DEVELOPING A NEW MODEL OF UNDERSTANDING SELF-INJURY IN SECURE SETTINGS: THE ROLE OF RISK, PROTECTIVE AND ATTITUDE FACTORS by Charlotte Caton A Thesis submitted in partial fulfilment for the degree of Doctor of Philosophy at the University of Central Lancashire May 2018 STUDENT DECLARATION FORM Concurrent registration for two or more academic awards I declare that while registered for the research degree, I was with the University’s specific permission, a *registered candidate/*enrolled student for the following award: Two day University Certificate on Aggression – This was agreed to assist with my clinical skills and knowledge base. Material submitted for another award I declare that no material contained in the thesis has been used in any other submission for an academic award and is solely my own work Collaboration Where a candidate’s research programme is part of a collaborative project, the thesis must indicate in addition clearly the candidate’s individual contribution and the extent of the collaboration. Please state below: Not part of a collaborative process Signature of Candidate ______________________________________________________ Type of Award ______________________________________________________ School _______________________________________________________ ii ABSTRACT This PhD aimed to develop further the Integrated Model of Self Injurious Activity (Ireland & York, 2012) within a secure forensic population. This model was based upon the Interpersonal Psychological Theory of Suicidal Behaviour (Joiner, 2005). The PhD aimed to explore risk, protective and function factors for self-injurious behaviour focusing upon components such as attitudes, cognitions, temperament, state and social environmental factors. Study 1 comprised a Delphi study with 33 experts. Experts generated questions to ask individuals about their attitude towards engaging in self- injurious behaviour. These questions were based upon exploration of the components of the Theory of Planned Behaviour (Ajzen, 1991). Study 2 was conducted with 47 participants using a functional assessment approach of file information, patient interviews and staff interviews. Thematic analysis was used to examine background factors, triggers, consequences and functions for self-injurious behaviour. It was also used to examine times when risk of self-injury was raised but not carried out in order to gain protective information. Some differences between staff and patients were observed as predicted. There was overlap with the Integrated Model of Self Injurious Activity and Self Determination Theory as predicted. Study 3 was conducted with 111 participants, again using a functional assessment approach of file information, patient interviews and staff interviews. These results also indicated overlap with the Integrated Model of Self Injurious Activity. The results of studies 2 and 3 indicated that the majority of protective factors identified were cognitive in nature which is a novel finding. Study 4 involved 80 participants. They were asked to complete psychometrics relating to coping, social support, resilience, impulsivity and suicidal ideation. They were also asked about their attitudes towards self-injury. The results indicated that previous tendency to engage in self-injurious behaviour was predicted by positive attitudes towards self-injury among other predictors. A revised model incorporating findings was developed. The current research indicates that the Revised Integrated Model of Self Injurious Activity holds potential in the explanation and understanding of potential risk and protective factors for self-injury. This is of benefit both theoretically and clinically. iii TABLE OF CONTENTS Page CHAPTER 1: Introduction 1 Rationale for study 1 Previous research 2 CHAPTER 2: Self-Injury definition: who self-injures and to what extent? 5 Structure of the chapter 5 Extent of suicide and self-injury 5 Definitional challenges regarding self-injury 6 Classification of self-injury 13 Defining the term within the current research 15 Who self-injures and to what extent? 16 Self-injury within the general population 16 Self-injury in clinical populations 18 Complex/comorbid diagnoses and self-injury 23 Self-injury within forensic populations 24 Concluding comments 27 CHAPTER 3: Theories of self-injury 29 Structure of the chapter 29 Integrated theories of self-injury 29 The Cry of Pain Model (Williams, 1997) 30 Four Function Model (Nock & Prinstein, 2004, 2005) 31 The Integrated Theoretical Model of Self-Injury (Nock, 2009) 33 The Integrated Motivational-Volitional Model of Suicidal Behavior 35 (O Connor, 2011) The Interpersonal Psychological Theory of Suicidal Behaviour (Joiner, 2005) 38 The Integrated Model of Self Injurious Activity (Ireland & York, 2012) 42 The social environmental context for self-injury 43 The forensic environment 44 The importance of attitudes and attitude theory 45 Concluding comments 52 CHAPTER 4: Risk and protective factors for self-injury 53 Structure of the chapter 53 Risk factors for self-injury 53 Previous self-injurious behaviours and ideation 53 Childhood abuse 54 Substance abuse 55 Serious illness or accidents 56 Social factors 57 Negative cognitions 57 Impulsivity 58 Difficulties with emotion 59 Summary of the risk factor literature 60 iv Protective factors for self-injury 61 Self Determination Theory (Deci & Ryan, 1985) 65 Concluding comments 68 CHAPTER 5: Addressing the research problem 70 Structure of the chapter 70 Rationale for the current research 70 Research questions and hypotheses 73 How the PhD will address these research questions and hypotheses 76 CHAPTER 6: Study one: Using the Delphi method to explore risk and protective factors for self-injury and exploring the attitudes of those who engage in this behaviour 77 Introduction to study one 77 The research question 79 Rationale for using a Delphi study 79 Round one of the Delphi study 80 Round one: participants 80 Round one: materials 80 Round one: procedure 83 Round one results 83 Round two of the Delphi study 86 Round two: participants, materials and procedure 86 Round two: results 87 Round three of the Delphi study 91 Round three: participants, materials and procedure 91 Round three: results 91 Finalising Theory of Planned Behaviour questions 93 Discussion 96 Strengths and limitations of this study 100 Issues for further research 102 CHAPTER 7: Study two: Function, risk and protective factors for self-injury in a secure forensic psychiatric population 103 Introduction to study two 103 The research questions and hypotheses 105 Study overview 106 SORC assessment 106 Participants 107 Materials 108 Procedure 108 Results 111 SORC information 111 Differences between patients and staff 125 Discussion 129 Strengths and limitations of the study 135 Issues for further research 137 v CHAPTER 8: Study three: Function, risk and protective factors for self-injury within a high secure forensic psychiatric population 140 Introduction to study three 140 The research questions and hypotheses 141 Study overview 142 Participants 142 Materials 143 Procedure 143 Results 146 SORC results 146 Differences between patients and staff 167 Discussion 173 Strengths and limitations of the study 181 Issues for further research 182 CHAPTER 9: Study four: Psychometric testing of components within the Integrated Model of Self-Injurious activity 184 Introduction to study four 184 The research question 187 Participants 187 Measures 187 Procedure 189 Results 190 Data screening 190 Data analysis 191 Comparing the no self-injury group to the self-injury group 194 Discussion 196 Strengths and limitations of the study 202 Issues for further research 204 CHAPTER 10: General discussion 207 Research questions and hypotheses 207 Novel findings overall 208 Risk factors for self-injury 211 Temperament factors 212 State factors 213 Negative cognition 214 Negative environmental factors 215 Increased propensity 217 Increased capacity 219 Functions of self-injury 221 Protective factors for self-injury 221 Limitations of the research 226 Implications for treatment and risk management planning 228 Directions for future work 230 Overall conclusion 235 REFERENCES 231 vi APPENDICES 283 Appendix 1: Information sheet for Delphi study 283 Appendix 2: Questionnaire for round one of Delphi study 285 Appendix 3: Debrief sheet for Delphi study 291 Appendix 4: Questionnaire for round two of Delphi study 293 Appendix 5: Group summary of data following round one of Delphi 302 Appendix 6: Round three information for Delphi study 309 Appendix 7: Blank SORC 318 Appendix 8: Example SORC 319 Appendix 8a: SORC prompt questions 320 Appendix 9: Study 2, Responsible Clinician Information Sheet 323 Appendix 10: Study 2, Part 1 Responsible Clinician Consent Form 327 Appendix 11: Study 2, part 1, Information Sheet 328 Appendix 12: Study 2, part 1, Patient Consent Sheet 331 Appendix 13: Study 2, part 2 Patient Information Sheet 333 Appendix 14: Study 2, part 2, Patient Consent Sheet 337 Appendix 15: Study 2, part 2, Staff Information Sheet 339 Appendix 16: Study 2, part 2, Staff Consent Sheet 342 Appendix 17: Study 3, Responsible Clinician Consent Form 344 Appendix 18: Study 3, part 1, Patient Information Sheet 345 Appendix 19: Study 3, Patient Consent Sheet 348 Appendix 20: Study 3, part 2, Patient Information Sheet 350 Appendix 21: Study 3, part 2, Staff Information Sheet 353 Appendix 22: Study 3, part 2, Staff Consent Sheet 356 Appendix 23: Study 4, Theory of planned behaviour questions 358 Appendix 24: Study 4, Brief COPE 360 Appendix 25: Study 4,