Copyright by Emily Hall Ray 2007 The Dissertation Committee for Emily Hall Ray certifies that this is the approved version of the following dissertation: A MULTIDIMENSIONAL ANALYSIS OF SELF-MUTILATION IN COLLEGE STUDENTS Committee: Ricardo Ainslie, Co-Supervisor Alissa Sherry, Co-Supervisor Keenan Pituch, Member Deborah Tharinger, Member Alexandra Loukas, Member A MULTIDIMENSIONAL ANALYSIS OF SELF-MUTILATION IN COLLEGE STUDENTS by EMILY HALL RAY, B.A.; M.A. Dissertation Presented to the Faculty of the Graduate School of The University of Texas at Austin in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The University of Texas at Austin August 2007 DEDICATION To my dear husband Mick. I am ever honored and privileged to be on this journey with you. ACKNOWLEDGMENTS I extend thanks to all of my committee members for their support of this project. I am particularly indebted to my co-chairs, Alissa Sherry and Ricardo Ainslie, for their ongoing mentorship and encouragement. To Julian Chapa for creating and monitoring the online website for this study. To Chris Brownson for disseminating information about my study to the staff at the UT Counseling and Mental Health Center and for following up to ensure I was receiving referrals. To the many historical influences who, perhaps without even realizing it, have led me to pursue a doctorate in psychology: J.A. Skelton, Irma Dosamantes-Beaudry, Pamela Fairweather, Janet Lester, Ilene Serlin, Beverly Manley-Rose, and Anne Krantz. To my friend Scarlet for her editorial eye and consultation. To Karen for her companionship and support throughout this process. Thanks to all of my family for their love and inspiration. To Robi and his brother, Miles, for their constancy. And finally, thanks to Mick, for his love, humor, and unwavering belief in me. v A MULTIDIMENSIONAL ANALYSIS OF SELF-MUTILATION IN COLLEGE STUDENTS Publication No._____________ Emily Hall Ray, Ph.D. The University of Texas at Austin, 2007 Supervisors: Ricardo Ainslie and Alissa Sherry This study explored whether female college students who endorse a history of self-mutilation and those who do not can be reliably differentiated across the following constructs derived from object relations theory: representations of parental care and overprotection, separation-individuation conflicts, emotional body investment, affect regulation, and perceived stress. While these variables have been implicated in the self- mutilation literature, there have been few attempts to empirically assess them. Moreover, there has been very little research investigating self-mutilation in non-clinical, college age youths, despite the reported risk and prevalence of this behavior within the college population. The operational definition of self-mutilation utilized in this study was borrowed from Favazza (1996) and refers to deliberate, non-suicidal infliction of harm to the body. Self-mutilation was assessed using the Deliberate Self-Harm Inventory (DSHI; Gratz, 2001), from which a group of 85 self-mutilators and a group of 176 non-mutilators were identified. A mixed methods approach was utilized and included the collection of vi quantitative data via a secure, online questionnaire, as well as a qualitative interview component with a small number of self-mutilators designed to offer a more complete, phenomenological understanding of this experience. Logistic regression analyses indicated the following variables were significant predictors of self-mutilation: Mother Care, Father Overprotection, Separation Anxiety, Body Care, and Body Protection. Self-mutilators were more likely to experience their fathers as encouraging of autonomy and to experience separation anxiety compared to non-mutilators. Self-mutilators were also less likely to perceive maternal care as warm and affectionate and less likely to care for and protect their bodies compared to non- mutilators. Qualitative interviews uncovered salient themes related to self-mutilation in this sample. The overall results suggest that object relations may be a useful perspective from which to conceptualize self-mutilation and offer important implications for future research and clinical practice. vii TABLE OF CONTENTS LIST OF TABLES xii CHAPTER I: INTRODUCTION 1 CHAPTER II: REVIEW OF THE LITERATURE 7 Self-Mutilation 7 Prevalence 8 History and Inquiry of Self-Mutilation 10 Categories of Pathological Self-Mutilation 14 Major Self-Mutilation 15 Stereotypic Self-Mutilation 15 Compulsive Self-Mutilation 16 Impulsive Self-Mutilation 16 Correlates of Self-Mutilation 18 Eating Disorders 18 Trauma 19 Borderline Personality Disorder 21 Suicide 22 Summary 23 Self-Mutilation in Adolescence and Early Adulthood 23 Summary 28 Psychological and Behavioral Functions of Self-Mutilation 28 Affect Regulation 29 viii Depersonalization 30 Biological Factors 31 Social Factors and Contagion 32 Summary 37 Object Relations Theory 37 Object Relations and Early Development 38 Object Relations and Development in Adolescence and Young Adulthood 44 Object Relations and Adolescent Self-Mutilation 48 Summary 55 CHAPTER III: METHOD 57 Purpose 57 Research Questions 58 Recruitment 59 Participants 62 Group Comparisons 65 Instrumentation 65 Procedure 72 Data Analysis 73 CHAPTER IV: RESULTS 78 Self-Mutilating Group 78 Data Screening 81 Factor Analysis 84 Reliability Analysis 89 ix Analysis of the Data 90 Analysis I 91 Analysis II 94 Combined Model 97 CHAPTER V: THE PHENOMENOLOGY OF SELF-MUTILATION: A CRITICAL REFLECTION OF QUALITATIVE INTERVIEW DATA 101 Recruitment 103 Procedure 105 Participants 107 Qualitative Analysis 109 Triggers to Self-Mutilation 113 Functions of Self-Mutilation 115 Feelings About Self-Mutilation 122 Scars 123 Others’ Reactions to Self-Mutilation 124 Self-Mutilation and the College Experience 129 Co-Occurring Self-Harm Behaviors 131 Professional Response 132 Correcting Myths and Misunderstandings about Self-Mutilation 134 Self-Mutilation and Suicide 136 Looking Toward the Future 137 Summary 139 CHAPTER VI: DISCUSSION 142 x Clinical Implications 151 Limitations 153 Future Research 157 APPENDICES 161 Appendix A: Recruitment Flyer 162 Appendix B: Measures 163 Appendix C: Online Consent Form and Instructions 174 Appendix D: DSHI Item 17 Endorsements 180 Appendix E: Correlation Matrix 181 Appendix F: Factor Analysis: Additional Output 183 Appendix G: Logistic Regression: Additional Output 187 Appendix H: Interview Cover Letter and Consent Form 188 Appendix I: Sample Interview Questions 195 Appendix J: Interview Matrix 196 REFERENCES 197 VITA 208 xi LIST OF TABLES Table 1: Responses to Demographic Questionnaire by Group 63-64 Table 2: Endorsements of Self-Mutilating Group on DSHI Items 79 Table 3: Mean Age of Onset for DSHI Items 80 Table 4: Intercorrelations Among BIS Factors, Four Factor Solution 87 Table 5: Rotated Factor Loadings of BIS Items, Four Factor Solution 88 Table 6: Internal Consistency Estimates for Predictor Variables 89 Table 7: Logistic Regression Analysis I: Group Membership as a Function of Intrapsychic Variables 93 Table 8: Logistic Regression Analysis II: Group Membership as a Function of Behavioral/Symptomatic Variables 96 Table 9: Logistic Regression Analysis: Group Membership as a Function of Combined Variables, Outliers Retained 98 Table 10: Logistic Regression Analysis: Group Membership as a Function of Combined Variables, Outliers Removed 98 xii CHAPTER I INTRODUCTION If you can imagine fighting your way through a howling gale and then stepping into a soundproof room and shutting the door, then I can begin to describe the transition wrought by the stroke of the razor. One moment, chaos; the next, rich exquisite silence (Kettlewell, 1999, p. 101). Self-mutilation refers to the deliberate infliction of harm to the body without conscious suicidal intent (Favazza, 1996). Self-mutilation covers a wide range of behaviors from making cuts on the skin to burning and bone breaking. This behavior has been observed within clinical and non-clinical groups and is associated with a variety of psychological symptoms and disorders. Researchers generally agree the onset of self- mutilation typically occurs sometime during adolescence and that the behavior often persists over a period of several years (Alderman, 1997; Favazza, 1996). After reviewing numerous studies of self-mutilation, Pattison and Kahan (1983) concluded that peak incidence of the behavior occurs between the ages of 16 to 25. As such, late adolescents and young adults appear to be at increased risk for this behavior. Indeed, the prevalence rate of self-mutilation within college samples has been found to range anywhere from 12- 38% (Favazza, 1992; Favazza, DeRosear, & Conterio, 1989; Gratz, Sheree, & Roemer, 2002; Whitlock, Eckenrode, & Silverman, 2006). Despite these high estimates, there are surprisingly few published studies exploring this phenomenon during the college years. The importance of investigating self-mutilation in non-clinical groups, and in particular among college students, is underscored by the fact that the behavior is often kept hidden with many self-mutilators never seeking treatment (Conterio & Lader, 1998). Furthermore, constructs that have 1 been theoretically implicated in adolescent self-mutilative behavior, such as conflicts over separation-individuation, have been shown to remain salient among college age youths and to predict college adjustment (Hoffman, 1984; Holmbeck & Leake, 1999; Rice, Cole, & Lapsley, 1990). A primary purpose of this study was to contribute to a deeper understanding