bodily expression
of emotion, and personal reflection, VMT
provides shared meaning to, and words for,
emotional experience, as well as suggesting
emotion regulation strategies. Through
mindfulness VMT improves distress tolerance.
Through personal acceptance VMT changes
impulsivity. In turn, these impact on self-esteem,
anxiety, depression, and social avoidance.

28. Wilcoxon (z)
Sig.
17.82
15.36
-2.22
p = .03
14.31
-1.79
p = .07
NS
Lack of Emotional
Awareness
21.36
18.83
-1.40
p = .16
NS
16.38
-1.29
p = .20
NS
Impulsiveness
22.47
18.84
-2.41
p = .02
17.77
-1.44
p = .15
NS
Non-acceptance of
Emotional Responses
22.75
18.94
-2.80
p<0.01
20.38
-0.77
p = .44
NS
Difficulty Engaging in
Goal Directed Behaviour
20.19
17.00
-2.94
p<0.01
17.38
-0.80
p = .42
NS
Limited Access to
Emotion Regulation
Strategies
30.24
26.16
-2.36
p = .02
26.62
-0.71
p = .35
NS
DERS Total Score
134.83
115.12
-3.09
p<0.01
112.85
-0.94
p = .35
NS
Difficulty Identifying
Feelings
TAS
Post
VMT
Lack of Emotional
Clarity
DERS
Pre
VMT
10-week
Wilcoxon (z)
Follow-up
28.29
25.21
2.55
p = .01
26.08
-0.12
p = .91
NS
Difficulty Describing
Feelings
19.65
17.88
-2.11
p = .04
18.00
-0.36
p = .72
NS
Externally Oriented
Thinking
20.06
19.47
-0.53
p = .60
NS
20.32
-0.06
p = .95
NS
TAS Total Score
68.00
62.52
-2.41
p = .02
64.40
-0.56
p = .57
NS
Sig.

29. Wilcoxon
(z)
Sig.
10-week
Follow-up
Wilcoxon
(z)
Sig.
RSES Total Score
Self-Esteem
19.07
21.04
-2.54
p = .01
19.21
-1.73
p = .08
NS
11.74
9.44
-2.26
p = .02
10.46
-0.53
p =.60
NS
Anxiety
GHQ
Post
VMT
Somatic Symptoms
RSES
Pre
VMT
14.70
12.00
-2.71
p<0.01
11.38
-0.28
p = .78
NS
Social Dysfunction
12.88
9.88
-2.95
p<0.01
11.00
-0.36
Depression
13.94
11.25
-1.82
p = .07
NS
11.54
-0.24
GHQ Total Score
53.25
42.56
-2.79
p<0.01
44.38
-0.42
p = .72
NS
p
= .81
NS
p
= .68
NS

30. What is different about VMT?
it does not focus directly on self-injury leaving that
to the discretion of the young person.
It gains access to the emotional state through
exercises that are fun, easily understandable.
It rediscovers the pleasure of music and
movement and builds strengths to manage
negative emotion. It builds mindfulness about the
self, through all of the exercises, but never names
this, not does it provide didactic teaching about
the concept.

31. Are there other therapies?
Do we have to base all our therapies on variants
from CBT?
Would ACT or MBCT be of assistance to our
patients who self-injure?
Are there other Experiential Therapies which
might do the job?
Very little Art Therapy, Music Therapy seems to
have been researched in the context of Selfinjury

32. Australia needs….
Funding allocated to this preventable problem
For a program of education of key professionals
For longitudinal studies to clarify the long-term
outcomes
For further development of new therapies
For randomized controlled studies on therapies
we should invest in