An exploratory comparative study of perspectives on non-suicidal self-injurious behaviors among social work students in the United States,Greece,Cyprus,and Jordan: Implications for social work practice and education

Abstract

There has been a call for cross-cultural research in the understanding of non-suicidal self-injury (NSSI). The purpose of this study was to explore the influence of ethnicity and culture on the understanding of NSSI among social work students in the United States, Greece/Cyprus, and Jordan. A convenience sample of 438 social work students was used. Participants completed a 60-item questionnaire. Results revealed statistically significant differences in students’ knowledge and cultural beliefs about NSSI by country. This study makes a novel contribution to the exploration of cultural aspects of NSSI and has implications for international social work practice and education.

Keywords

Cross-cultural mental health parasuicide self-harm social work education

Introduction

Non-suicidal self-injury (NSSI) has been identified as a complex and perplexing behavior to understand and treat due to our instinctual aversion to pain and its overlap with suicide (Author’s own, 2014; Nock and Favazza, 2009). Over the last decade, significant advances have been made with respect to the understanding of the phenomenology of NSSI (Jacobson and Gould, 2007; Whitlock et al., 2011).

Although there are a plethora of studies particularly in the Western countries such as the United States and the United Kingdom, there are limited studies elsewhere and there is a call for cross-cultural NSSI research (Muehlenkamp et al., 2012). However, those few non-Western studies indicate that NSSI may be a concerning mental health issue worldwide (Muehlenkamp et al., 2012; Shahid and Hyder, 2008). This may be attributed to several factors including inconsistency in terminology, inadequate measures, cultural prohibitions, and negative stereotypes, as well as the fact that NSSI overlaps with suicide and has been difficult to investigate (Muehlenkamp et al., 2012).

In the United States, social work programs and allied mental health professions continue to offer limited education in the understanding and treatment of NSSI (Feldman and Freedenthal, 2006; Jacobson et al., 2004, 2012). As a result, social workers and mental health professionals report limited knowledge of NSSI preventing them from being able to identify individuals who may engage in NSSI (Roberts-Dobie and Donatelle, 2007). This leaves social workers unprepared to treat individuals who are known to engage in NSSI behaviors (Duggan et al., 2011). To the best of our knowledge, there are no epidemiological studies on NSSI in Greece or Cyprus, and there is only one in Jordan (Hanania et al., 2014).

The purpose of this study was to explore the influence of ethnicity and culture on the conceptualization of NSSI among social work students in the United States, Greece/Cyprus, and Jordan. Given the dearth of studies outside countries such as the United States and the United Kingdom, gaps in our knowledge base, and the complexity of NSSI behavior, the current authors felt this study would make an important contribution to our understanding of cross-cultural differences in NSSI.

Literature review

NSSI also goes by terms such as self-mutilation, self-injury, parasuicidal behavior, and self-harm. NSSI refers to purposeful injuries toward one’s body that involve some tissue alteration without suicidal intent, excluding socially accepted practices such as ear piercing and tattooing (Kokaliari et al., 2008; Gonçalves et al., 2012; Nock and Favazza, 2009; Selby et al., 2012; Whitlock, 2010; Whitlock et al., 2013). Most common types of non-suicidal behaviors include cutting, burning, scratching the skin to the point of bleeding, head banging, self-biting, and self-hitting. Most individuals tend to employ multiple methods (Kokaliari, 2014; Gratz et al., 2012; Hamza et al., 2012) of injuring themselves (Whitlock et al., 2011). Self-injury is usually a repetitive act performed on arms and legs in isolation and more rarely on thighs, genitals, breasts, or face (Whitlock, 2010; Whitlock et al., 2011). NSSI usually starts in adolescent years between the ages of 10 and 15 (Heath et al., 2008) and has been described as a female phenomenon (Bakken and Gunter, 2012) with rates as high as double (Madge et al., 2008; Whitlock et al., 2011) or triple that of males (Tsai et al., 2011; Yates et al., 2008). NSSI has been reported in alarming rates in adolescent samples varying from 13 to 23.2 percent (Bakken and Gunter, 2012; Jacobson and Gould, 2007) and in young adults and college students from 16 to 44 percent (Kokaliari, 2014; Gratz, 2006; Gratz and Chapman, 2007; Whitlock et al., 2006, 2011). In response to the escalating rates reported in the literature, a new standalone diagnosis for NSSI has been added to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) (American Psychiatric Association, 2013).

International studies provide emerging evidence that NSSI may be a worldwide phenomenon (Shahid and Hyder, 2008). One study in Turkey investigated self-injury among abused female adults and found a 33.3 percent rate of self-injurious behavior (Baral et al., 1998). Two other Turkish studies found that 21.4 percent of high school students (Zoroglu et al., 2003) and 15.4 percent of college students reported NSSI (Toprak et al., 2011). In China, two large-scale studies reported adolescent rates of 15 percent (You et al., 2011) and 17 percent (Wan et al., 2011). In Indonesia, a study of college students found that 38 percent had self-injured (Tresno et al., 2012). In Taiwan, two studies among high school students reported rates of 22.4 percent (Chen, 2006) and 11.3 percent (Tsai et al., 2011). Finally, in Jordan, a study of self-injury among 950 adolescents reported a lifetime prevalence of 22 percent and that males were more likely than females to self-injure (Hanania et al., 2014).

Treatment issues

NSSI is associated with depression (Klonsky et al., 2003); a history of neglect, physical, and sexual abuse (Gratz, 2006; Yates, 2009); and overall poor affect regulation (Crowell et al., 2008). NSSI has been predominantly associated with borderline personality diagnosis with self-injury, one of its diagnostic symptoms (Muehlenkamp et al., 2011; Selby et al., 2012; You et al., 2011). This has sometimes resulted in the inappropriate diagnosis of individuals who engage in NSSI behavior (Kokaliari et al., 2008; Shaw, 2002). NSSI has also been seen worldwide as a ‘manipulative’, ‘attention seeking’, ‘female’ behavior (Long and Jenkins, 2010; Matsumoto et al., 2005) contributing to ineffective mental health interventions (Kokaliari et al., 2005).

Although NSSI has been distinguished from suicidality, it has been estimated that about a quarter of suicides are preceded by non-fatal self-harming acts (Anestis et al., 2013). Thus, NSSI has been identified as a risk factor for suicide as it shares several correlates, such as affect regulation, with suicide (Hasking et al., 2008). However, individuals who self-injure predominantly deny suicidal ideation (Cheng et al., 2010). As a consequence, research into NSSI has been submerged within a broader spectrum of self-destructive and suicidal behaviors, without differentiating intent (Hamza et al., 2012; Muehlenkamp et al., 2012; Plener et al., 2009; Whitlock, 2010).

Due to NSSI’s ambiguous relationship to suicide, strong association with borderline personality, the derogatory terms used to describe it, and the stigma associated with NSSI, individuals who self-injure are often burdened with shame, unnecessary hospitalizations, and dismissive attitudes by professionals (Kokaliari et al., 2005; Shaw, 2002).

Research sites: United States, Greece, Cyprus, and Jordan

While the US population is predominantly Christian, there is religious diversity and a legal and political system that is explicitly secular. Cultural values and social mores are markedly more progressive than most highly religious countries, with widespread acceptance of women’s rights, ethnic, and cultural diversity.

Unlike in the United States, in Greece, Cyprus, and Jordan there is no legal separation between church and state. In Greece, 98 percent of the population identifies as Greek Orthodox, which is closely related to Greek identity (Grigoropoulou and Chryssochoou, 2011). Similarly, in Cyprus, more than 80 percent of the population identify as Greek Orthodox. In both countries, traditional social values and conservative cultural attitudes remain strong, and intolerance with respect to mental illness and gender issues such as sexual orientation is common (Madianos et al., 2012; Onoufriou, 2009). Greece and Cyprus have long historical ties and share the same language, religion, and sociocultural structures (Zacharakis et al., 2005).

Jordan is an Arab society, and the majority (95%) of the population identifies as Muslim (Al-Krenawi et al., 2004). It is a deeply conservative country where Islam plays a major role in the organization of social and political life (Kokaliari, 2005). The sociocultural context is highly relevant to social work, with a particular emphasis on gender and religion (Kokaliari et al., 2008). There is an implicit cultural and religious meaning embedded in social work teaching and practice interventions. Issues that are typically the domain of social work in Western countries are likely to be mediated by religious authorities in Jordan. For example, cases of domestic violence or chronic illness may be dealt with by the intervention of a priest or Shaik, reflecting the prevailing belief that religion teaches us to return hatred with love, and those problems are tests from God (Kokaliari, 2005; Kokaliari et al., 2008). Gender segregation in Jordan also has an impact on social work practice. For example, a male social worker who visits a single woman or widow at home must have a female social worker along to protect both the woman’s and his own reputation. Conversely, female social workers might invoke a fictitious kinship with male clients, calling them ‘brother’, ‘uncle’, or ‘father’ to overcome gender sensitivity and male dominance. Social workers might use Zakat and Sadaqa practices, religious charity work to help the poor when there is a lack of resources and funding at the work setting.

Social work education

Sites also differed widely in terms of social work history and tradition. The United States has the longest tradition in the profession of social work reaching back to the late 19th century. There are approximately 700 social work programs in the United States. Professional social work in Greece has a more recent tradition dating back to 1945 when the first school for social welfare was established similar to programs in the United States. Currently, there are three social work programs in Greece. Cyprus, highly influenced by the Greek curriculum, established its first social work program in 2001 and now has three social work programs (Kokaliari, 2005). Jordan does not yet recognize social work as a profession, but has four social work programs and, unlike the other three sites, the curriculum is heavily influenced by religion and culture.

Methodology

Study design

A non-randomized cross-sectional survey design was used to explore cultural differences among social work students in the United States, Greece, Cyprus, and Jordan. The purpose of this study was to explore the influence of ethnicity and culture on the conceptualization of NSSI among social work students. (Note that because of the cultural, historical, and religious similarities between Greece and Cyprus, we treated these countries as a single site.) The sites were selected because they represent distinct groups in terms of ethnicity and culture. US students were a heterogeneous group, identifying as 72.2 percent Christian, 8 percent Muslim, 1.2 percent Jewish, 2 percent Buddhist, 8 percent Hindu, and the remaining 23 percent as ‘other’, predominantly atheists. Among Greek/Cypriot students, 100 percent self-identified as Christian (Greek Orthodox), and 100 percent of Jordanian students self-identified as Muslim. This study offered a unique opportunity to generate cross-cultural discussion of a complex mental health issue.

Sample

Sample sizes were as follows: United States (254), Jordan (85), and Greece/Cyprus combined (99), for a total of 438 completed surveys. Survey respondents were enrolled in social work programs, which represented the terminal degree in each of their respective countries. For US students, this was the two-year Master of Social Work (MSW) program, and for Greek/Cypriot and Jordanian students, this was the four-year Bachelor of Social Work (BSW) program. The programmatic differences of the social work programs from which our samples were drawn reflect the reality of how professional social work education is delivered within each country.

Instrumentation

After a review of the literature, it was apparent there was no measure available to analyze the variables of interest addressing social work students’ knowledge and perceptions of non-suicidal self-injurious behavior. Therefore, the current authors based on the NSSI literature developed a five-part instrument titled Social Work Students’ Understanding of Non-Suicidal Self-Injury. The five sections included the following: Part I consisted of 11 items on demographics; Part II consisted of 23 items on NSSI knowledge; Part III consisted of eight items on NSSI treatment; Part IV consisted of 13 items on culture; and Part V consisted of five items on social work curriculum for a total of 60 survey items. This study focuses on parts I–IV.

The instrument was first pilot tested with eight students in the United States. The feedback provided was integrated into the survey instrument. Second, the instrument was translated into Greek and Arabic and these translated versions were pilot tested with eight students in Cyprus and Jordan, respectively. Feedback from this second pilot test was also incorporated into the final survey instrument. The final survey instrument was reviewed for linguistic appropriateness in all three languages. Human Subject Review approval was granted by all participating institutions ensuring that the study conformed to internationally accepted ethical guidelines and relevant professional ethical guidelines and informed consent was completed by all participants. The surveys were administered in class using online software via SurveyMonkey in the United States and Greece/Cyprus. Due to a software limitation of SurveyMonkey with the Arabic language, students in Jordan were administered the survey through paper and pencil also in the classroom. The following hypotheses were tested: overall knowledge of NSSI will differ by country (H1); understanding of NSSI treatment will differ by county (H2); NSSI behaviors will differ by country (H3); and cultural beliefs about NSSI will differ by country (H4).

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 19. Frequencies were run to check for anomalies, and the data were cleaned. Given the similar demographic characteristics of religion, language, and ethnicity among the Greek and Cypriot students and the small sample sizes, data from Greece and Cyprus were combined. Hypothesis 1 and Hypothesis 2 consisted of a nominal-level independent variable with three groups and an interval-level dependent variable. Therefore, a one-way analysis of variance (ANOVA) was used for analysis along with a Tamhane’s T2. For Hypothesis 3, a contextual assessment was appropriate because students responded to a series of open-ended questions. Hypothesis 4 consisted of two-nominal-level variables, and therefore a Chi-square test, along with a Cramer’s V, was used to test the strength of the associations.

Findings

Descriptive statistics

In the United States, 87 percent of the sample were female, in Greece/Cyprus 90.9 percent were female, and in Jordan 67.1 percent were female (see Table 1). The modal age of students was 18–24 years in the United States, Greece/Cyprus, and Jordan. In terms of race, in the United States 56.3 percent reported being White, 15.5 percent Hispanic, 20 percent African American, and 7.8 percent Other. In Greece/Cyprus, 100 percent identified as White/European, and nearly all students in Jordan identified as Arab (98.8%). In terms of religion, in the United States 72.2 percent self-reported as Christian, 23 percent reported no religion, and 5 percent reported other. In Greece/Cyprus, 100 percent self-reported as Christian (Greek Orthodox), and in Jordan, 100 percent self-reported as Muslim. In terms of sexual orientation, 92 percent of students in the United States reported being straight, 100 percent of students in Greece/Cyprus reported being straight, and 94 percent of students in Jordan reported being straight. In response to whether they had direct experience with clients who engaged in NSSI, 36.7 percent of students in Greece/Cyprus reported experience with clients who engaged in NSSI, whereas 39.3 percent of students in Jordan did, and 77.3 percent of students in the United States reported experience with clients who engaged in NSSI.

Table 1.

Characteristics of sample

Demographic variables	Overall	Greece/Cyprus	Jordan	United States
	n = 438 (%)	n = 99 (%)	n = 85 (%)	n = 254 (%)
	n (%)	n (%)	n (%)	n (%)
Gender (n = 438)
Female	368 (83.8)	90 (90.9)	57 (67.1)	221 (87)
Male	69 (15.8)	9 (9.1)	28 (32.9)	32 (12.6)
Other	1 (.2)	–	–	1 (.4)
Race (n = 429)
White/European	237 (55.3)	99 (100)	–	138 (56.3)
Arab	85 (19.8)	–	84 (98.8)	1 (.4)
Hispanic	38 (8.9)	–	–	38 (15.5)
Afr./Amer.	49 (11.4)	–	–	49 (20)
Other	18 (4.6)	–	1 (1.2)	19 (7.8)
Ethnicity (n = 436)
Greek	96 (22)	95 (96)	–	1 (.4)
Jordanian	85 (19.5)	–	84 (98.8)	1 (.4)
American	202 (46.3)	–	–	202 (80.2)
Other	53 (12.2)	4 (4)	1 (1.2)	48 (19)
Religion (n = 426)
Christianity	271 (63.6)	89 (100)^a	–	182 (72.2)
Islam	87 (20.4)	–	85 (100)	2 (.8)
Judaism	3 (.7)	–	–	3 (1.2)
Buddhist	5 (1.2)	–	–	5 (2)
Hindu	2 (.5)	–	–	2 (.8)
Other	58 (13.6)	–	–	58 (23)
Sexual orientation (n = 428)
Heterosexual	403 (94.2)	93 (100)	79 (94)	231 (92)
LGBT	25 (5.8)	–	5 (6)	20 (8)

LGBT: Lesbian, Gay, Bisexual, Transgender

Greek Orthodox.

Results for Hypothesis 1 were statistically significant (F(2, 435) = 13.25, p ≤ .05). Specifically, there was a statistically significant difference in mean scores in knowledge by country. A post hoc follow-up test, Tamhane’s T2, indicated US students had more accurate NSSI knowledge (M = 14.65) compared to Greeks/Cypriots (M = 12.35) and Jordanian students (M = 13.09). Results for Hypothesis 2 revealed that there was no significant difference (p > .05) between countries in terms of understanding treatment of NSSI. Results for H3 were limited by a computer glitch, and data were collected from the United States and Jordan only. Our results revealed NSSI behaviors differed markedly between countries. The majority of US students report cutting (93.4%), followed by burning (51.6%) and hair pulling (12%). The majority of Jordanian students report burning (50.8%), followed by substance abuse (22.2%) and cutting (18.5%). Unique methods reported by Jordanian students for NSSI included jumping from a height, masturbation, and removal of finger nails. Greek/Cypriot students were not included due to a software problem. Results for Hypothesis 4 (see Table 2) revealed that cultural beliefs regarding NSSI differed by country (p ≤ .05). Cultural beliefs appeared to be influenced by religion and gender. Jordanian students associated NSSI with having weak or absent ties to religion and supported including religious leaders in therapy, while Greek/Cypriot students did not support religious involvement in therapy. US students, on the other hand, viewed NSSI treatment as a matter of individual choice. Both US and Greek/Cypriot students attributed NSSI to mental illness and to the influence of socioeconomic factors.

Table 2.

Cultural beliefs and NSSI

Re: persons who engage in NSSI	Greece/Cyprus, n (%)	Jordan, n (%)	United States, n (%)	χ²	df	p	Cramer’s V
Do culture and religion prevent them from seeking help?	44 (71)	70 (83.3)	196 (84.5)	6.19	2	.046	.13
Are family and societal pressures the main contributors to NSSI?	48 (77.4)	75 (89.3)	139 (61.2)	24.92	2	.001	.26
Do males find it easier to seek therapy than females?	6 (10)	42 (50)	3 (1.3)	122.07	2	.001	.58
Do you think they are not religious?	7 (12.3)	61 (72.6)	7 (3.2)	181.04	2	.001	.71
Would you consider religious leaders helpful in your intervention?	10 (16.9)	73 (86.9)	130 (58.6)	69.80	2	.001	.44
Do they prefer their social worker to be of same gender?	35 (59.3)	68 (81)	111 (51.4)	21.96	2	.001	.25
Are they more likely to be single?	27 (46.6)	62 (74.7)	114 (52.8)	14.74	2	.001	.20
Can extended families be a good source of help?	35 (59.3)	56 (67.5)	188 (83.6)	19.36	2	.001	.23
Do you think where they live (city, rural) is related to NSSI?	35 (55.6)	64 (77.1)	104 (47.5)	21.39	2	.001	.24
And identify LGBT do receive equal treatment in your culture?	24 (39.3)	24 (30.4)	76 (33.6)	1.2	2	.535	Not run
Do LGBT easily seek out help in your culture?	7 (11.3)	21 (26.3)	49 (21.7)	4.9	2	.085	Not run

NSSI: non-suicidal self-injury; LGBT: Lesbian, Gay, Bisexual, Transgender; df: degrees of freedom.

Discussion

Our findings for hypothesis 1 (as indicated by the ANOVA test (F(2, 435) = 13.25, p ≤ .05) suggest that social work students in the United States have more accurate and thorough knowledge of NSSI compared to the social work students in Greece/Cyprus and Jordan. One reason for greater knowledge among students in the United States may be due to the fact that the United States has over a 100-year history in social work, and understanding of NSSI behavior as part of the social work curricula has had more time to evolve. In contrast, in Greece/Cyprus and Jordan, social work education is a more recent phenomenon, varying from a low of 11 years to a high of about 50 years. Second, the influence of culture and taboos on social work academics cannot be underestimated. After all, educators are affected by the same community values as the rest of society. For example, in Jordan there is no clearly unified social work code of ethics and religion informs the curriculum (Gharaibeh, 2012), while in Greece and Cyprus social work is informed by sociopolitical factors such as war and dictatorship (Koukouli et al., 2008). Third, factors that may make social work students in Greece/Cyprus less prepared is that family matters such as divorce, domestic violence, and child abuse are primarily managed within the family, and social work has a limited presence in mental health settings, both factors that undermine the development of NSSI knowledge. Additionally, this finding may be attributed to the lack of strong research culture among social work academics in the area of mental health (Koukouli et al., 2008). In Jordan, social work is not a recognized profession, and family members and religious leaders tend to serve as counselors and healers in response to psychological distress (Sullivan et al., 2010). Finally, stigma toward mental health issues and the use of mental health services remains strong (Al-Krenawi et al., 2004). This finding may elucidate Favazza’s (1989) claim that NSSI behaviors are seen by professionals as manipulative and attention seeking, which may also contribute to the fact that training programs exhibit particular neutrality over such high risk and prevalent behavior (Clarke and Whittaker, 1998). On the other hand, in developing societies that are ravaged by severe health and social issues such as food insecurity, HIV/AIDS, and child abuse, NSSI may not be relevant to the educational agenda of social work students or even the focus of practicing social work professionals. Therefore, the incorporation of NSSI education depends on the local culture and local needs which are used as a primary source for knowledge and practice development. Thus, particular types of social work practice and curricula, such as NSSI, are emerging in many parts of the world to deal with problems unique to individual sociocultural contexts (Gray et al., 2010).

Our findings for hypothesis 2 (as indicated by the ANOVA results; p > .05) suggest that social work students’ understanding of NSSI treatment was similar across countries. These results may be due to the general nature of the questions about treatment. Further research should focus on how social workers in different regions understand and implement NSSI treatment models.

For our third hypothesis, we asked students to record the most common behaviors they identify as NSSI. A contextual analysis was used to explore types of NSSI behaviors, but due to a computer glitch data were collected from the United States and Jordan only. Results indicated that NSSI behaviors differed between the two countries. For students in the United States, and congruent with the literature, the main form of NSSI was cutting (93.4%), followed by burning (51.6%) and hair pulling (12%). For Jordanian students, the most common form of NSSI was burning (50.8%), followed by substance abuse (22.2%) and cutting (18.5%). It is worthy of note that self-immolation is a more common method of suicide for women in the Middle East compared to women in the West (Rezaeian, 2010). While NSSI is, for the purposes of this research, explicitly distinct from suicidality, one wonders whether burning, the main form of self-harm reported by the Jordanian social work students, is related to the high number of self-immolations that have been observed in the Middle East. Substance abuse is not considered an NSSI behavior in Western literature, but in this study it emerged as the second most common NSSI behavior by Jordanian students. This may be related to the fact that substance abuse in Islam is considered self-harmful and forbidden and is severely punished (Pridmore and Pasha, 2004). Other behaviors not commonly reported included eating fatty foods and masturbation.

Cultural beliefs about NSSI were mediated by gender and religion. In particular, students’ perspectives differed when asked whether or not persons who use NSSI are religious. Unlike US students (3.2%) and Greeks/Cypriots (12.3%), the majority of students in Jordan (72.6%) felt persons who self-harm are not religious. Although views in the Middle East vary, it is commonly believed that behaviors that harm the body are a manifestation of mental health issues, are a punishment by Allah, or are related to evil demonic possession (Pridmore and Pasha, 2004). In Jordan, students (50%) reported that it is easier for males to seek treatment for NSSI than females, while this was not the case in Greece/Cyprus (10%) and the United States (1.3%). This discrepancy may be due to the fact that Muslim countries remain largely patriarchal, a stance that derives from the dominance of Islam, which puts the burden of maintaining honor on women (Rezaeian, 2010). Because acts of self-harm may be interpreted as an honor issue, women who seek help may be more stigmatized compared to men (Al-Krenawi et al., 2004). Interestingly, Jordanian social work students (74.7%) were also more likely to believe that persons who self-harm were likely to be single, compared with Greek/Cypriot (46.6%) or students from the United States (52.8%). Again, this finding may be related to the concept of honor in Jordanian society, the shame of not being married, especially for women, and to the central value of the marriage (Al-Krenawi et al., 2004).

Notably, Jordanian (86.9%) and US students (58.6%), unlike their Greek/Cypriot (16.9%) counterparts, reported that they would consider religious leaders as a component of treatment intervention with persons who self-harm. We might make sense of this finding when we consider that religion has been identified as a protective factor for mental health issues (Borrill et al., 2011), and it is therefore reasonable to assume social work students from the United States would be open to the idea of involvement by religious instructors in treatment. However, the Jordanian students’ responses are based on a very different perspective, where religion in Jordon is embedded in the lives of the community, and religious leaders rather than social workers assume the primary role in responding to psychological distress (Kokaliari, 2005). For students in Greece and Cyprus this was not the case, which may speak more to the identification of religion with ethnicity rather than practice (Grigoropoulou and Chryssochoou, 2011). The role of religiosity in Greece and Cyprus is extended mainly in the provision of social welfare organizations having to deal with social needs and, in particular, poverty.

Finally, unlike US students (47.5%) and Greek/Cypriot students (55.6%), Jordanian students (77.1%) report that where one lives (rural vs urban) relates to self-injury. The reason for this finding may once again be related to safe-guarding the honor of the family – a phenomenon more prevalent in the rural areas of Jordan – which is manifested in the stigma associated with mental health services and the pressure to not disclose psychological distress (Al-Krenawi et al., 2004).

Overall, culture and religion emerged as dominant themes in the received responses, congruent with the literature that indicates religion may serve as a more comprehensive way of assessing and comparing different ethnic groups who self-harm (Borrill et al., 2011). Thus, one may expect that while the social work tradition itself varies across regions, it is each country’s cultural and religious traditions that impact the way in which social work students understand NSSI.

Limitations

The primary limitation of this study is the use of non-randomized cross-sectional design that limits the representativeness of the study. While the convenience sample enabled us to understand these particular social work student perceptions at one point in time, it does not allow us to extrapolate to social work students at other institutions. Another limitation is sample size at each site. Relatively small numbers of students were surveyed in Greece and Cyprus (hence our need to combine Greece/Cyprus samples). Larger sample sizes at each site would strengthen our ability to assess the relationships among variables. In addition, a randomized design would have made for a stronger study, but the sensitivity of the content makes it particularly challenging.

Another limitation is that the survey was constructed by the authors and has not been validated. In fact, there is a shortage of valid and reliable international measures that address NSSI and suicide in the context of culture and religion. Still, our results indicate a clear need for large-scale international studies to further illuminate the influences of cultural and religious beliefs on the identification, treatment, and understanding of NSSI among social workers and allied professionals.

Implications for social work practice and education

NSSI is a particularly complex behavior to understand and treat. This study has important implications not only for international social work practice, but for social work curricula as well. This study highlights the need for social work students and professionals to be attentive to cultural issues especially as they are mediated by religion and gender when treating someone who engages in NSSI. Schools of social work should integrate NSSI content in their curriculum so that emerging social workers will feel knowledgeable and competent when confronted with the complicated mental health issue of NSSI.

Future research

Future research should focus on developing valid and reliable measures that capture NSSI, suicide-related matters, and cultural issues. We have come to understand through the responses of these developing social work practitioners that more comprehensive research on knowledge, treatment, and culturally relevant issues is needed on NSSI. For example, future research should explore the impact of variables such as anxiety, depression, culture, and ethnicity on NSSI and their relationship to suicidal behavior.

Footnotes

Funding

This research received funding from the International Association of Schools of Social Work (IASSW).

Author biographies

Effrosyni Kokaliari, PhD, is an associate professor of Social Work at Springfield College School of Social Work in Springfield, Massachusetts. Dr. Kokaliari received her MSW from University of Portsmouth and Hogeschoolf Utrecht, and her PhD from Smith College.

Ann Roy, PhD, is a professor of Social Work at Springfield College School of Social Work in Springfield, Massachusetts. Dr. Roy received her MSW from Louisiana State University and her PhD from Case Western Reserve University.

Christos Panagiotopoulous, PhD, is an associate professor of Social Work at the University of Nicosia, Cyprus. Dr. Panagiotopoulous received his MSW and his PhD from the University of Manchester.

Sahar Al-Makhamreh, PhD, is an associate professor in the Social Work Department at Princess Rahma College, Al-Balqa Applied University in Salt, Jordan. Dr. Makhamreh received her MA in Sociology from the University of Jordan and her PhD from the University of Warwick.

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