‘A scar is what happens when the word is made flesh’ – Leonard Cohen, The Favorite Game.
The term deliberate self-harm (also known as self-mutilation) is used more often when individuals take overdoses or use other methods to try to kill themselves. However, most people who self-harm can make a clear distinction between suicidal acts and other motives for self-harming behaviour. Some of the ways individuals may harm themselves include cutting or scratching the skin (particularly the arms), burning themselves, biting or punching themselves or hitting their body against something. Cutting seems to be the most common type of self-injury. “Cutters” usually use razors, utility knives, scissors, needles, broken glass, or whatever they have to hand to make repetitive slices on their arms, legs or other body parts. Some may swallow or insert objects into themselves or pull out their hair or eyelashes. The majority of individuals who self-harm say that the episode was triggered by a particularly stressful or anxious event. In describing her experience of self-harm, Meredith said that, “It serves a lot of functions in my life. I use it as a way to punish myself, I use it as a way to medicate myself, I use it for the tension release when things get too strong or too built up” (Meredith, in Jane Wegscheider Hyman’s Women Living with Self-Injury). Self-harm is more common than most of us would think. However, the true extent of the problem is unknown. Deliberate self-harm (DSH) represents a significant health problem in the UK and is one of the most common reasons for emergency hospital admission. Approximately 20% of patients repeat self-harm in the 12 months after admission (Gunnell et al., 2002).
Almost half the population knows of someone who has self-harmed and every thirty minutes a teenager cuts or burns themselves or takes an overdose as the only way they feel able to communicate their distress. Self-harm is considered by some to be a ‘cry for help’ or for ‘someone to talk to’. Cutting is usually a private process and the scars are typically hidden. However, some individuals will cut an arm and purposely wear a short-sleeve shirt. Tragically, the stigma of self-harm and suicide can prevent people seeking help and can also prevent people offering the support needed to save that individual’s life. Some researchers have argued that the fear of being involuntarily admitted to hospital, as well as having feelings of being ‘a waste of time’ and an ‘inconvenience’ to hospital staff, are just some of the reasons these individuals do not seek help. Madge et al. (2008) carried out a questionnaire study of over 30,000 15 and 16 year olds in Europe and Australia. Overall, they found that self-harm was more than twice as common among females as males. Also, at least one in ten females had harmed herself in the previous year. Crucially though, was the finding that the majority failed to seek help. The challenges of working in the area of self-harm are also emphasised by Turp (2003) when he points out that self-harm is expressed in various ways from the “highly dramatic to the virtually invisible”. These ‘hidden’ manifestations of self-harm make this a phenomenon that cannot be easily identified and circumscribed (Turp, 2002).
The importance of self-harm research is further emphasised by both retrospective and prospective studies which have indicated that individuals who self-harm are more likely to attempt or complete suicide. Evidence of self-harm remains the strongest predictor in identifying individuals who will later complete suicide. Suicide risk among self-harm patients is hundreds of times higher than in the general population (Owens, Horrocks & House, 2002). In addition, Cooper et al. (2005) conducted a study in order to estimate suicide rates up to 4 years after a deliberate self-harm episode. They found an approximately 30-fold increase in risk of suicide, compared with the general population with higher suicide rates within the first 6 months after the index self-harm episode.
Self-harm as a ‘Cry for Pain’: a shift away from the traditional ‘Cry for Help’ model
The extent to which events and/or experiences are appraised as primarily stressful has been highlighted by the Cry of Pain (CoP) model as being an important factor in suicide and self-harming behaviours. The ‘cry of pain’ hypothesis (Williams, 1997) was proposed as a psychological model of suicidal behaviour extending existing theories of escape (Baumeister, 1990) and arrested flight (Gilbert & Allan, 1998). The CoP model views suicidal behaviour as a behavioural response to a stressful situation with three components which interact to increase suicidal risk, namely: (1) the presence of defeat, (2) no escape or entrapment, and (3) no rescue. The idea then is that suicidal behaviour should be seen as a cry of pain as opposed to the traditional idea of it being simply a cry for help. Relatively few studies have specifically tested the CoP model. In sum, the cry of pain model recognises that not all depressive patients are suicidal and implicates the role of entrapment and hopelessness in exacerbating feelings of defeat and depression in the development of suicidality.
Strengths of the CoP Model
There are various findings which supports the CoP model. Firstly, there is strong empirical support for the defeat and entrapment components of the model. O’Connor (2003) found that suicidal patients reported significantly higher levels of defeat and entrapment (measured as escapability), and lower levels of social support when compared to hospital controls. Secondly, support for the model also comes from the idea that there is an evolutionary basis to defeat and entrapment. The model is derived from social rank theory, which describes depression as the result of involuntary subordination in animals that have lost rank either through defeat or harassment and are unable to escape. The model utilises the analogy of arrested flight where an animal, for example, a bird is defeated but flight is blocked and it is unable to escape. Despite no physical injury, the bird may display depressive-like behaviours such as demobilisation and drooping head and wings. Suicidal ideation is when the individual experiences thoughts about committing suicide, which may even involve a formulated plan, without carrying out the suicidal act itself. It has been argued that suicidal ideation arises from the feeling of entrapment but it is when the individual cannot find a solution to their problem that suicide ideation changes into suicidal behaviour. If the distressed animal (in the above example a bird) is removed from the situation, it will eventually recover. Williams (1997) argue that this indicates the existence of a third factor, which is the presence or absence of rescue factors.
Thirdly, various cognitive factors affecting perceptions of defeat and entrapment have been found. The role for problem-solving ability has been implicated and many studies have related poor problem solving to suicidality. Research has also indicated the tendency for high levels of perfectionism, over-general memory and poor future positive thinking in individuals who self-harm (O’Connor, 2003; Rasmussen, O’Connor & Brodie, 2008). Johnson, Gooding and Tarrier (2008) show that appraising an event as defeating increased subsequent defeated mood and led to impaired episodic memory, independently of low mood in general. This suggests a causal role of a specific negative mood state on impaired memory. Further, Rasmussen et al. (2010) found that total entrapment and internal entrapment mediated the relationship between defeat and suicidal ideation, whilst impaired ability to think positively about the future (but not social support) moderated the relationship between total and internal entrapment and suicidal ideation.
Lastly, the model can explain individual’s varying responses to social stressors. Variations in response to stress have been found in animals. For example, Von Holst (1986) observed that whilst some tree-shrews adopted a submissive pattern of behaviour following defeat and continued normal activities in a timid and cautious way, others became demobilised and died within 14 days. In a study of high-stress mothers, Willner and Goldstein (2001) demonstrated that perceptions of defeat and entrapment mediated the relationship between stress and depression. By demonstrating that there is individual variation in perceiving events as defeating and entrapping is arguably one of the greatest strengths of the model.
Limitations of the CoP Model
However, the CoP model is not without limitations since a testable model should have clearly defined concepts that are both mutually exclusive and parsimonious, areas in which the CoP model may fall. First is the complexity surrounding the component of defeat in the CoP model. Rooke and Birchwood (1998) describe defeat as ‘the absence of a way forward or failure to reaffirm an identity’ (p. 259). In other words, defeat is the perception or experience of being unable to see a route forward or solution. This overlaps with the concepts of entrapment and hopelessness which relate to the perception that escape is impossible and will continue to be so in the future. Therefore, it is uncertain whether defeat is simply a feeling of failure, or whether it also encompasses some feelings or expectation of future entrapment. Difficulty also arises when determining situations that cause defeat. Gilbert et al. (2002) suggests that feelings of defeat will result from a fall in perceived social hierarchy and a reduced access to resources. However, Rohde (2001) has found situations other than the ones proposed by Gilbert et al. (2002), where individuals have felt defeated.
Secondly, there is great ambiguity surrounding the third component of the model. Whilst it is sometimes referred to as ‘hopelessness’, other studies refer to it as ‘no rescue’. There are also some cases where hopelessness and ‘no rescue’ are presented simultaneously as if they are analogous. Hopelessness can be defined as pessimism for the future and ‘no rescue’ as the belief that one will not receive any external help. Studies which have used ‘no rescue’ as the third component of the model have measured it as a level of social support (or loneliness) and have found it to be an important factor in explaining suicide and self-harming behaviours. On the other hand, studies employing ‘hopelessness’ have measured it using the Beck Hopelessness Scale, which measure cognitive, affective and motivational factors. Additionally, there is a temporal discrepancy between the hopelessness and ‘no rescue’ in that while hopelessness is specifically concerned with expectations for the future, the expectation of rescue can be related to both a present or future situation.
Thirdly, despite advocating hopelessness and entrapment as independent concepts, previous research falls short of defining hopelessness in a way that separates it cognitively from entrapment to which it shares a close relation. Although entrapment is related to arrested flight in the animal literature or frustrated escape in humans, it is likely that hopelessness will develop (or is an aspect of entrapment) from the perception of blocked escape. It is argued that the greater the perceived entrapment the greater the level of hopelessness experienced by an individual.
There has been a shift away from the typical misleading perception that individuals self-harm only as a means of getting attention. There is growing empirical support for the CoP model as an explanation of self-harming behaviours (and suicide) and despite some limitations, it remains the strongest model used to understand suicide and self-harm behaviours. By increasing our understanding using such a model, it is then possible to develop appropriate interventions to reduce a broad spectrum of self-harming behaviours.Discuss