psychological factors that are commonly associated with self-injury — depression, hopelessness or dissociation, for instance?
Somewhat surprisingly, her team found no significant
associations. So having interviewed all of her self-injuring
research participants in detail, she returned to her notes in
search of clues.
That’s when one factor stood out: How often they
spontaneously described themselves as being “bad,” “defective”
or “deserving of punishment.”
“It was as if harming themselves or experiencing pain was
somehow congruent with their highly negative self-image,” she
To test this possibility, her team developed a measure that
specifically assesses self-beliefs about being “bad” and deserving
criticism. This time, they found an answer: The higher a
person’s score on negative self-beliefs, the longer they were
willing or able to endure pain.
Given his conversations with Hooley, Franklin was thinking
along similar lines. When he asked himself why people would
undertake this behavior, he looked at it in context of the fact
that most people probably like themselves and therefore don’t
want to hurt themselves. In ongoing, still unpublished work, he
asked participants to rate words like “me,” “myself” and “I” on a
10-point scale ranging from most unpleasant to most pleasant.
Most people rated themselves between a seven and eight, but
self-injurers gave themselves only a two or a three.
Likewise, Franklin reasoned that most people would not
be overly fond of stimuli that depict blood, wounds, knives or
equivalent images. But he surmised that people who self-injure
might feel differently, partly because his findings suggested they
would associate such images with pain relief. A 2014 study in
Clinical Psychological Science shows this is the case: People who
had engaged in NSSI over the past year or who had 10 or more
lifetime episodes of self-cutting were much less likely to report
aversion to these kinds of stimuli than non-injuring controls.
Meanwhile, Hooley has recently completed a neuroimaging
study looking at how people process such stimuli.
“We’re predicting that images of self-injury will activate
reward-processing areas in the brains of people who engage in
NSSI,” she says, “but not in non-self-injuring controls.”
Now, based on some of these findings, the researchers and their
colleagues are exploring new ways to treat self-injury.
In keeping with her discovery that self-worth is an
important intervention variable, Hooley is taking a cognitive
route. Clinicians might be able to lift self-injurers’ inclination to
do bad things to themselves, she thinks, by helping them change
what are often deeply engrained negative self-views.
In a 2014 paper in Clinical Psychological Science, Hooley
and then-graduate student Sarah A. St. Germain report on
the results of a five-minute intervention they developed that
seeks to change beliefs about self-worth, but in ways that are
believable, grounded in reality and relatively subtle.
“You can’t do this by simply telling people who self-injure
that they should think more positively about themselves,” she
The team asked people with NSSI and controls to
choose which positive characteristics on a list best described
themselves, and then to elaborate on some of those
characteristics in detail using examples. Before and after the
intervention, the researchers tested people’s pain endurance
by recording how long they kept their fingers clamped in a
pressure device. (To control for noncognitive effects of good
mood, the researchers also included a “happy music” condition
with NSSI and healthy controls.)
After the intervention, self-injurers in the cognitive
condition kept their fingers in the device for only about
half the time they did initially. And the more their sense of
self-worth increased, the less willing they were to stay in the
painful situation. Meanwhile, the pain endurance of those
in all other conditions remained the same. She has not yet
looked at effect duration.
“The natural and adaptive response is to say, ‘I’m done with
this.’ But people who engage in self-injury don’t necessarily see
pain as something to escape from,” Hooley explains. Instead,
experiencing pain validates their sense of being a bad or
Increasing their sense of self-worth may undermine this
propensity, she adds.
“The more valuable that people feel, the less willing they
are to endure a bad situation,” she says. “Conversely, the worse
people feel about themselves, the more inclined they will
be to try [painful] methods of mood regulation that most
other people would not even consider.” Franklin, meanwhile,
is using his findings to test a behavioral intervention using
novel counter-conditioning techniques. The intervention
targets self-injurers’ propensity to pair pain images with
relief, and to harbor negative associations to self-related
words. The study is under review, but preliminary evidence
suggests that changing people’s feelings about self-related
words and NSSI-related images can be effective treatments,
Studies also show that associating pain with relief and
negative thoughts with self-related words are good predictors of
future self-injury, suggesting such tasks could be used as early
screening tools for NSSI, report Franklin and colleagues in a
2014 article in the Journal of Abnormal Psychology.
These efforts are a step toward effectively treating
people who self-injure, and Hooley and Franklin hope that
psychologists who create and study interventions will add their
own insights to the mix.
“We hope that our research is improving our knowledge
about how self-injury works and providing novel treatment
targets,” Franklin says. “Our goal is for researchers and clinicians
to use their creativity to attack these targets in new ways.” n