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Criminal Behaviour and Mental Health

17: 312321 (2007)


Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/cbm.665

Characteristics and predictors of


self-mutilation: a study of
incarcerated women
DOMINIQUE ROE-SEPOWITZ, Arizona State University, USA
ABSTRACT
Background Research on self-mutilating behaviour and incarcerated adults has found
that nearly 50% of people in prison participated in it (Holley and Alborleda-Florez,
1988). This is an enormous liability for the criminal justice system as well as a human
concern.
Aims/hypotheses The research question for this study was to explore whether a
history of childhood abuse in a sample of incarcerated women would increase their
likelihood of self-mutilation.
Methods Participants were 256 female inmates from five prisons in a large southern
state who volunteered to attend a 12-week trauma and abuse psychosocial intervention
group. The participants were evaluated for childhood abuse, criminal history, risktaking behaviour and self-mutilation. Data are presented regarding individual, criminal, abuse, family and risk-taking behaviours comparing self-mutilators (n = 109) with
non-self-mutilators (n = 147).
Results The self-mutilation group was more likely to report higher rates of emotional,
sexual and physical abuse and on clinical significance scales of anxiety, depression,
dissociation, impaired self-reference, anger, tension reduction and intrusive experiences. The self-mutilation group was also younger and was more often Caucasian.
The results of the regression model suggest that a history of suicide attempts, emotional
abuse, sexual abuse, bingeing and vomiting and impaired self-reference are predictors
of self-mutilation.
Conclusions/implications for practice Recommendations and implications for
practice are discussed. Copyright 2007 John Wiley & Sons, Ltd.
Background
Intentional self-mutilation is one of the most perplexing clinical phenomena
(Briere and Gil, 1998). Self-mutilation is said to occur when a person
intentionally harms, damages or mutilates him- or herself (Lester, 1972). It includes
cutting, burning, inserting objects, head banging, drinking known poisons, inter-

Copyright 2007 John Wiley & Sons, Ltd

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DOI: 10.1002/cbm

Self-mutilation in incarcerated women

fering with wound healing or hitting oneself. Little is known about how to
predict, prevent or treat self-mutilation.
Self-mutilation is not a new phenomenon. Researchers have explored selfmutilating behaviours in clinical settings since the 1880s but often did not differentiate self-mutilation from other behavioural problems of the mentally ill
(Favazza, 1998). Self-mutilation first appeared in the psychiatric literature 90 years
ago in a single psychoanalysis case study by Emerson (1913); there have been
many publications on it during the past 20 years. Menninger (1935, 1938) was
the first to make a distinction between suicidal behaviours and self-mutilation in
his study of self-destructiveness.
Research has shown that the incidence of self-mutilating behaviour in the
general population is between 750 and 1800 per 100,000 per year (Morgan et al.,
1975; Favazza and Conterio, 1989; Brier and Gil, 1998). Researchers have found
rates of self-mutilation in college students range from 1% (Rodriguez-Srednicki,
2001), to 14% (Favazza, 1998), to 38% (Gratz et al., 2002). Adults with clinical
or psychiatric diagnoses had a far higher incidence than the general population.
Self-mutilation incidence levels among adult psychiatric patients ranges from 21%
of surveyed child abuse survivors (Briere and Gil, 1998) through 76% of surveyed
adults with borderline personality disorder (Dulit et al., 1994), to 85% of surveyed
German psychiatric inpatients (Herpertz, 1995). A study of adult inpatients with
eating disorders found that 34% reported self-mutilation (Paul et al., 2002). In a
clinical sample of psychiatrically hospitalized adolescents, 61% were found to
have been self-harming (DiClimente et al., 1991).
Research suggests that nearly 50% of people in prison self-mutilate (Holley
and Alboleda-Florez, 1988). In a study of incarcerated mentally ill adult offenders,
Gray et al. (2003) that 52% of the 34 subjects had self-mutilated at least once. A
similar high rate of self-mutilation was also found among 301 female prisoners in
a study by Borrill et al. (2003).
During the last 15 years, hospitals, schools, emergency rooms, psychiatric
units, prisons and juvenile facilities have widely reported acts of self-mutilation
but it is rarely mentioned in medical or clinical textbooks or treatment manuals
(Strong, 1998). Self-mutilation has often been misidentified as suicidal action, or
classified as a symptom of a psychiatric disorder without looking further into the
phenomenon (Favazza, 1987).
The role of early childhood experiences and/or difficult life circumstances
appears to be an important contributing factor to the development of self-mutilation behaviours (Van der Kolk, 1996). Childhood experiences, such as physical
and sexual abuse, neglect and a lack of a strong attachment to a caregiver, have
received extensive research attention, with childhood sexual abuse receiving the
greatest amount. Van der Kolk (1996) has challenged the idea that childhood
exposure to trauma, lack of secure attachment and neglect may contribute to the
development of adaptive behaviours associated with traumatic stress, including
self-mutilation. Gratz et al. (2002) concluded that the theoretical literature sug-

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gests that it is childhood experiences that take place within the context of the
family, in particular, within the context of the care-giving relationship that are
most strongly associated with self mutilation (p. 129).
Himber (1994) found in her analysis of eight self-mutilators that their use of
self-mutilation was a by-product of inadequate interpersonal relationships and
their inability to manage and control their own overwhelming feelings. She also
found that the self-mutilators had great difficulty in being comforted by others,
indicating possible attachment disorder. Insecure or disrupted attachment has
been proposed as a potential risk factor for self-mutilation (Gratz et al., 2002).
Brown et al. (2002) identified emotional distress as the most common reason
reported for non-suicidal self-mutilation. Other possible reasons for non-suicidal
self-mutilation were found to be for tension and anger relief (Jones et al., 1979;
Walsh and Rosen, 1988).
Self-mutilation appears to be negatively reinforced by the reported reduction
in tension following a self-mutilation behaviour (Gratz, 2003). This reduction in
tension increases the likelihood of its occurring again and becoming a regularly
used coping mechanism. Other rationales suggested for self-mutilation behaviours
apply specifically to incarcerated individuals who may deliberately harm themselves for reinforcing benefits. They may receive more attention, disrupt the daily
routine or be taken to the hospital or mental health centre (Schwartz et al., 1989).
Prisoners often lack or have a limited social support system and report feelings
of isolation and hopelessness. Self-mutilation may help them to reduce or alleviate
these feelings (Inch et al., 1995).
Research questions
Our research question was: do incarcerated women with histories of childhood
sexual abuse, physical abuse or emotional abuse show higher rates of self-mutilation than incarcerated women without such histories? We hypothesized that
incarcerated women with a history of childhood abuse would have higher rates
of self-mutilation.
Methods
Participants were 256 female inmates from five prisons in a large southern state
of the USA who volunteered to attend a 12-week trauma and abuse psychosocial
intervention group that met for two hours per week from 2003 until 2006.
Written informed consent was obtained at the first group meeting with the
participants. The purpose of the study was described and the voluntary nature
of participation emphasized as part of the consent procedure. In further
consideration of the vulnerability of incarcerated women, potential participants
were informed of the research plan before and after testing; during the administration of a life-history survey they were reminded that they could stop their

Copyright 2007 John Wiley & Sons, Ltd

17: 312321 (2007)


DOI: 10.1002/cbm

Self-mutilation in incarcerated women

participation at any time and that there were no prison-related benefits or penalties for their participation. Institutional Review Board approval was obtained at
Florida State University. The 256 participants who were included in the study
completed a pre- and post-test and a paper-and-pencil survey; those who had not
finished the group or had chosen not to complete the instruments were excluded.
The group leaders offered to assist any participants if they had difficulty reading
the instruments, but none of the participants requested help.
The Child Maltreatment Interview Schedule (CMIS; Briere, 1992) (slightly
modified), was used to create child abuse-related subscales: emotional abuse subscale ( = 0.96), physical abuse subscale ( = 0.67), and sexual abuse subscale (
= 0.67). The modification of the CMIS was the exclusion of all questions other
that those in the three areas of childhood abuse. An example of the questions
is Before the age of 18, did anyone ever sexually molest you, touch your body, in
a sexual way, or make you touch their sexual parts?. The emotional abuse scale
was constructed of seven items on a five-point scale. The sexual abuse and physical abuse scales were summaries of three questions (for each scale) with a dichotomous outcome (yes/no sexually abused). This scale has been used in many settings
including the clinical and general population but use with incarcerated clients
has been limited (Roe-Sepowitz et al., 2007).
The Trauma Symptom Inventory (TSI; Briere, 1995) assesses symptoms experienced by trauma victims, including dissociation, post-traumatic stress and
related psychological symptoms (Briere, 1995). The full 100-item measure was
used. The TSI asks respondents about how often specific experiences were currently occurring (note that this was modified from the original instructions of
during the past six months). The modification of the TSI was done to assess
their current experiences and enable the researchers to conduct a post-test on
their experiences currently after 12 weeks. Responses were scored on three-point
frequency scales. The TSI has adequate reliability and validity (Briere, 1995).
Cronbachs alphas for each subscale are: anxious arousal (0.84), depression (0.87),
anger/irritability (0.87), intrusive experiences (0.88), defensive avoidance (0.79),
dissociation (0.84), sexual concerns (0.87), dysfunctional sexual behaviour (0.91),
impaired self-reference (0.83), and tension reduction behaviour (0.84).
The definition of self-mutilation used in our study is an affirmative answer to
the question Have you ever intentionally hurt yourself (for example, by scratching, cutting or burning) even though you were not trying to commit suicide?
from the Trauma Symptom Inventory (Briere, 1995).
The Esuba survey was created by the researcher to obtain history of childhood
experiences (for example, exposure to domestic violence), risk-taking behaviours
(for example, history of a suicide attempt, drug and/or alcohol use, prostitution,
not eating for long periods) and criminal behaviours (for example, Have you ever
sold drugs?). It is a self-administered questionnaire and the questions are categorized into six sections: demographics, family history, health, substance use, behaviour and justice system contact.

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The TSIs were completed by the participants during the initial session of each
treatment group, but due to the sensitive nature of the Esuba survey and CMIS,
these measures were administered midway through the psychosocial programme,
at the sixth week, in an attempt to utilize the relationship and trust the participants had established with the group leaders. The decision to administer during
the middle of the programme was made to attempt to obtain more accurate
answers and to protect the clients from possible negative experiences associated
with answering the questions. Individuals were debriefed after completing the
questionnaire if they were identified as having overwhelming feelings associated
with completing the instruments.
Participants were divided into two groups: a self-mutilation and a comparison
group who had not self-mutilated. The first step in the analysis was to investigate
the differences between the two groups with regard to individual and family
characteristics, risk-taking behaviour, criminal behaviour, childhood abuse history
and scores on the TSI trauma subscales. Inspection of scatter plots and crosstabulation tables for the various variables did not show any obvious signs of outliers or suggest any other data problems or errors in the data. The Type 1 error
was set at p < 0.05, but the findings should be interpreted with caution due to
the use of multiple comparisons.
Results
The mean age of the participants (n = 256) was 35.46 years (range 1964; standard deviation (SD) = 9.28). They were serving sentences of 4480 months (M
= 64.69, SD = 70.33), with eight women sentenced to life. Their range of convictions included drug sales and possession, theft, robbery, child abuse, murder,
manslaughter, assault/battery and burglary. The sample included 138 (53.9%)
Caucasians, 102 (39.8%) African-Americans, 13 (5.1%) Hispanics and two (1%)
Native Americans; one (0.5%) was Asian.
Self-mutilation was reported by 42.3% (n = 109) of the participants.
Chi-squared analysis indicated that being Caucasian, younger, or serving a higher
than average length of sentence was associated with a higher rate of reported
self-mutilation (see Table 1).
Details of group differences regarding abuse history, risk-taking behaviours,
criminal behaviour and family characteristics are in Table 2. A chi-squared
analysis yielded significant differences between the self-mutilation group and the
comparison group regarding reported emotional, sexual and physical abuse. More
self-mutilators than expected reported emotional, sexual and physical abuse, with
emotional and sexual abuse accounting for most of the difference between the
groups. The self-mutilation group reported participating in risk-taking behaviour,
such as attempted suicide, excessive alcohol use, drug use, having sex with strangers, bingeing/vomiting and not eating for long periods, at a significantly higher
rate that the non-self-mutilators.

Copyright 2007 John Wiley & Sons, Ltd

17: 312321 (2007)


DOI: 10.1002/cbm

Self-mutilation in incarcerated women

Table 1: Distribution of race, age and sentence length by group


Race**

Self-mutilation group (n = 109)

Comparison group (n = 147)

Caucasian
African-American
Hispanic
American Indian

72 (66.1%)
31 (28.4%)
5 (4.6%)
1 (0.9%)

66 (44.9%)
71 (48.3%)
8 (5.4%)
2 (1.4%)

Mean

Mean

34.07 (SD = 8.98)


69.93 months (SD = 75.34)

36.48 (SD = 9.39)


61.07 months (SD = 66.44)

Age
Sentence length

Note: **Significant at the 0.01 level.

Table 2: Family, abuse, risk-taking and criminal behaviour histories


Self-mutilation group
(n = 109)

Comparison group
(n = 147)

Abuse factors:
History of emotional abuse**
History of sexual abuse**
History of physical abuse*

41 (37.6%)
98 (89.9%)
64 (58.7%)

21 (14.3%)
99 (67.3%)
63 (42.9%)

Risk-taking factors:
History of suicide attempt**
Excessive alcohol use**
Drug use*
Sex with strangers**
Risk taking**
Bingeing/vomiting**
Not eating for long periods**

87 (79.8%)
71 (65.1%)
89 (81.7%)
69 (63.3%)
65 (59.6%)
31 (28.4%)
53 (48.6%)

25 (17%)
68 (46.3%)
102 (69.4%)
49 (33.3%)
41 (27.9%)
5 (3.4%)
32 (21.8%)

Criminal behaviour:
Gang involvement
Prior incarceration
History of prostitution**
Prostituted another
Drove drunk
Sold drugs

12 (11.3%)
31 (28.4%)
82 (75.2%)
26 (23.6%)
78 (71.6%)
76 (69.7%)

8 (5.4%)
45 (30.6%)
71 (48.3%)
17 (11.6%)
95 (64.6%)
91 (61.9%)

Family factors:
Parental domestic violence/Yes
Parent with a drug/alcohol problem
Social Services involved**

64 (58.7%)
75 (68.8%)
54 (49.5%)

79 (53.7%)
91 (61.6%)
38 (25.9%)

Note: **Significant at the 0.01 level, * significant at the 0.05 level.

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The two groups were similar on most criminal behaviour characteristics, with
the exception that the self-mutilation group reported a higher rate of
prostitution.
Examination of family characteristics of the participants revealed that the
self-mutilation group had reported somewhat higher rates of observing domestic
violence in their childhood and having a parent with a drug and alcohol problem.
A higher number of women in the self-mutilation group reported that they had
a family member in jail/prison. A significantly higher number of the self-mutilation group (49.5%: 25.9%) reported having social services involvement.
The groups were significantly different on all of the TSI subscales with the
self-mutilation group consistently having higher than expected and clinically
significant scores on each of the subscales (Table 3).
Table 3: Group differences on trauma subscales

Clinically significant subscale scores


Anxious arousal*
Depression*
Anger/irritability*
Intrusive experiences*
Defensive avoidance*
Dissociation*
Sexual concerns*
Impaired self-reference*
Tension reduction*

Self-mutilation group
(n = 109)

Comparison group
(n = 147)

43 (39.4%)
52 (47.7%)
44 (40.4%)
60 (55%)
69 (63.3%)
59 (54.1%)
43 (39.4%)
55 (50.5%)
69 (63.3%)

29 (20%)
30 (20.7%)
34 (23.4%)
48 (33.1%)
65 (44.2%)
51 (34.7%)
36 (24.5%)
37 (25.2%)
54 (36.7%)

Note: *Significant at the 0.05 level.

Logistic regression was then used to determine the likelihood of a participant


being in the self-mutilation group, and to develop a predictive model for group
membership. The dependent variable was self-report of self-mutilation (yes/no).
The results indicated that suicide attempt, emotional abuse, sexual abuse,
bingeing and vomiting, and impaired self-reference were associated with selfTable 4: Results of logistic regression analysis

Suicide attempt
Emotional abuse
Sexual abuse
Bingeing/vomiting
Impaired self-reference

Wald

df

Sig.

Exp(B)/OR

95% CI

52.990
10.249
4.486
7.980
5.061

1
1
1
1
1

0.001**
0.001**
0.013*
0.005*
0. 024*

26.32
5.67
4.486
5.84
2.683

10.911, 63.490
1.960, 16.417
1.367, 14.714
1.717, 19.881
1.136, 6.34

Note: *p < 0.05, **p < 0.01.

Copyright 2007 John Wiley & Sons, Ltd

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DOI: 10.1002/cbm

Self-mutilation in incarcerated women

mutilation. Women who self-mutilated were 26 times more likely to attempt


suicide. Self-mutilators were five times more likely to report that they had been
emotionally abused and had participated in bingeing and purging than those who
did not self-mutilate. Women who reported a history of sexual abuse reported a
four times higher likelihood of self-mutilation than those not reporting a history
of sexual abuse. The self-mutilation group was twice as likely to have impaired
self-reference as those who did not self-mutilate. None of the other variables in
the model was independently significant.
Discussion
Study limitations
Our sample was non-random in that it was made up of voluntary participants in
a trauma-intervention programme which may disproportionately attract women
affected by childhood abuse and trauma. Our findings are not, therefore, necessarily generalizable to all female prisoners. Second, our measure of self-mutilation
was limited to one question on the TSI, coded in a simple yes/no format without
consideration of reported frequency. This did not allow for more complex analysis
of the phenomenon.
Conclusions and implications for practice
The questions guiding our study involved exploration of the differences between
incarcerated women who reported a history of self-mutilation and incarcerated
women who did not report this. Our results suggest that incarcerated women who
reported childhood experiences of sexual, emotional and physical abuse were
more likely to self-mutilate than those who were not abused. This finding may
indicate that these women are using self-mutilation to externalize their feelings
about their abuse histories. Women who reported self-mutilation were also younger
and were more likely to be white than non self-mutilators.
Although significant relationships were found between self-mutilation and
mental health problems or psychiatric symptoms such as dissociation, depression,
eating disorders and drug and alcohol use/abuse, the temporal order of such
relationships is not clear. Our results are also indicative of a general tendency to
self-harm, as women who self-mutilated were 26 times more likely to attempt
suicide, and to be involved in bingeing and purging than those who were not
self-mutilators. Women who self-mutilated also had a higher rate of prostitution.
It may be that offending which results in incarceration is merely another form
of self-abuse.

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Recommendations
1. Assess female children, adolescent girls and women for self-mutilating behaviours when they have been identified as survivors of sexual, physical and/or
emotional abuse.
2. Evaluate self-mutilating behaviours among runaway youth and teenage prostitutes who have come into contact with the law and/or child welfare
system.
3. Train prison personnel, child welfare workers, and mental workers in identifying correlates and possible predictors of self-mutilating behaviours.
4. Develop preventive programmes for elementary, middle and high school
teachers to enable them to identify self-mutilating behaviours, and related,
possible predictive factors.
5. Create specific self-mutilation treatment groups for incarcerated women, in
which they can learn new coping strategies and narrate their life
experiences.
6. Offer tools for body awareness such as breathing exercises, guided imagery
and body scans for victims of self-mutilating behaviours to develop a healthy
relationship with their body (Napoli, 2004).
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Address correspondence to: Dominique Roe-Sepowitz, MSW PhD, Arizona State


University, School of Social Work, 411 N. Central Ave Ste 800, Phoenix, AZ
85004-0689, USA. Email: Dominique.roe@asu.edu

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