Nielsen, Emma Louise
(2021)
Dealing with Difficult Days: Can Experiential Avoidance and Functional Dimensions of Coping Explain Change in Self-harm Thoughts and Behaviour?
PhD thesis, University of Nottingham.
Abstract
Self-harm affords people a means of coping, at least in the short term. The reasons most consistently given for self-harm pertain to the reduction of intense aversive emotions; relief from a terrible state of mind. A contemporary theoretical account of non-suicidal self-injury, the Experiential Avoidance Model (EAM: Chapman et al., 2006), proposes that experiential avoidance – the tendency for non acceptance or avoidance (e.g., escape; suppression; modification; control) of negative affective, but not overtly dangerous, states – may be a central psychological factor in the development of, and cyclical reengagement in, self-injurious behaviours. While the EAM framework is specified for non-suicidal behaviours, notions of avoidance and escape motives, related to psychological distress, are also established in models of suicidal behaviours.
To date, no research has explored experiential avoidance and transactional, self-defined, functional coping dynamics in relation to distinguishing self-harm thoughts (ideation) and behaviours (enactment). This thesis is concerned with change in self-harm thoughts and behaviour. Here, the work focused primarily on understanding change in those with histories of selfharm and theoretically-derived, psychological factors which may: (i) determine self-harm experience (no self-harm; ideation only; enactment) in response to a given situation, and (ii) predict the repetition of self-harm over time (e.g., frequency). Change is also considered by examining whether factors which are predicted to differentiate those who have ever self-harmed from those with no history of self-harm behaviour also: (i) predict the recency and frequency of self-harm, and (ii) differentiate groups with differing intent histories (no self-injury; non-suicidal self-injury only; non-suicidal self-injury plus suicidal behaviour). Finally, the research presented considered change by exploring young people’s views of an intervention (harm minimisation – sensation and process proxies) designed to prevent the transition from self-harm thought(s) to self-harm behaviour(s).
While understanding transitions between thought(s) and action(s) is highlighted as a research priority, the extant literature typically aggregates experience, grouping people on lifetime experience. It is important to note that transitions between ideation and enactment are not uni directional. Indeed, understanding what psychological factors are related to self-harm experience in those with history of self-harm is important for understanding ‘recovery’ and consequently intervention planning.
Research presented in this thesis aims to investigate:
1) Whether experiential avoidance and functional coping dynamics can: (i) differentiate those with and without a lifetime history of self-harm, and (ii) predict the recency and frequency of self-harm (Chapter 2).
2) The relative importance of experiential avoidance and functional coping dynamics in self-harm of differing suicidal intent (Chapter 4).
3) Whether exploring functional coping dynamics can help us to understand when someone might: (i) think about harming, and (ii) self-harm (Chapter 3; Chapter 5).
4) Whether harm minimisation (sensation and process proxies) is viewed by young people with a history of self-harm, as being effective in stopping the transition from thinking about self-harming to acting upon those thoughts (Chapter 6).
Chapter 1 provides a general introduction to the thesis. In Chapter 1, The Experiential Avoidance Model (Chapman et al., 2006) is presented, with evidence in support of the model outlined. A brief overview of the history of ‘coping’ as a construct is provided, with detailed delineation of styles and process accounts. Within this, the position of functional coping dynamics is explicated and the key conceptual differences between experiential avoidance and functional coping dynamics outlined. The position, structure and rationale of the thesis is outlined, and key research questions defined. Consideration is also given to the scale of the problem of self-harm, nomenclature, ethics, and the differing conceptualisations of suicidal intent.
Study 1 (Chapter 2) investigated the relationship between experiential avoidance, coping and the recency and frequency of self-harm. Participants (N = 1,332; aged 16-69 years; community sample) completed online, self-report measures assessing self-harm, momentary affect, experiential avoidance and coping in response to a recent stressor. Participants who had self-harmed reported significantly higher levels of experiential avoidance and avoidance coping, as well as lower levels of approach, reappraisal and emotional regulation coping, than those with no self-harm history. Moreover, more recent self-harm was associated with lower endorsement of approach, reappraisal and emotion regulation coping, and also higher levels of both avoidance coping and experiential avoidance. Higher experiential avoidance and avoidance coping also predicted increased lifetime frequency of self-harm. Conversely, increased approach and reappraisal coping were associated with a decreased likelihood of high frequency self-harm. Although some of the effects were small, particularly in relation to lifetime frequency of self-harm, overall results suggest that experiential avoidance tendency may be an important psychological factor underpinning self-harm, regardless of suicidal intent (e.g., including mixed intent; suicidal intent; ambivalence), which is not accounted for in existing models of self-harm.
Study 2 (Chapter 3) explored whether and how functional coping dynamics differ between stressful situations in which people self-harm (enactment), think about harming (ideation), or experience no self-harmful thoughts or behaviours. Participants (N = 1,157; aged 16−49 years; community sample) with a recent history of self-harm (past 3 months) reported how they coped in response to their most significant recent stressor (past 3 months). Almost 40% of participants, all of whom had self-harmed in the last 3 months, had no self-harm experience (thoughts or behaviours) in response to their most significant stressor in that timeframe. In multivariate analysis, adjusting for symptoms of depression and anxiety, reappraisal coping was predictive of selfharm thoughts. Approach, emotion regulation and reappraisal coping were predictive of self-harm behaviour. Emotion regulation coping differentiated self-harm ideation and enactment groups. Taken together, the findings suggest that functional coping dynamics may be differentially associated with selfharm ideation and enactment. Further, results indicate that seemingly innocuous events may have a profound impact as tipping points for enaction. This has implications for clinical practice, including the co-production of safety plans.
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