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Running head: JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 1

Journaling Compared to Typical Treatment for Self-Mutilators

Student Name

University of Dayton

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 2

Abstract

Research has been conducted concerning the act of self-mutilation and its detrimental

effects as a coping method; however, an effective treatment that deters self-mutilators from

conducting the act in the future has not been found. Journal therapy uses journaling as an asset to

therapy sessions and encourages the client to write rather than harm themselves. This study tests

the effectiveness of journal therapy as a means of treatment for people who self-mutilate. It is

expected that journal therapy will be more successful compared to typical therapy due to the fact

it is an independent coping method – similar to self-mutilation itself – and can be an effective

and easy way to cope at any stage of life.

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 3

Journaling Compared to Typical Treatment for Self-Mutilators Self-mutilation. This is a term that can be intimidating, frightening, and possibly even

confusing to some. It is an action that many people may find hard to understand, and this is

partially because, despite the fact that this is a growing problem, it is still not a widely researched

behavior. One reason for this could be that it is a complicated topic to deal with. Not only is it a

very private action that can often go undetected for years, but it is also one that is hard to

concretely define.

By definition, self-mutilation is deliberate harm or alteration to the body without

intentions of suicide (Hicks & Hinck, 2007). A current debate with this definition is whether the

term “alteration” includes behaviors such as tattooing, piercing, plastic surgery and other body

modifications. Some experts in the psychology field claim that these actions should be included

because they are intentional alterations to the body; however, these cases will not be considered

for this study since they are typically seen as enhancement of physical appearance rather than an

uncontrollable action or destructive form of stress release.

There are two categories of self-mutilation: culturally sanctioned and pathological.

Culturally sanctioned self-mutilation is acts that are considered ritual, traditional, spiritual, or

believed to heal. They include dismemberment, punishing the self to repent for a sin,

modifications to indicate the entrance of a youth into adulthood, etc. (Favazza, 1998). These

types of self-mutilation are often seen in various cultures – specifically ones of tribal descent. An

example of culturally sanctioned self-mutilation is the Chinese ritual of foot-binding. While this

action is now deemed illegal, it is a perfect example of a cultural tradition influencing self-

mutilation. Women would bind their feet – breaking the bones and completely disfiguring the

foot – to make sure their foot remained small and attractive. While these acts are considered self-

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 4

mutilation, they are not common in regular society and often do not signify signs of mental

distress, but rather a dedication to one’s culture.

The other form of self-mutilation is pathological. It is purposeful injury done to the body

without desire to end life, and there are three forms of it: major, stereotypic, and

moderate/superficial. Major mutilation involves serious, often permanent, bodily injury such as

amputation and eye gouging. This form is usually associated with people suffering from

psychosis. Stereotypic self-mutilation is monotonous and repetitive and is associated with people

who have autism, Tourette’s, and mental retardation. Moderate/superficial self-mutilation is the

form that adolescents typically engage in and is intentional, conscious harm to skin tissue

(McDonald, 2006).

Moderate/superficial self-mutilation is further divided into three forms. The first form,

compulsive, occurs frequently throughout the day and do not do much physical harm. These

actions include hair pulling, scratching and picking at the skin, etc. Episodic self-mutilation, the

second type, is the occasional self-inflicted laceration or burn as a way to alleviate negative

feelings. These actions are often associated with people suffering from depression or anxiety.

Repetitive self-mutilation, the third form, is amplified episodic self-mutilation. It is when the act

of self-harm completely preoccupies the person and it becomes a sort of addiction (Favazza,

1996). Adolescents engaging in episodic and repetitive self-mutilation are the primary concern

for the study.

Various forms of mutilation exist, such as cutting, burning, picking and/or scratching of

the skin, forceful pulling of the hair, beating oneself against hard objects, and so on. There is also

a variation in where the inflictions occur – wrists/arms, inner thighs, stomach, under the breasts,

ankles, etc. The form of mutilation and the location where it occurs varies from person to person

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 5

based on their convenience and how satisfying the harmful act is for them (McDonald, 2006).

Locations of injuries are often in places where the self-injurer can easily hide the marks. Also,

the term satisfying is used because the act of self-mutilation is predominately done as a form of

coping mechanism and stress relief. People who self-harm often have trouble dealing with

stressful factors in their lives, suffer from depression, anxiety, eating disorders, or alcohol/drug

abuse – it can even be a combination of two or more of these factors (Nock & Prinstein, 2004).

Each case is unique which is why the study of self-mutilation can be quite difficult.

Self-mutilation can often begin at an early age – typically middle school and beyond. It

usually begins with stressors or traumatic events causing a build-up of tension within an

individual. Adolescents do not yet possess the mental capacity needed to adequately handle their

feelings (Nock & Prinstein, 2004) so they may act on impulse and engage in self-destructive

behavior. The act of self-harm can be seen in a myriad of ways by people who partake in it: a

sense of relief, a distraction from their problems, the feeling of physical pain numbs the feeling

of emotional pain, etc. It can also be a cry for help – adolescents who do not know how to

verbalize the emotional distress they are experiencing may self-harm to signal to others that they

are in need of help, but just don’t know how to ask (Williams, 2008).

The act of self-mutilation is a serious and growing problem. Nock and Prinstein report

that between 14-39% of adolescents harm themselves as a way to alleviate stress, and that this

percentage is growing exponentially (2004). Different theories have risen as to why self-

mutilation is gaining momentum as a coping mechanism, ranging from media influence to peer

pressure (Williams, 2008). If a teen has a friend who uses cutting or burning to cope, they may

adapt those practices as well. Regardless of the reason why they start, an effective strategy and

treatment needs to be created and implemented to cease the actions of self-mutilation.

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 6

Typical treatments for self-mutilators vary from SSRI medications to traditional therapy

sessions. Oftentimes group therapy is implemented along with individual therapy, and much

success has been found with this method. People who self-mutilate often feel alone and as if no

one understands the pain they feel inside. Group therapy allows them to recognize they are not

alone and create relationships with others who are sharing the same experiences and fighting

through the same struggle to cease their self-harm (Favazza, 1996).

However, while medications, individual and group therapy are effective means of helping

a self-mutilator overcome their problems, they all induce dependence – whether it is on a pill, a

therapist, or members of a group. The problem that ignites the cycle of self-mutilation is the

inability to cope with stressors in a productive and non-self-destructive way. While typical

therapies may teach a person who self-harms coping methods, they often do not actively

implement one within the therapy.

There are currently no studies on the use of journaling as a method of therapy, along with

none related to self-mutilation; however, based on common knowledge of the benefits of

journaling, it could prove to be a highly successful treatment style for those suffering from self-

mutilation. Journal writing is already seen as a form of therapy for many – the documentation of

one’s thoughts and life events help the writer reflect and learn from the words they have written.

Journaling is a way to help cope with problems and is completely self-produced – there is no

dependence on anyone but oneself.

The purpose of this study will be to see if a therapy style implementing required

journaling will be more effective in both the short and long term for people struggling with self-

mutilation. It is predicted that those who form a habit of journaling whenever an urge to self-

harm arises (or whenever the participant feels like writing) will overcome the habit quicker and

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 7

more effectively. It is also predicted that participants who develop a journaling habit will fare

better in the long term because, while they may form relationships with people they can depend

on for help, they are not completely dependent on others and will know how to effectively cope

by themselves.

Method

Participants

Participants would be acquired through various means including health networks,

counseling centers, support groups, and other institutions across the nation that may come into

contact with people who use self-mutilation as a coping method. The study will be advertised

both through flyer notifications and doctor recommendations. Age and gender will not be crucial

to the experiment. Participants should have a recent history of self-mutilation, meaning their last

self-inflicted injury occurred three weeks or sooner prior to selection.

Materials

Resources to advertise and contact various health networks will be needed, such as fliers

and descriptions of the study so fellow doctors and/or counselors can adequately inform their

clients of the study. Clinical areas would be needed for participants to meet for therapy. Three

different licensed therapists will be needed for each clinic. Journals will be provided for all

participants placed into journal therapy, and several varieties will be available to allow

participants to choose a journal they will enjoy writing in.

Procedure

Once participants have been acquired, they will all be screened using a survey. The

survey will ask questions such as the participant’s motivation to self-mutilate, what triggers him

or her to self-mutilate, etc. in order to potentially gather more background information. There is

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 8

one question that is vital to the study, however, and that is one asking if the participant is

currently on any psychological medication. Participants will then be split into two groups – no

medication and medication. From these two groups, they will be randomly assigned to either

regular talk therapy or journal therapy. This creates four different conditions for the study:

medication with regular therapy; medication with journal therapy; no medication with regular

therapy; no medication with journal therapy.

Once participants are separated into their respective therapies, they will meet for therapy

three times a week with a different therapist each day. For instance, if a participant has therapy

scheduled for every Monday, Wednesday, and Friday, they will have Doctor A every Monday

meeting, Doctor B every Tuesday meeting, and Doctor C every Friday meeting. This system

supports the internal validity of the study with inter-observer reliability. This eliminates the

problem of participants possibly lying about their improvements because one doctor may be able

to detect a lie that the other could not. Each participant will be evaluated by their therapists using

a Likert Scale ranging from one (always uses self-mutilation as a coping method) to seven (never

uses self-mutilation as a coping method). The scores from the three therapists will be averaged

for each participant to provide a post-treatment baseline.

The regular talk therapy group will receive therapy typical for self-mutilators. They will

discuss their problems with their therapists, reasons why they self-mutilate, and try to implement

new coping methods to phase out their method of self-mutilation.

The journal therapy group will use journals as an asset to their therapy sessions.

Participants will be encouraged to write (in any way they wish to – words, drawings, scribbles,

mash up of words, etc.) whenever they would like to, but they are strongly encouraged to do so

whenever they feel triggered to self-mutilate. If they do self-mutilate instead of write, they must

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 9

write an entry after the event describing everything they are feeling at the time, why they chose

to self-mutilate, etc. Participants would bring their journals with them to every therapy session

and add content from their entries to their discussions with their therapists.

These therapy sessions with continue for a total of six months. Participants will be

evaluated by their therapists as to their levels of improvement using the Likert Scale used pre-

treatment. All participants will be offered continued therapy of their choice once the study is

complete. A follow up assessment will be conducted six months after the study is completed to

determine the long term effects of the study – are participants still self-mutilating? Are

participants who received journal therapy still using their journals as a coping method? Etc.

Results

Results of the study will be expressed using both quantitative and qualitative data.

Quantitative data will come from the Likert Scale results from each condition, and an ANOVA

analysis will be used. Scores ranging from one to four indicate unsuccessful treatment, while

scores ranging from five to seven indicate successful treatment. It is predicted that the groups

using journal therapy – both on and off medication – will show the greatest improvement scores

overall in the study. Follow up scores will also be added and analyzed.

Qualitative data will come mainly from therapists’ notes. Ideally, testimonials from

participants, excerpts from journal entries, etc. will contribute to the data, but it cannot be

guaranteed that participants will want to share any of this information. The identities of any

participants who choose to share testimonials, excerpts, etc. will be kept anonymous unless they

wish otherwise.

Discussion

If the predicted outcome of journal therapy participants showing the most improvement

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 10

occurs, this will ideally pave the way for successful treatment of self-mutilators with a low rate

of relapse. Journal therapy provides an independent coping method for people that is not harmful

and can prove effective both as a coping method and as a lifelong hobby.

Since the study is conducted nationally and open to all age groups and genders its results

should be able to generalize to all self-mutilators; however, if participants predominately come

from one certain demographic (mostly teenagers, mostly women, majority of participants from

one area, etc.) then the results may not be as generalizable, but it will still be known that a certain

type of therapy (preferably, journal therapy) is most effective in treating self-mutilators of that

particular demographic.

Also, the use of three different therapists for each participant increases the reliability of

the results. Some may find this a problem because the relationship between therapist and client is

a personal one; however, since each participant sees the same three therapists for six months, it

can be assumed that relationships will be adequately built with each therapist. Some participants

may prefer one (or two) therapists over the other, but a variance in relationships would not

necessarily be a bad thing since trust being either dispersed or centralized does not affect the

outcome of the study – all therapists will have different viewpoints concerning the participant

and it is the convergence of all those opinions that create the results.

If journal therapy produces significant results, this will be the first study correlating a

relationship between journaling and self-mutilation. Journal therapy could potentially prove to be

the most effective form of therapy for self-mutilators, and more studies could occur.

JOURNALING COMPARED TO THERAPY FOR SELF-MUTILATORS 11

References

Favazza, A. R. (1996). Bodies under siege: self-mutilation and body modification in culture and psychiatry. Baltimore, Maryland: The John Hopkins University Press.

Hicks, K. M., & Hinck, S. M. (2008). Concept analysis of self-mutilation. Journal of Advanced Nursing, 64, 408-413. doi:10.1111/j.1365-2648.2008.04822.x

McDonald, C. (2006). Self-mutilation in adolescents. The Journal of School Nursing, 22, 193- 200. doi:10.1177/10598405050220040201

Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self- mutilative behavior. Journal of Consulting and Clinical Psychology, 72, 885-890. doi:10.1037/0022-006X.72.5.885

Williams, M.A. (2008). Self mutilation: opposing viewpoints. Farmington Hills, Michigan: Greenhaven Press.