Dr Cate Curtis. SPINZ Symposium Presentation, Dunedin, 28 November 2006. http://www.spinz.org.nz

1. Non-fatal suicidal behaviour
in young women: links to
self-mutilation
Dr Cate Curtis
ccurtis@waikato.ac.nz

2. Introduction:
Although there is an increasing body of research
into youth suicide in New Zealand, much of it is
with clinical populations and quantitative in nature.
My research was with a community sample of
women and focused on finding out about their
perceptions and understandings of events. It also
included interviews with service providers/key
informants.

3. Areas of discussion will include:
• The relationship between self-mutilation and
suicidal behaviour
• Survivors’ perceptions of the services they have
encountered and the recovery process (if time
allows)
Other key findings included the importance of
sexual abuse as a risk factor, alongside issues of
powerlessness

4. Key features of the study
• Who: 25 women and 25 key informants
• Where: throughout New Zealand
• How: The women were invited to discuss their
experiences of becoming and being suicidal and
recovering from suicidality. The narratives were
collated and thematic analysis undertaken.

5. Method: I
• Recruitment: class presentations, newspaper &
magazine articles, word of mouth.
• Participants: 25 women who had engaged in
suicidal behaviour while aged under 25. Ages
ranged between 21 and 46 at the time of the
interview.
• Procedure: Mostly unstructured interviews, in
person (19). Some by phone (2), email (3), letter
(1). Thematic analysis using Nu*Dist.

6. Literature – self-mutilation
• Little risk of death, goal of short-term alleviation
through alteration of consciousness. Some
overlap with suicide attempters (Walsh & Rosen,
1988)
• Counter-suicidal (Ross & McKay, 1978)
• Secret, most common among adolescent
females. Sense of relief through endorphin
release: self-reinforcing (Alderman, 1997).
• Abuse history very common (Dieter, Nicholls &
Pearlman, 2000).

7. •Cognitive distinction between suicide and self-mutilation,
though linked to other self-destructive behaviour, e.g.
eating disorder (Favazza, 1986, 1996).
•Differing levels of depression and suicidal ideation,
attitudes to life (Muehlenkamp, Gutierrez, 2004).
•Dunedin study – most self-harm not suicidal
(Shyamala-Rada et al., 2004).
Overall: part of the self-harm continuum, quite distinct
from suicidal behaviour, although some self-mutilators
may go on to attempt suicide. Links to psychosis,
dissociation. Manipulative, attention-seeking (older lit.).

8. Results
18 of the 25 had self-mutilated*
• Most common forms:
• Cutting (14)
• Burning (4)
• Hitting/kicking (2)
• Abrasions (1)
• Frequency & duration varied: several times a day for
several years, to three times in total. Usually several
times a month.
* These results are provided for interest’s sake only.

9. Different from suicide:
• “Cutting is playing with dying – it’s not consciously wanting
to die…It’s a means of self-expression, stress and tension-
relief. It made me sane when I was going crazy. It’s not really
any different from smoking or drinking except that it’s not
socially acceptable.”
• “Cutting wasn’t a suicide thing, it was a release of emotion. It
does hurt, but it doesn’t matter because you feel like you
deserve to hurt. The internal pain is far worse than the
physical. Sometimes cutting could be a way of dealing with
feeling suicidal, releasing the pain instead of making a suicidal
act.”
• “I tried cutting myself on my arm to see what it would be like
to cut my wrists, because I didn’t want to fail at a suicide
attempt … cutting gave me a sense of release of tension, it
changed my state.”

10. Expression of emotions:
• “…an expression of anger, punishment for
eating [when anorexic]… pressure release, a way
of relieving suicidal feelings.”
• “Cutting made me feel better for a while – it
hurt so it felt like a strong thing to do, although
I knew it was kind of stupid… It was a clear
decision to do it, when I felt kind of powerless”

11. Fourteen of the 18 women who had self-mutilated
link their behaviour to sexual abuse:
“I was unable to express myself, the [emotional]
pain was like a physical ache. I felt raw, as if I’d
been peeled. Cutting provided a release of
tension…[the focus on] physical pain made the
emotional pain easier to bear.”

12. “It was because of anger, frustration, inability to express my
emotions. I had no-one safe to talk to, no-one would
understand, I was ashamed, and I just wouldn’t have been
able to bring myself to talk. I hadn’t even acknowledged it
[sexual abuse] to myself - I kept a very tight lid on my
thoughts – so how could I talk to anyone about it anyway?
It was also about proving that I was tough, strong, leave me
alone, don’t fuck with me, no-one can hurt me. Which of
course was bullshit. I didn’t hurt because I didn’t allow
myself to feel… at the time I wouldn’t have been able to say
why I did it. Some-times it was quite public…I guess I was
also wanting some-one to notice and help me, or just give
me some attention, but at the time if any-one had asked
what was wrong I probably would have said ‘nothing’.”

13. Power and control
A key issue, frequently emphasised
• “I felt absolutely powerless, I was absolutely
powerless. My depression took a turn I couldn’t
control, and I was over the edge…. I felt that
nothing was in my control except this aspect of
my body and my life.”
• “I felt mesmerised by the knife and the blood,
and felt like I was getting a slice of power back.”

14. Abuse sense of externally-targeted attempts successful
powerlessness to regain sense of control
no further
fail action
self-mutilation to
regain sense of control
temporarily successful
sense of powerlessness returns
suicide attempt / further mutilation

15. Differences between the behaviours
• self-mutilation began before the first suicide attempt,
and nearly half continued after the last suicide attempt;
• means used for self-mutilation usually different from
those used for suicidal behaviour;
• participants typically interspersed suicide attempts with
self-mutilation;
• self-mutilation usually occurred more frequently, with
several episodes increasing in frequency before
culminating in a suicide attempt;
• a period of respite from self-harming behaviours often
followed. However, for most participants this respite
was temporary.

16. Key Findings
• Definite relationship, although quite distinct
behaviours:
• Goal of self-mutilation: short-term release, to
feel better cf not feel at all
• Change focus of pain to physical
• Punishment
• Reclaim control of the body
• Statement of strength
• For most it is physically painful

17. • However, participants brought up the topic of
self-mutilation without prompting and made
clear links between self-mutilation and suicide
attempts, particularly discussing self-mutilation
as a way of dealing with suicidal ideation.
• Although many self-mutilators may not be or
become suicidal, it seems many female suicide
attempters also self-mutilate.
• In contrast to a self-harm continuum, this
research suggests a repetitive, wave-like pattern

18. Implications for treatment
• Importance of partnership
• Awareness of power dynamics
• Realisation that abuse likely, but may be too
painful to deal with
• Assistance to find other ways of recovering a
sense of power e.g. support to leave a
destructive relationship, prosecute an abuser
• Non-reinforcement (by medical staff) – matter
of fact attitude

19. Key features of successful counselling/therapy:
•an empathetic counsellor
•a sense of control/partnership in the counselling process
•feeling listened to
•not feeling like a burden (cf to talking to family/friends)
•feeling the counsellor could relate– similar demographics
•feeling that the counsellor genuinely cared
•feeling the counsellor could be trusted –particularly
important issue for women who felt betrayed by others
including parents and previous counsellors.

20. Implications for treatment:
• Importance of partnership in the therapeutic process
• Awareness of power dynamics
• Realisation that abuse likely, but may be too painful to
deal with immediately
• Assistance to find other ways of recovering a sense of
power e.g. support to leave a destructive relationship,
prosecute an abuser
• Non-reinforcement (by medical staff) – matter of fact
attitude

21. Conclusion:
• Although distinct behaviours in terms of intent
and lethality, there are clear links, in particular,
using self-mutilation as a way of dealing with
potential suicidality.