Influences on Repetitive Self-Mutilation
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Running head: REPETITIVE SELF-MUTILATION
Media and Other Social Influences on Adolescent
Repetitive Self-Mutilation
Laura E. Peek, Karen O’Brien Lightner, and Amy R. Murrell
University of North Texas,
Laura S. Howe-Martin
University of Texas Southwestern Medical School
Online Publication Date: July 10, 2010
Journal of Media Psychology, Volume 15, No. 3, Summer, 2010
Abstract
The rise of adolescent self-harm behaviors, specifically repetitive self-mutilation, has
become a major point of interest to both researchers and treatment providers in recent years.
Repetitive self-mutilation is discussed in terms of its function, with an emphasis on social
function. A review of literature discussing various influences on this behavior is explored, with
consideration of both the Experiential Avoidance Model (Chapman, Gratz, & Brown, 2006) and
the Four Factor Model (Nock & Prinstein, 2004) of self-harm behavior. Additionally, the role of
the media, a social force which has increased the availability of knowledge on self-harm
behaviors, is examined, and potential impacts of publicity on this subject are discussed. A brief
review of findings from a recent study on adolescent self-mutilation is introduced as a source of
empirical support for the impact of social models on self-mutilation in this age group. Future
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research ideas are proposed, as little empirical research that examines the effects of the media on
repeated self-mutilation has been conducted
Influences on Repetitive Self-Mutilation
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The prevalence of self-harm behaviors among adolescents is on the rise (Gratz, Conrad,
& Roemer, 2002; Lloyd, 1997), increasing almost 10% in recent years (Olfson, Gameroff,
Marcus, Greenberg, & Shaffer, 2005). It is now estimated that as many as 2.1 million adolescents
engage in self-harm behavior each year (Miller & Smith, 2008). Even more alarming, this
behavior is not limited to inpatient and outpatient mental health settings (Howe-Martin, 2007).
Self-harm behavior spans a number of contexts and can be found among individuals admitted to
general hospitals (Hawton et al., 2003; Olfson et al., 2005) as well as among those in the broader
community (Briere & Gil, 1998; Favazza, DeRosear, & Conterio, 1989; Gratz, 2001; Gratz et al.,
2002; Hawton, Rodham, Evans, & Weatherall, 2002; Ross & Heath, 2002). In addition, selfharm has been portrayed in various forms of media (Baker & Fortune, 2008; Howe-Martin &
Murrell, 2007; Whitlock, Powers, & Eckenrode, 2006).
Before proceeding any further, it is important to define the particular self-harm behavior
of interest to this article. The term “self-harm” has been broadly used to define self-destructive
acts ranging from risk-taking behaviors to suicide (Skegg, 2005). However, the behavior of
interest in this article is more specific and better captured by the term “repetitive self-mutilation”
(RSM). Although some have argued the term “self-mutilation” is more stigmatizing (Gratz,
2001), this term captures several key aspects of the specific behavior in question (Pattison &
Kahan, 1983; Suyemoto, 1998). First and foremost, RSM is repetitive and involves conscious
intent to directly cause mild to moderate physical injury. RSM as defined in this study is not
associated with developmental impairments (e.g., Lesch-Nyan syndrome) or the type of major
tissue damage associated with intense psychotic episodes. In addition, although RSM has also
been used synonymously with “parasuicide” (Linehan, 1993), the latter term can be misleading,
as RSM behavior by definition lacks suicidal intent. However, a history of engaging in this
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behavior is correlated with suicidal ideation and heightened suicide risk (Andover, Pepper,
Ryabchenko, Orrico, & Gibb, 2005; Cyr, McDuff, Wright, Theriault, & Cinq-Mars, 2005;
Darche, 1990; Langbehn & Pfohl, 1993; Lloyd, 1997; Nixon, Cloutier, & Aggarwal, 2002) and
should be taken seriously by treatment providers and other healthcare professionals, as well as by
parents, teachers, and peers of adolescents who engage in this behavior.
In order to establish effective behavioral intervention strategies, the functions of RSM
must first be understood. One approach to this issue is the Experiential Avoidance Model (EAM;
Chapman, Gratz, & Brown, 2006), which proposes that RSM belongs to a set of experientially
avoidant behaviors that serve the similar function of allowing escape or avoidance from
unwanted inner experiences, such as thoughts, feelings, or bodily sensations. Indirect support for
this theoretical model derives from studies that indicate RSM and experiential avoidance (EA)
share a number of correlates, including alexithymia (Zlotnick et al., 1997), psychological
impairment (Darche, 1990), borderline personality disorder (Chapman, Specht, & Cellucci,
2005; Kwawer, 1980; Leibenluft, Gardner, & Cowdry, 1987; Sansone, Gaither, Songer, & Allen,
2005; Shearer, 1994), depression (Ghaziuddin, Tsai, Naylor, & Ghaziuddin, 1992; Nixon et al.,
2002), suicidal ideation (Andover et al., 2005; Cyr et al., 2005; Darche, 1990; Nixon et al.,
2002), anxiety (Andover et al., 2005; Favazza, 1996; Langbehn & Pfohl, 1993; Ross & McKay,
1979; Strong, 1998; Turp, 2003), obsessive compulsive-disorder (Langbehn & Pfohl, 1993),
posttraumatic stress disorder (Zlotnick et al., 1997; Shearer, 1994; Cyr et al., 2005), dissociation
(Skegg, 2005; Turell & Armsworth, 2000; Zlotnick et al., 1996), eating disorders (Claes,
Vandereycken, & Vertommen, 2005; Davis & Karvinen, 2002; Dulit, Fyer, Leon, Brodsky, &
Frances, 1994; Favaro & Santonastaso, 1999, 2000; Favazza & Conterio, 1988), and substance
abuse (Langbehn & Pfohl, 1993; Nixon et al., 2002; Parker et al., 2005; Romans, Martin,
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Anderson, Herbison, & Mullen, 1995; Shearer, 1994). Additionally, more direct empirical
research lends support to the specific underlying tenets of the EAM (Chapman et al., 2006;
Howe-Martin, Adcock, Murrell, & Guarnaccia, 2008; Rosenthal, Cheavens, Lejuez, & Lynch,
2005) and clearly indicates that experiential avoidance is involved at some level. Still, the rising
pervasiveness of RSM across settings, as well as findings supporting the role of peer and media
influences in RSM, suggest that this behavior serves functions in addition to experiential
avoidance.
The Importance of Social Environment
Peers, Contagion, and RSM
Social acceptability, competition, and peer influence appear to be important components
in the instigation and repetition of adolescent self-mutilation. In general, adolescent behavior is
greatly influenced by the perceived degree of similarity between personal and peers’ symptoms,
behaviors, or attitudes (Heilbron & Prinstein, 2008). Kandel (1978a) explained this influence as
selection and socialization effects. Adolescents want to be around similar others, and how these
“similar others” act influences those around them. This influence can occur within dyadic
relationships (Simon, Aikins, & Prinstein, 2008; Urberg, Luo, Pilgrim, & Degirmencioglu, 2003)
and even extend to the relationship between grade mates (La Greca, Prinstein, & Fetter, 2001).
Therefore, acquaintances of adolescents who self-mutilate may be influenced to do the same in
order to gain social acceptance within their peer group. This influence may be exacerbated by
EA, as the need to avoid feelings of not fitting during adolescence is common. It appears,
though, that there is something unique to be gained, as opposed to simply gotten rid of, by RSM
in peer interactions.
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Numerous studies have documented self-harm contagion in inpatient settings, in which
one incident of self-harm was associated with another, even without any prior history of selfmutilating behaviors (see Heilbron and Prinstein, 2008, for review). Early descriptions of
institutionalized self-cutters indicate that such individuals may cluster as a social group and form
a strong, long-lasting group identification as “cutters.” As early as the 1960s, Grunebaum and
Klerman (1967) referred to “co-conspiratorial dyads” between two individuals who treated wrist
cutting as a form of bonding, as well as a form of competition. There may be competition to be
the “chief cutter” and to prove oneself as the most unhappy person in an inpatient treatment ward
(Graff & Mallin, 1967; Grunebaum & Klerman, 1967; Rosen & Walsh, 1989).
These findings are consistent with more recent observations that self-mutilative acts are
often “clustered” in time, indicating that RSM behavior in others may trigger repetition of selfharm among individuals who already do it, or even trigger an initiation of self-mutilation among
previously naïve individuals (Taiminen, Kallio-Soukainen, Nokso-Koivisto, Kaljonen, &
Kelenius, 1998; Walsh & Rosen, 1985). Individuals who do not engage in such behavior before
inpatient admission may first learn this behavior from fellow patients. Among a small sample of
inpatient adolescents, approximately half of the patients began to self-cut for the first time while
in the hospital (Ghaziuddin et al., 1992). Gardner and Gardner (1975) reported a similar finding,
in that 14 of 22 non-psychotic female self-cutters in their study engaged in their first episode of
self cutting after inpatient admission.
This behavior is evident beyond institutionalized and inpatient youth. Anecdotal accounts
by school counselors, teachers, and youth ministers who work regularly with adolescents indicate
that RSM is becoming more common among middle and high school students. These students
often do not demonstrate any other form of pathology, and the behavior is often instigated by a
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“ringleader” and/or a small, close-knit group of peers. When the leader or one member of the
group stops engaging in RSM, moves away, or graduates, this behavior in the others appears to
dissipate (Brand, personal communication, August 2006; Hamilton, personal communication,
June 2006; Martin, personal communication, January 2006).
Empirical evidence supports these anecdotal accounts. Hawton and colleagues (2002)
reported that awareness of self-harming peers was a strong risk factor for RSM in their schoolaged sample. Nock and Prinstein (2005) also found that a large proportion of adolescents in their
sample had friends who engaged in self-mutilation. In addition, the number of RSM incidents
among friends was associated with self-reported positive reinforcement aspects of RSM behavior
(e.g., engaging in RSM to feel like part of a group; see also Nock & Prinstein, 2004). Ross and
McKay (1979) observed that 86% of the girls in an adolescent correctional facility carved words,
letters, or insignia on their skin to indicate group membership and control. Ross and McKay
(1979) also commented on the “carving parties” held at the Grandview School for delinquent
adolescent girls, and Favazza (1996) reported recent interactions with a teenager who belonged
to a “cut of the month” club (p. 240). Therefore, given that self-mutilation is influenced by social
factors, group process variables should be emphasized in any understanding of RSM (Walsh &
Rosen, 1988).
The Four Factor Model
Acceptance and belonging are not the only social functions of RSM. The four factor
model (FFM; Nock & Prinstein, 2004, 2005; Nock, 2008) of non-suicidal self-injury helps
explain repeated self-mutilation in terms of automatic versus social, as well as positive versus
negative reinforcement, and presents RSM as a means of social communication. Nock (2008)
elaborated on the social functions piece of the four factor model by first proposing that RSM can
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be understood as either an effort to communicate distress or as an effort to communicate strength
and fitness. In both cases, these efforts to communicate can be either positively or negatively
reinforced by the social environment. For example, if an individual receives positive
reinforcement for crying (e.g., attention and soothing), then more intense distress signals, such as
RSM, might result in even more positive reinforcement. Self-mutilation can therefore be used to
influence other’s behavior (Nock & Prinstein, 2004). Alternately, negative reinforcement (e.g.,
escape from demands) can also serve to maintain RSM. RSM may also be used as an effort to
communicate strength or fitness. Signals of strength and fitness, like athletic performance, can
lead to behaviors, such as punching walls, in which people place themselves in harm’s way.
Likewise, tattooing can lead to self-mutilation in order to produce “battle scars” (Nock, 2008).
Though Nock (2008) asserts that language is generally a better form of communication
than overt behavior, the opposite may be true for some adolescents. That is, adolescents may
revert to self-mutilation in order to communicate via overt behavior, because they have difficulty
communicating with words or their language fails altogether (Nock, 2008). In addition,
adolescents who self-mutilate are more likely to have issues with problem-solving abilities.
Instead, they choose to use more harmful or maladaptive social responses in comparison to those
who do not self-mutilate (Nock & Mendes, 2008).
Even though research has demonstrated that social functions might explain only a
minority of self-mutilation cases (Brown, Comtois, & Linehan, 2002; Nock & Prinstein, 2004,
2005; Rodham, Hawton, & Evans, 2004), Nock (2008) points out that this paucity of evidence is
likely influenced by adolescent social desirability. Certainly, reporting that one engages in RSM
out of a desire to influence others sounds less socially acceptable than self-mutilation for affect
regulation. Nock also proposed that those who self-mutilate may not want to accept the fact that
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a social function is the motivation behind their behavior. This would be a sign of weakness that
is not often accepted in Western cultures and would imply dependency (Nock, 2008).
Media Influences on RSM
The four factor model and socialization function of repeated self-mutilation lead one to
wonder what effect various media sources have on this increasingly prevalent issue. Media
influences may play a role in the peer contagion effect of self-mutilation, for example when the
subgroup of choice is found via the internet, in movies, or television shows. As previously
mentioned, self-mutilation by one individual has been observed to influence other individuals to
self-mutilate for the first time (Ghaziuddin et al., 1992; Rada & James, 1982; Raine, 1982; Rosen
& Walsh, 1989; Taiminen et al., 1998; Walsh & Rosen, 1985). Thus, self-mutilation via peer
contagion may be affected by the availability of the media portrayals and asynchronous
communication in today’s society.
Although the media is encouraged to downplay focus or sensationalism regarding
suicidal deaths (Hawton & Williams, 2002), there is not a similar unspoken policy for RSM.
Several “role models” within popular media have admitted to engaging in self-mutilating
behaviors, including Princess Diana, Johnny Depp, Courtney Love, and Angelina Jolie (Favazza,
1996; Hooley, 2008; Howe-Martin, 2007). Books by Patricia McCormack (Cut, 2002), Emma
Forest (Thin Skin, 2001), and Shelley Stoehr (Crosses, 1991) discuss the topic of repeated selfmutilation in books written for teens. Movies have also introduced adolescents to the concept of
self-mutilation. Individuals in the movie Thirteen (London, Levy-Hinte, Hardwicke, & Reed,
2003) were displayed wearing wrist bands as a technique for covering up scars from cutting.
Popular musicians, such as Avril Lavigne, have mimicked this trend.
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This leaves one wondering what message is being sent to adolescents about their favorite
musicians, actors, and similar-aged fictional peers. If they perceive themselves to be in the subgroup of a celebrity, one might expect socialization effects to occur, and the adolescents might
potentially mimic these self-harming behaviors in order to fit in. Adolescents’ social scenes are
changing as more asynchronous forms of communication are developed. They are exploring their
identities online through instant messaging, e-mail, social networks, chat rooms, online forums,
and video conferencing. Each new generation is exposed to different forms of communication,
and the role of the internet in the self-harm trend has yet to be fully understood. The impacts of
this effect on adolescents, as well as other effects, need to be assessed if our society wants to
address self-mutilation.
Despite the intention to educate the public and raise awareness regarding the negative
aspects of RSM, such media inadvertently introduces the concept to adolescents and increases
their exposure. The internet is one source that provides mixed messages regarding repetitive
self-mutilation. Whitlock and colleagues (2006) brought to focus internet message boards and
their use in self-injury discussions. Their study found that these message boards are a “powerful
vehicle for bringing together self-injurious adolescents” and “may also expose vulnerable
adolescents to a subculture in which self-injury is normalized and encouraged” (Whitlock et al.,
2006, p. 415). One website, “Pro-Self-Injury” (http://razorblades.tribe.net; now dismantled),
allowed the posting of pictures, experiences, techniques for self-mutilating, and ideas on how not
to get caught (Howe-Martin, 2007). Though this site has been shut down, many internet forums
that support self-injury still exist for adolescents to potentially frequent. Fischoff (2006)
mentions another potential problem concerning violence on the internet, the third-person effect,
which asserts that the viewer feels immune to the effects of the mass media.
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Additionally, given that exposure to media portrayals of suicide may be a risk factor in
adolescent suicide (Insel & Gould, 2008), exposure to RSM in the media may be a risk factor for
adolescent RSM. As individuals who engage in repeated self-mutilation are more at-risk for
engaging in separate suicidal behaviors (Howe-Martin, 2007; Langbehn & Pfohl, 1993; Lloyd,
1997), it is important to note the availability of information about suicide on the internet as well.
Given the complex relationship between RSM and suicide (Rodham et al., 2004; Simpson &
Porter, 1981; Walsh & Rosen, 1988), suicide websites may impact those who self-mutilate.
Baker and Fortune (2008) found that users of internet websites on suicide viewed them as
communities of understanding, empathy, sources of coping, and even friendship. The
participants in their study felt socially valued as a result of participating in these websites and
perceived having a broader support system. This is similar to the findings of Miller and Gergen
(1998), who found suicide site users experienced validation, encouragement, and sympathy. The
participants in the Baker and Fortune (2008) study viewed the “support” of their families and
friends as “judgement,” but indicated internet contacts who also engaged in self-mutilation were
supportive due to the existence of a shared identity.
The implications of these Baker and Fortune (2008) findings are two-fold. If an
adolescent feels “understood” and “supported” on a self-harm website, they will be willing to
disclose more about their personal experiences, which leads to a greater feeling of unity
(Vinogradov & Yalom, 1990). Secondly, the forming of this group may prevent the adolescent
from seeking help elsewhere, which could potentially be hazardous. The individual may feel that
their similar peers have all of the “answers” and that anyone else would not understand them.
Interestingly, many of the participants in the Baker and Fortune (2008) study viewed the
websites as therapy alternatives.
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With the exception of a few recently published studies (e.g., Baker & Fortune, 2008;
Whitlock et al., 2006), little empirical evidence exists regarding the impact of the media on
repeated self-mutilation. If repeated self-mutilation can be spread through peer contagion
“offline” (Taiminen et al., 1998; Walsh & Rosen, 1985), one might wonder if RSM or even
suicidal behaviors could spread online as well. Existing research on media influences and
adolescent socialization alludes to the fact that viewing information about self-mutilation on the
internet and in other media forms or engaging in socially supportive websites could potentially
increase the risk of engaging in these behaviors.
The Importance of Examining Social Influences
As noted, the Experiential Avoidance Model designates RSM as behavior whose function
it is to help avoid painful private experiences. Some of this avoidance may relate to negative peer
factors; however, the EAM does not specifically pinpoint the role of the social influence in
perpetuating the cycle of RSM. Although researchers have evaluated the role of peer influence in
self-injury among inpatients (e.g., Rosen & Walsh, 1989; Taimenan et al., 1998) and the roles of
positive and negative reinforcement among adolescent psychiatric inpatients (Nock & Prinstein,
2004, 2005), there is very little research on peer influence in community samples or the impact
of media on this behavior.
Peer and Media Influences in Community Samples
One exception is Whitlock and colleagues’ (2006) study on internet message boards. A
second exception is Howe-Martin’s (2007) study, which aimed to fill this gap in the EAM by
exploring the social aspect of reported self-mutilation among a community sample. A broad
overview of the results of this study is provided, in efforts to lend empirical support for the
information addressed in the literature; interested readers should consult the Howe-Martin paper
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for more details. Adolescents (N = 211; ages 13 to 18), from three educationally diverse school
environments, were administered anonymous surveys that measured exposure to self-mutilation
by peers and through the media, as well as historic and current self-mutilation. A large
percentage of these adolescents reported at least some exposure to self-mutilation via peers
(44%) or media sources (85%). Adolescents with a history of repeated self-mutilation behavior
reported significantly more of this exposure than their non-mutilating peers (Howe-Martin,
2007).
These results follow with Nock and Prinstein’s (2004, 2005) conclusions that the number
of self-injury incidents among friends was associated with a positive reinforcement function of
self-mutilation behaviors. However, it should be noted that a majority of adolescents in the
Howe-Martin (2007) study reported exposure to some form of self-mutilation among peers or in
the media, but did not report engaging in repetitive self-mutilation (only about 16% of the total
sample engaged in RSM, defined as self-harm 5 or more times). Thus, it appears that simple
exposure to one or two sources was not enough to prompt repeated mimicry of the behavior.
There were several findings from the Howe-Martin (2007) study alluding to the existence
of a temporal relationship between exposure to self-mutilation among peers/media and RSM.
First, there were no differences between male and female adolescents regarding the amount of
self-mutilation peer/media contacts reported prior to initiation of self-mutilating behavior.
However, there was a significant increase in self-mutilation peer/media contacts following
initiation of self-mutilation behaviors for female adolescents. In addition, the severity of selfmutilating behaviors was positively correlated (r = .50, p < .01) with reported peer/media
contacts after initiation of self-mutilation. The correlation was higher within the female
subsample, indicating this effect as particularly strong for girls.
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One potential interpretation of these findings is that peer/media contacts interact with
self-mutilation in a causal feedback loop (Howe-Martin, 2007). For example, adolescents who
engage in self-mutilation may be initially exposed to one or two poignant models of selfmutilation. Such contacts, coupled with psychological distress and/or practices of experiential
avoidance, could prompt the initial self-mutilation episode. It is possible that adolescents who
engage in an initial episode of self-mutilation may seek out further models and images of such
behaviors. These models and images could take a variety of forms, depending on one’s context
and preferences (e.g., internet images for adolescents who are more computer-oriented and/or
introverted). If self-mutilation is supported within an inner social network and this behavior
functions to temporarily provide avoidance of unwanted inner experiences, it would be expected
that the behavior would then become repetitive. In addition, results that indicate a stronger trend
for female adolescents may be because females are more susceptible, due to the tendency for
females to solicit more social support than males (Fuhrer, Stansfield, Chemali, & Shipley, 1999;
Whitlock et al., 2006).
Suggestions for Further Research
Clearly, more research is needed to gain a clearer picture of the functions of RSM with
respect to social influence during adolescents. Empirical longitudinal tests of the causal feedback
loop proposed by Howe-Martin (2007) are needed for a more precise understanding of the
temporal relationship between the development of RSM, various peer/media influences, life
events, and psychological distress. In addition, a greater understanding of the actual influence of
self-mutilation images among peers and in the media on adolescents’ RSM, through the use of
experimental paradigms, would provide the empirical support necessary to implement the public
Influences on Repetitive Self-Mutilation
policy changes necessary to better monitor the content and disclaimers related to portrayals of
self-mutilation in various forms of media.
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Influences on Repetitive Self-Mutilation
Acknowledgements
Funding was received from the University of North Texas Department of Psychology.
The authors would like to thank the UNT Contextual Psychology Group for data collection,
editing, and other support.
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Influences on Repetitive Self-Mutilation
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Influences on Repetitive Self-Mutilation
Laura E. Peeka, , Karen O’Brien Lightnera, and Amy R. Murrell a,c
a
University of North Texas, Department of Psychology, 1611 W. Mulberry, Terrill Hall Room
151, Denton, TX, USA 76203
Laura S. Howe-Martinb
b
University of Texas Southwestern Medical School, Department of Psychiatry, 5323 Harry
Hines Blvd., Dallas, TX, USA 75390
c
Corresponding Author: University of North Texas, Department of Psychology, 1611 W.
Mulberry, Terrill Hall Room 358, Denton, TX, USA 76203, Phone: 001- 940-565-2967, Fax:
(940) 565-4682, E-mail: amurrell@unt.edu
25