Severe Addiction as Self-Harm through the lens of ACT's Functional Contextualism

Functional contextualism (a.k.a. functional analysis of behavior)* is bedrock to the conduct of Acceptance and Commitment Therapy (ACT), and rarely is it more crucially applied than in the context of self-harm by patients with borderline personality disorder.

While the article by Gratz quoted below confines self-harm more strictly than most addiction therapists would (e.g.: severe addictive behaviors as “suicide on the installment plan”), the concepts of functional contextualism and self-harm, as well as the two lists of functional purposes of self-harming behaviors are broadly applicable to understanding the behavioral motives of all manner of addicts in the denial / pre-contemplation and contemplation / consideration phases of addiction treatment.

Thanks to Wiley-Blackwell for making Gratz’s article available at no charge.

*see Hayes, Strosahl & Wilson, p. 18, and Hayes, Follette & Linehan, p.11.

Risk Factors for and Functions of Deliberate Self-Harm: An Empirical and Conceptual Review (excerpts)

Kim L. Gratz
Clinical Psychology: Science and Practice
Volume 10, Issue 2, pages 192–205, June 2003

http://onlinelibrary.wiley.com/doi/10.1093/clipsy.bpg022/full

FUNCTIONS OF DELIBERATE SELF-HARM

Linehan's (1993) description of the development of BPD also suggests the potential function of self-harm behavior. Specifically, Linehan suggests that the way emotional vulnerability and invalidating environments interact to influence the development of self-harm is through their impact on emotion dysregulation. For instance, invalidating environments during childhood may contribute to the development of emotion dysregulation by failing to teach effective regulatory strategies for managing emotional arousal and tolerating emotional distress (Linehan, 1993). Moreover, childhood trauma in the form of physical abuse, sexual abuse, or both may contribute to chronic hyper-arousal and, consequently, increased risk for emotion dysregulation (given that high levels of arousal are more difficult to regulate; see Eisenberg, Cumberland, & Spin-rad, 1998; Flett, Blankstein, & Obertynski, 1996). In addition, emotional vulnerability in the form of emotional reactivity and intensity may also contribute to emotion dysregulation (see Calkins & Johnson, 1998; Eisenberg et al., 1998; Melnick & Hinshaw, 2000;Thompson, 1994), as more intense emotions pose a greater challenge for emotion regulation (Flett et al., 1996). Thus, the interaction of these factors increases the likelihood of emotion dys-regulation, which, in turn, increases the risk for deliberate self-harm (as self-harm may function to regulate painful emotions that cannot be tolerated; see Linehan, 1993).

Although Linehan's (1993) theoretical work offers the most detailed and comprehensive description of the emotion regulating function of self-harm behavior, other researchers have also conceptualized self-harm as an emotion regulation strategy (see Haines & Williams, 1997; van der Kolk, 1996)—a conceptualization supported by clinical and empirical literature. Given the relative dearth of empirical research on the functions of self-harm, most of the extant literature on this topic is clinical in nature, consisting of clinical observations and the nonsystematic description of the self-reported functions of self-harming clients. This clinical literature indicates that deliberate self-harm may function in one or more of the following ways:

(1) to relieve anxiety;
(2) to release anger;
(3) to relieve unpleasant thoughts and feelings;
(4) to release tension;
(5) to relieve feelings of guilt, loneliness, alienation, self-hatred, and depression;
(6) to externalize and concretize emotional pain;
(7) to provide an escape from emotional pain;
(8) to provide a sense of security;
(9) to provide a sense of control;
(10) to self-punish;
(11) to set boundaries with others;
(12) to terminate depersonalization and derealization;
(13) to end flashbacks; and
(14) to stop racing thoughts

(Connors, 1996; Coons & Milstein, 1990; Favazza, 1989b, 1992; Favazza, DeRosear, & Conterio, 1989; Greenspan & Samuel, 1989; Kennerley 1996; Lyons, 1991;Shapiro, 1987). Although no data are available on the number of ways in which self-harm may function for any given individual, researchers have suggested that self-harm is likely an overdetermined behavior, serving multiple functions simultaneously (Suyemoto, 1998).

Empirical literature is consistent with this clinical literature. For instance, Favazza and Conterio (1989) examined the self-reported functions of self-harm among a community sample of 240 self-selected females with a history of this behavior. Among these participants, self-harm functioned to facilitate relaxation, control racing thoughts, and relieve feelings of depression, loneliness, and derealization. However, the authors did not specify whether the participants were allowed to describe (by means of an open-ended question) the functions of their self-harm behavior, or whether they were forced to choose from a list of alter natives provided by the researchers—a factor that may have implications for the validity of the results.

Briere and Gil (1998) also examined the functions of self-harm among a group of 93 self-identified (predominantly female) individuals with a history of this behavior (the vast majority of whom also had a history of sexual abuse). These individuals were asked to select the functions of their self-harm from a list of reasons commonly provided by self-harming clients for this behavior. The participants selected a wide variety of functions for their behavior, including self-punishment, distraction from and release of painful feelings, management of stress, reduction of tension, release of anger, and enhancement of feelings of self-control (each endorsed by more than 70% of the self-harming individuals). A factor analysis performed on the reasons for self-harm cited by more than 20% of the participants resulted in nine factors, leading the researchers to conclude that the self-harm behavior of the participants in their study functioned to:

(1) decrease dissociative symptoms such as depersonalization,
(2) prevent flashbacks and upsetting memories,
(3) reduce stress and tension,
(4) express distressing emotions,
(5) provide a sense of safety and protection,
(6) reduce anger,
(7) punish the individual,
(8) show others that the individual needed help, and
(9) protect the individual from hurting others.

Briere and Gil's (1998) use of a close-ended questionnaire to assess the functions of self-harm may be premature in light of the relative lack of empirical research on the functions of this behavior. Results of a qualitative study that used open-ended interviews to assess the functions of self-harm behavior (Gratz, 2000) may help elaborate upon their findings. Despite the study's limited sample (21 college students with a self-identified history of self-harm behavior), the results were comparable to those reported by Briere and Gil (1998), as well as Favazza and Conterio (1989).

Specifically Gratz (2000) found that the most frequently described function of self-harm was to relieve unwanted feelings, reported by 76% of the participants. These participants reported that self-harm relieved feelings of stress, anger, frustration, sadness, emotional upset, tension, anxiety, grief, emotional pain, and being overwhelmed.

Consistent with the aforementioned clinical literature, participants also reported that self-harm externalized emotional pain, thereby making the pain more physical and tangible, and thus less abstract and easier to understand. Participants also noted that self-harm provided an escape, a way to forget about worries and fears, and a way to divert attention from painful internal experiences. According to participants’ reports, self-harm also functioned to express feelings of self-hatred, to self-punish, to provide a sense of control, and to prove something to the individuals (e.g., that they were capable of doing something or that they were tough enough to endure pain). Finally, for six participants (29%), self-harm functioned as a way to communicate with others, including showing others that they were hurting and setting boundaries with others.

Interestingly, and somewhat inconsistent with the clinical and empirical data already described, one of the most frequently cited functions of self-harm within the general literature in this area is the elicitation of a caring response from others (Conterio & Lader, 1998; Favazza, 1992)—a function often described as a means of manipulating or coercing others into providing love or attention (Barstow, 1995; Feldman, 1988;Schwartz et al, 1989). This is the function that historically has been attributed to most self-harm behavior, contributing to the common belief that individuals who engage in this behavior are manipulative and attention seeking (Feldman, 1988; Tantam & Whittaker, 1992). However, researchers have recently begun to address the fact that this negative belief about the function of self-harm is most likely a misconception.

First, self-harm is often a private and secretive act, with many individuals choosing to conceal this behavior from others (Conterio & Lader, 1998; Favazza, 1992). In these instances the purpose of this behavior could not possibly be to manipulate others or gain attention, suggesting that, at the very least, the function of self-harm is not always interpersonal in nature. Also, some researchers argue that even in the case of individuals who harm themselves in the presence of others, it may not be accurate to conceptualize their behavior as manipulative. According to Linehan (1993), who thoughtfully argues against conceptualizing the parasuicidal (including self-harming) behavior of individuals with BPD as manipulative, the fact that the self-harm behavior of an individual may influence others does not mean that this was the intent of the behavior, as “function does not prove intention” (p. 17).

Linehan's (1993) argument is very similar to Levenkron's (1998) discussion of “secondary gain” (p. Ill), in which eliciting a caring response or influencing others is not the intent or primary goal of the behavior but may end up reinforcing the behavior nonetheless. The benefit of framing the interpersonal function of self-harm behavior in this way is that doing so separates the conscious intent of the behavior from the unintended but still possibly reinforcing outcome of the behavior, consequently challenging the stereotype that self-harm behavior and the individuals who engage in it are manipulative.

Moreover, within the empirical research on the functions of self-harm, the elicitation of a caring response from others is not the most frequently cited function of self-harm among self-harming individuals themselves. For example, Gratz (2000) found that less than one third of participants (n= 6) reported that self-harm functioned to get the attention of others, and half of these participants (n= 3) seemed unsure as to whether this was actually one of the functions of their behavior. Conversely, self-harm was also described by three participants as a means to push people away and make others leave them alone.

Similarly, Briere and Gil (1998) found that although 40% of their sample reported engaging in self-harm to get attention or help from others, the majority of self-harming individuals (more than 70%) endorsed the intrapersonal functions of self-punishment, enhancement of self-control, and relief from painful feelings, stress, tension, and anger. Favazza and Conterio (1989) do not report that obtaining the care or attention of someone was one of the functions of self-harm described by the participants in their study; however, it is unclear whether this function was even an option provided to participants. Related to this topic, though, only 20% of the participants in their study endorsed the statement that they liked the attention resulting from self-harm.

Although clinical and empirical data lend support to Linehan's (1993) theory that self-harm serves an emotion regulating function, knowing the particular way in which self-harm may operate to regulate emotions would add depth to an understanding of its function (considering that emotion regulation strategies may take a variety of forms that are more or less adaptive). One emerging construct that may be particularly useful for understanding the specific form of emotion regulation that self-harm most often takes is experiential avoidance (i.e., attempts to alter the form or frequency of unwanted internal experiences, including emotions, thoughts, memories, and bodily sensations; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996).

Because experiential avoidance is a particular type of emotion regulation strategy with commonly associated short-and long-term consequences (including the reduction of distress and subsequent negative reinforcement of the behavior in the short-term and paradoxical, dysregulating effects in the long-term; see Hayes, Strosahl, & Wilson, 1999; Hayes et al., 1996), it may offer a useful conceptual framework for understanding the function of self-harm. In fact, examination of the functions of self-harm reported by research participants and clients suggests that this behavior does often function as a form of experiential avoidance (as it is often used to escape, avoid, or alter emotions or thoughts).