Theories of SIV originated in the psychological literature in 1913 when Emerson provided the first contribution to the clinical literature on repetitive SIV with a case study of Miss A (as cited in Walsh & Rosen, 1988). His account revealed an approach to understanding SIV that was grounded in Miss A’s subjective experience: She articulated that her practice of SIV was related to her need to relieve both her headaches and the nightmares of sexual abuse she experienced.
Emerson presented an empathic explanation for Miss A’s cutting by suggesting it represented the tension between her difficulty in bearing the psychological pain and anger as a result of the abuse she incurred and her unconscious desire to live a rewarding life (as cited in Walsh & Rosen). The first major advance in the modern understanding of SIV was made by Karl Menninger in his highly influential and widely cited book, Man Against Himself (1938).
Menninger argued against the then-prevalent notion that attempts to harm the self were incomplete attempts at suicide. He suggested that individuals who engage in SIV were searching for a means of self-preservation and self-healing, and he believed that SIV was a compromise between aggressive impulses and the survival instinct that represents a sacrifice of one part of the body in preservation of the whole. He noted that “mutilation is an attempt at self healing … local self destruction being a form of partial suicide so as to avert total suicide” (p.
271). While Freud conceptualized suicide as an expression of the unconscious mind, he did not comment specifically on SIV (though it is believed that he referred to the idea of SIV). In his early work, he characterized the unconscious mind as composed of two psychic drives: eros and thanatos (Jacobs, 2007). Eros represents the drive for love and life and is directed toward other persons, as well as toward the self.
The psyche develops and internalizes symbolic representations for the deep attachment that is felt for the other person (object). The destructive drive of thanatos creates a tug-of-war with eros. Hopefully, thanatos coexists in equilibrium with eros in the unconscious mind (Jacobs). Freud’s theory of the ambivalent need for homeostasis between the opposing forces of eros and thanatos may be parlayed to SIV behavior. It was not until the 1960s that mental health professionals began studying SIV in earnest.
In the early ’70s, more articles began appearing in peer-reviewed psychology journals as professionals devoted a steadily increasing amount of research time to this phenomenon, and so by the mid-’70s researchers had proposed a profile of the typical individual who self-inflicts violence as a young female (adolescent to just-post-adolescent) who was usually attractive (Ross & McKay, 1979). Having insisted that SIV “is not a phenomenon which is to be found only in girls, or only in institutions, or only among disturbed delinquents” (p.
9), researchers Ross and McKay sought to dispel the myth of the typical SIV-utilizing individual within the scientific discourse, yet their quantitative study contributes to continued stereotyping of the SIV-utilizing individual by focusing on 71 adolescent females in a Canadian training school. In the 1970s, the feminist movement challenged contemporary social constructs by revealing that the most common trauma experiences are not those of men in war but is those of women (and girls) in civilian life.
In turn, consciousness-raising for the public increased. A 1986 epidemiological study by Diana Russell (as cited in Briere, 1992) was at the forefront of the challenge. Of 930 women in the general population who were interviewed regarding their experiences of domestic violence and sexual exploitation, 1 in 4 had been raped, and 1 in 3 had been sexually abused as a child. Furthermore, 78% of the women reported resulting negative and long-lasting psychological problems. Russell helped redefine sexual abuse and rape as acts of violence rather than acts of sex.
Such violence against women was conceptualized as a method of political control through the enforcement of the subordination of women through terror. Feminist theorists have opposed traditional definitions and pathologizing of the female body and female behavior in relation to the body; instead, they have sought to expose the mechanisms of social control and medicalization that attempt to constrict and define representations of the female body by redefining the female body as a site of political struggle.
Despite feminist efforts to change the nature of research, including conceptual and definitional issues of SIV, the model developed by psychiatric studies decades ago, and one created from a particular social bias that pathologizes and objectifies the female body, continues to predominate in both scientific and popular discourse today.
Continuing work in the feminist realm, specifically on the connection between physical and sexual violence against women and men and the long-term effects of emotional trauma presenting as SIV, has been slowly emerging. An example of this ongoing contemporary work is a case-study article in which Brown & Bryan (in press) articulate a client’s personal experiences and struggle with SIV resulting from childhood maltreatment.
Employing feminist praxis, they describe the client’s therapy progression and favorable outcome. Favazza (1987) and Walsh and Rosen (1988) greatly expanded our understanding of SIV when they suggested the behavior be understood as a survival strategy that has both psychological and biological underpinnings. In the early ’90s, Favazza and Rosenthal (1993) further contributed to the SIV literature when they proposed a conceptual organization for a behavior that encompasses a broad range of situations.
They suggested that SIV behavior be divided into three typological classifications: (a) ‘Major or Psychotic Self-Mutilation,’ which is the most extreme form of SIV and includes eye enucleation and self-castration to atone for sins; (b) ‘Stereotypic Self-Mutilation,’ which is seen in autistic and developmentally disabled populations and is typically a habitual and rhythmic action that lacks symbolic value; and (c) ‘Superficial or Moderate Self-Mutilation,’ in which the ultimate intent for the individual is to feel better, and the behavior typically holds symbolic value.
Trauma-related ‘Superficial/Moderate Self-Mutilation’ is the type of SIV that is the focus of this dissertation. Favazza later diffused some of the myths and mysteries surrounding SIV with the publication of his seminal work Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry (1996).
Researchers and authors (Briere & Gil, 1998; Brown & Bryan, in press; Courtois & Lader, 1998, Gratz, 2006, 2007; Hawton & Harriss, 2005; Straker, 2006) continue to contribute to this large body of literature with concern and compassion in a pursuit to further understand and find effective resolutions for this challenging yet important issue. Epidemiology Research from Brickman and Mintz (2003) revealed that the prevalence of SIV behavior across the developmental spectrum is astounding; in addition, the numbers of individuals engaging in SIV are growing.
While more women than men report the use of SIV as a coping strategy (Hyman, 1999), the margin of difference is narrowing (Briere & Gil, 1998; Gratz & Chapman, 2007). Of note: Historically more studies have been conducted on women than on men, which may explain why women appear to engage in SIV more than men do. In epidemiological studies, the prevalence of individuals who SIV varies depending upon the population group being studied.
Briere and Gil (1998) estimated that 1 to 4% of the general adult population and 21% of adult psychiatric inpatients practice SIV. Darche (1990) found approximately 40% of adolescents in psychiatric inpatient settings use SIV, and among incarcerated adult populations as many as 30% engage in this behavior (Jelic, Vanderhoff, & Donovick, 2005). A year-to-year increase in the number of older people presenting to emergency departments with SIV has been found, especially in men (Hawton & Harriss, 2006; Lamprecht, Pakrasi, Gash, & Swan, 2005).
Although exact prevalence and incidence is difficult to ascertain due to definitional variance among authors and the conflation of SIV and suicide ideation, the use of this behavior, predominately as a coping strategy, is clearly on the rise (Hawton & Harriss; Lamprecht et al. ). SIV most commonly begins in adolescence and peaks between the ages of 16 to 25 years of age (Favazza & Conterio, 1988), but there are cases in which the behavior begins in adulthood, for example, following rape (Greenspan & Samuel, 1989) and following combat exposure (Brown, 1986).
Although there are many forms of SIV, cutting has been found to be the most common (Babiker & Arnold, 1997; Favazza & Conterio), and damage is typically minimal but in some instances may require medical attention. Many researchers (e. g. Briere & Gil, 1998; Favazza, 1998; Suyemoto, 1998) agree that the statistics on the incidence and prevalence of SIV may be unreliable for several reasons. First, multiple definitions of the same phenomenon create inconsistencies and replication difficulties in epidemiological research studies.
Determination of accurate prevalence is difficult; thus, rates should be interpreted within the scope of the definition as stated in chapter 1. Next, some authors discussing SIV conflate SIV behavior and suicide intent as the same phenomenon (Linehan, 1987, 1993; Romans, Martin, Anderson, Herbison, & Mullen, 1995) making research comparisons and replication meaningless with regard to SIV alone.
In addition, SIV may be underreported because it remains socially unacceptable and is typically practiced in secrecy (Briere & Gil; Favazza, 1996; Linehan, 1993), and the guilt and shame as consequences of SIV may increase the likelihood of isolation (Favazza; Herman, 1992). Therefore, many SIV incidents that may require medical attention will instead be treated by the individual in private and will not reach the awareness of helping professionals and researchers (Mazelis, 2003).
Finally, in spite of the rise in numbers of those who SIV, the behavior continues to be highly stigmatized by laypersons and professionals (Foucault,). Service providers’ unfortunate misunderstandings about the motivations for and functions and meanings of SIV behavior help maintain the negative connotation of SIV and the belief that those who practice SIV use it as pathological manipulation of others.
Often individuals who SIV are pathologized and unfairly labeled as borderline or personality disordered by the very professionals who mean to help them (Linehan, 1987, 1993; Soloff, Lynch, & Kelly, 2002). Many professionals lack a clear understanding of how to intervene effectively with this growing concern (Crowe & Bunclark, 2000; Favazza & Rosenthal, 1993; Jeffery & Warm, 2002); consequently, these stereotyping labels exacerbate the perceived need for the individual who engages in this behavior to maintain a shroud of secrecy.
Despite the likely inaccurate estimations of prevalence rates of individuals who practice SIV, clinicians and researchers agree that the behavior is increasing rapidly and it is likely stretching care-giving resources to the limit (Conterio & Lader, 1998; Strong, 1998; Suyemoto, 1998; Suyemoto & MacDonald, 1995). While extensive literature exists on the physical and psychological aspects of SIV, this author discovered no research or information on the actual resource costs of the physical and psychological care associated with SIV behavior.
However, Walsh and Rosen (1988) suggested that SIV behaviors are likely to increase in repetitiveness and level of risk or lethality over time, leading to more severe behaviors and an increase in the cost of attending to the medical concerns of these behaviors. In addition, the increasing prevalence of individuals in Western cultures—and likely worldwide—who engage in SIV, coupled with the emergence of managed care systems in which clinicians are expected to provide more service with increasingly limited resources are all indicators of why research about SIV is urgently needed (Favazza & Conterio, 1988).