Young people’s stories of self–harm: A narrative study

Design

In this study a qualitative design was used in order to explore the stories of adolescents who self-harm and to allow them to give full accounts of their experiences. Narrative analysis was employed to allow examination of both the content of the adolescents’ stories and examination of the way in which the adolescents told these stories, thus providing a thorough understanding of their experiences.

Sample

Participants were recruited from a charitable organization that works with young people who have mental health difficulties or who may be at risk of developing mental health difficulties. All adolescents aged 13 to 18 years of age using this service who self-harm were invited to take part in the study. For the purpose of this project self-harm was defined as direct actions that injure the body. (Behaviours that fit into this category include cutting, burning, scratching, gouging and other similar actions).

Six adolescents agreed to take part in the study. This included five female adolescents aged 15, 16, 17 and two aged 18 years of age, and one male aged 13 years. All of the participants were either currently self-harming or had done so in the past six months (mainly by cutting, but also using other behaviours such as burning).

Life story interview

The life story interview was based on a modified version of the Biographical Narrative Interview Method (BNIM) (Wengraf, 2001). The BNIM uses a single broad narrative inducing question to prompt participants to tell the story of their experiences. Participants were first asked the question:

I am interested in hearing about the life experiences of young people who self-harm. I would like you to tell me the story of your life and all the experiences and events that seem important.

When it became apparent that the young person had finished responding to this question they were prompted to expand on the topics that they had raised in temporal order. The participants were also asked six additional questions directly related to their experiences of self-harm if these had not already been answered (Figure 1).

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Figure 1.

Interview Schedule

The purpose and nature of the interviews was discussed with the young people and it was made clear that it would be an opportunity for them to talk about their experiences in as much depth as they wished. It was made clear that since the topic could be distressing for them they could halt the interview at any time and that we would help to discuss their feelings and reactions. It was also made clear that follow-up support would be available if they need it from the voluntary organization they were connected with. Furthermore, the second reflective interview (see below) was employed both to gather further research material but also to serve as a source of reflection and support.

Reflective interview

The second reflective interview asked the participants to reflect on their experience of telling their story in the previous interview (see Figure 1 below for questions and prompts). It also provided an opportunity for the researcher to clarify issues brought up by the first interview or for the participant to add to their account.

Member Validation

The recreated stories and the thematic analysis of the interviews (see below for details) were taken back to the participants to check that they represented their views and experiences in a meaningful way and to invite them to change, add to, or exclude parts of the stories and analysis as they saw fit. Four of the participants chose to take part in this process. (Two of the adolescents chose not to see the results.)

Diane, 15

Umm well a few years ago umm where I used to live, there was one of my friends umm who I got very close to, and umm I ended up going out with him for ages but then umm because he took drugs umm his, he started getting jealous that I was like speaking to his brother and stuff like that, because he was older and he always seemed to be like more successful, but umm then in January 2006 umm he took an overdose, umm because he was in like drug induced psychosis or something, and he ended up killing himself through that I guess which is kind of like when it started probab … yeah about when it started. Umm and then his brother died earlier this year, umm that was in a car crash up country, um because he had been drinking or something, so he got hit by a car and umm then a few months ago … no not a few months ago … about a month ago I ended up having a miscarriage. Umm I don’t know what caused it or anything but umm that kind of didn’t help either.

Diane here can be seen to be making connections between the start of her problems and a number of difficult events including her boyfriend killing himself and a miscarriage. The way that Diane starts her account gives us the impression that these events happened to her (and the people around her) without her having any control over them.

Ben, 13

My mum left my dad when I was one to go to come down to (place) and live with my gran, where I live with my gran and granddad and then we moved into (place) and uh he never really kept in contact, and uh he recently he came down when I was younger and sort of threatened my Mum and stuff but he’s sort of stopped that now, and um he hasn’t been able to ever really talk to me properly cause he’s not really bothered and ur I’ve got a sister, she doesn’t live with him either and I’ve never met her because her Mum doesn’t want her to contact me … but she does anyway and ur I live with my Mum and my brothers … they’re okay … that’s really about it.

Here Ben can be seen to suggest that the start of the problems might have been related to his parents splitting up and possibly to domestic violence. This is followed by a sense of having been rejected by his father and kept from contact with his sister.

Brooke, 17

Umm … well I was with my parents until I was six, well my mum and her partners, but they were violent and abusive and there was a lot of drugs, my mum had mental health problems so … um … but I was known to social services and my brothers and sisters and me, and umm then we were all put into care when I was six and moved around quite a lot with the care system um … then … my brother and sister and me, my dad got custody of us so we all went to live back with my dad for a couple of months but he was just wanting the money basically so he was off and about with the benefits and we were left back at the house, and I was about nine, 10 and um then I got put back into care on my own and I moved around a lot and then I was locked up about four or five times on welfare um because I kept absconding from my children’s homes and that’s when I started self-harming. Umm … I first started probably around 13 when I first started self-harming. Umm … I was just I was locked up in a secure unit in (place) and then I just started self-harming then.

Brooke here recounts a progression of negative events in her life starting with experiences of violence, abuse and drugs in her family from a very young age. She describes events in a matter of fact way, but does not make explicit the possible effects on her of these events in terms of leading her to self–harm.

Kate, 18

Um … sorry, when I was younger umm I used to get abused and then I got bullied in school as well and then that just made me feel rubbish and I started self-harming … and it went like in a circle where I self-harmed and then felt bad about that and that made me do it again and just go around in circles. They just, it used to make me feel really rubbish and then it kind of like, I would self-harm and then it made me feel something, before that I couldn’t like, I just felt numb, so if I self-harmed it made me find something to focus on something and feel real. We lived in Ireland and then we moved here from Ireland and then that’s when the bullying started. It just used to be in school like everyday and quite a lot of people. It was like a big gang of people who didn’t like me so they bullied me. And most days in school they followed me and then it would be the end of the day and I would go home. And then like after a while I stopped but I started hearing things and I used to get threatened by someone who I thought was real and she was like “if you don’t hurt yourself I will hurt your family” so that made me.

Kate starts by making a fairly clear and definitive connection between negative events in her life—being bullied and how these affected her—made her feel rubbish which then led to her harming herself.

Rose, 18

Umm it’s easier to remember to the last couple of years, umm I’ve lived down here for quite a few years, I was originally from (place) and we moved back to (place) when my dad was dying umm and I think that’s when my … most of my self-harm, I tried it once before when I was 13 so being in a boarding school I got caught very earlier on and wasn’t allowed to do it umm but being out of school because I had left the boarding school at 14 and I never really found it. My mum was concentrating on my dad so then I found it and then he died and it got worse and then I lived with my auntie and she’s not the nicest of people when she wants to be so we eventually moved out there and we came home again down here and then it just got worse and worse until I was referred to (voluntary organization) and they have helped quite a lot and a lot of things in my life, my mum’s disabled so I’m her carer and … I’m having a baby so that’s quite a big responsibility and quite big in my life at the moment, I’ve never really done well at school as well so that didn’t help, I got bullied a lot and I’ve only really settled here at college now. Quite old now really aren’t I.

Rose starts by describing a potential causal event of her father dying, but then mentions that she had tried self-harming before at boarding school. She then follows this with a listing of some other events but without making any causal connections with how these may have started to shape her self-harming.

Alison, 16

Umm … I suppose like with my mum and dad who was ill. He didn’t like get up or anything, he had some kind of stress thing or something at work and I didn’t really understand much about it, cause he was never really ill I suppose, and I kind of didn’t understand it. No one, no one really talked to me about it much. I was kind of like just worried about him especially when mum was at work. I had self-harmed before though, like in that year but it was in the middle, I can’t really remember when that was. But it was kind of just like not that much; I burnt myself a few times but not much. When Dad got ill I was doing it pretty much every day just because I was worried about him and stuff, it was something else to worry about. I had also fell out with my friend just before. It meant that I didn’t really have anyone who I could talk to. Even though she was someone I moved form so I didn’t have to be around her because I felt that she like took control of me too much so I moved form but I was stuck on same bus as her, that was when that was I think. I also had a lot of problems with being quiet and nervous and stuff around people, but that was like several years before. When I first started self harming that was before my dad was ill, it was kind of, I didn’t feel like I was going anywhere with it.

Alison starts with a general connection to her father’s ‘illness’ and her concerns about him. However, the start of a narrative thread that this might have caused her harming drifts away as she mentions that she had done it before. However, as she continues the details that she increased her self–harming (burning) as her father deteriorated implies that she has some sense of these events being related.

When we tell stories about ourselves the start of the story often offers a condensed form or synopsis of what is to follow. In the young people’s stories in our study the start of their stories appeared to indicate the key features of the content—the key events that featured in their lives. In addition, the start of the stories also indicated the structure of their stories. In these six introductory passages it is only Kate who appears to start by drawing a clear causal link between some important events—being bullied and how this made her feel and her self-harming. The other young people start by some general allusions to possible causal connections between events. They offer enough factual material for the listener to impute causal connections between the events they describe but they do not appear to be able to or willing to make these themselves. From the offset with their stories we were led to anticipate that that they might be able to connect up the events to help make sense but typically the pattern of ‘how’ they would talk about their lives was indicated very early.

People just don’t understand, self-harm is my way of coping; it doesn’t mean that I’m weird or crazy

Ben explained the way in which his schoolmates would call him an ‘emo’ and make mocking gestures and noises towards him because they don’t understand why he self-harms: “they think that only weird people do it”. He also explained how he felt his parents just gave him ‘lectures’ and asked to see his arms (to check for cuts) all the time. These feelings of being misunderstood were echoed by all of the participants and seemed to alienate them from those around them. Diane felt that those around her judged her and failed to understand her self-harm:

A lot of people just don’t kind of understand it, they don’t understand why I do it because they managed to find other ways of like relieving their stress, but I cant it’s just kind of how I dealt with it and it has kind of become the only way I can kind of deal with things. So like there is people that who, not necessarily my friends, but people who just say “you are an emo’ sort of thing, it’s just like yeah emo’s don’t necessarily self-harm, you can look like an emo but not self harm and you can self harm and not look like an emo. I just happen to look like both”. She also suggested: “They try to put me into a category when they shouldn’t really cause I don’t categorize myself”.

All of the participants said that they tried to hide their self-harm from others because of this lack of understanding, often preventing them from getting support, from feeling accepted, and from discussing their difficulties openly. Alison tried to plead with her Dad not to tell her Mum when he found out about the self-harm because she didn’t think her Mum would understand:

I think my mum has got a very sort of negative view of like self-harm and she thinks that it’s weird and she thinks that it’s kind of … I don’t think she understands it. She knows someone who self-harmed and she said that wasn’t normal …

It seemed important for the adolescents to stress the way in which self-harm had helped them to cope, that even though some of them would now like to look at different ways of coping, it had helped them to get through difficult times:

it’s the way that I’ve taught myself to deal with things … it’s the only way that I can mentally cope with anything. I mean like have tried other things but they haven’t worked and I think that other people want me to stop but at the moment I think that it’s the best thing for me to do, there’s nothing else that I can do (Diane).

Brooke’s story is one of little choice or control over the decisions being made about her life. In her story she tells us about the way in which Social Services moved her from home to home giving her little say in where she wanted to live or what she wanted to do. She described the way in which she had control over the self-harm when she didn’t feel that she had control over anything else:

People have said to me you know is it kind of a way of control, and I have kind of thought to myself well yeah actually it is because if you think about it, you don’t have control over anything else and you have control over that, that’s something you’re doing, and you’re actually doing it so and you know how far you can take it.

All of these stories ask us to consider the way in which self-harm has been a necessary means for survival in the hope that understanding this might reduce the stigma; the idea that self-harming means that you are ‘weird’ or ‘crazy’.

Talking is difficult, so I keep it all inside

One point that came across powerfully both directly from the adolescents’ stories and from looking at the way that they told their stories is that talking is difficult. Rose outlined some of the main difficulties inherent in understanding the young person’s view of self-harm: “I don’t want to talk about it, that’s why I cut because I don’t want to talk about it”, (in a conversation with her counsellor) “I said that’s why I done it, there is just certain issues I cant talk about at the moment, he said ‘ that’s fair enough’ but I don’t think even he understood exactly, mind you I don’t, I cant expect anyone else to can I”.

This illustrates both the difficulties that adolescents experience in expressing and understanding their self-harm and also the motivation to do so at times when talking may mean re-living difficult memories and in lots of ways may be a difficult process, especially if others don’t have a good understanding of self-harm. Alison described self-harm as ‘the short way round’:

‘I don’t know just kind of just the short way round of feeling better’ and ‘because … I don’t know. It’s not like I have to think everything through. It makes me feel happier quicker, I know it’s a bit weird but when I do it kind of like, I get to a point, well just after I finished it, then I just feel like fine, like I don’t really think about it’.

In this way self-harm seems to act as an alternative to talking for the adolescents, a way of letting the emotion out without having to find the words to express it verbally.

The adolescents’ accounts suggest that talking may be difficult within their families. Kate describes arguments with her father where she feels that ‘there’s no point’ in voicing her opinions and that the best action is therefore to remain silent so that things calm down. In these situations she often self-harms afterwards to release tension and to punish herself for upsetting other family members. Ben also describes difficulty communicating with his parents. He says that his Dad “hasn’t been able to ever really talk to me properly” and describes the way in which he forgets ‘by accident’ to go to extra maths classes as his mother doesn’t ask him about whether he would like to go. Alison describes the way that her father’s illness was not discussed with her and how this lack of discussion made her worry and lack understanding about what his illness meant. All of these descriptions suggest that the adolescents’ difficulties talking may stem from family environments where open discussion is difficult or not possible.

The adolescents’ difficulty talking was evident in the research interviews, with several of the adolescents requiring considerable prompting and assistance in expanding their accounts. Interestingly, however, the adolescents seemed more at ease discussing the way that self-harm helped them to cope than other issues such as difficult events in their childhood or relationships.

Putting the anger inwards

Four out of the six adolescents talked about blaming themselves or believing that they deserved the self-harm, that they deserved to be punished. Brooke described the way that she learnt, in this way, to put the anger inwards:

I was an angry child and you know I was punching holes in walls and I was getting restrained all the time and try and run away you know lashing out at the staff and you know. Then in the end of constantly being told you know you’re always hurting other people and you’re always doing this and you’re always doing that, you know treat you like a bad child and everything and you know and you kind of think “oh well I’ll hurt myself then, I am not hurting you, not hurting anybody else” and I know now that I shouldn’t have, I was angry with everybody else and the situation that was going on and shouldn’t have taken it out on myself, but at the time I was just so upset and so angry about everything that when that became a habit.

For the other adolescents this seemed more difficult to explain. Alison struggled to describe why she felt she deserved to self-harm, saying that sometimes when she felt that she wanted to stop self-harming she thought that maybe she deserved it. She also described the way that self-harm allowed her to take control of herself so that she no longer lashed out at others which suggests that the anger is now directed at herself rather than others. Kate described a circular pattern where she would self-harm, then feel angry with herself for self-harming, then need to self-harm again in order to stop feeling angry. In these situations she would feel that she deserved it, and the self-harming behaviour and anger towards herself that made her self-harm would go round in circles. She also described the way in which the voice that she hears would tell her “if you don’t hurt yourself I will hurt your family” which suggests sacrificing her well-being for that of her family.

Structure and coherence

Four out of the six participants required considerable assistance in structuring their stories during the interviews. This included encouraging the adolescents to order their stories temporally and to expand on how the events made them feel or what it meant to them. Some of the adolescents’ stories seemed quite thin and lacking in detail, as if just giving a factual account of the events that had occurred. Answers from the reflective interviews suggested that this might be due to resistance in engaging with difficult memories; that this way of telling their story allowed them to remain emotionally distanced.

Integration

Integration relates to the extent to which the elements of narratives are woven together or synthesized in ways that do not indicate considerable contradictions or defended aspects. Although elements of the adolescent’s stories about self-harm were often quite well formed they were not well integrated with the other less dominant stories that emerged from our conversation. The adolescents’ ability to reflect on their lives and to be aware of gaps in their stories was also limited. Diane, for example, told a story about the difficult things that had happened in her life which lead her to self-harm. She also talked about her Mum’s depression and the way that her Dad left the family when she was five, but did not link these events in her story.

Resolution

Labov (1967) describes the main components of a story as being the abstract, orientation, complicating action, evaluation and resolution. While several of the accounts lacked somewhat in orienting information and may have needed assistance from the interviewer in order to expand on the meaning of the event (as described above), what was most striking was the lack of resolution (or meaningful conclusion) in these stories. For some of the adolescents it appeared that there was some resolution to their stories but this seemed limited or naive. Alison, for example, said that she felt closer to her parents as a result of her self-harm, as it allowed them to see how she was feeling and meant that she no longer lashed out. Without finding a different way of communicating, however, it seems unlikely that these difficulties have really been resolved. In a similar way Brooke described the way in which she aimed to work with young people in care so that she could listen to them and make changes in the way that Social Services treated young people. This may not provide her with the satisfaction or resolution that she expects, however, without being able to more explicitly address issues such as her relationship with her parents.

Lack of understanding from others

The plea for professionals, peers and parents to understand them better seemed to be the most important message that the adolescents put across in their stories. They felt misunderstood because those around them did not understand their reasons for self-harm and also suggested a broader sense of feeling misunderstood or not listened to. Their frustration seems well founded at this point in their development, as their experiences are incredibly difficult to understand (and integrate into a story that gives meaning and identity) without support from others. Their stories included annoyance at others people’s attempts to categorize them (suggesting that they were ‘crazy’, or an ‘emo’) and they spent a considerable proportion of the interviews justifying their self-harm as ‘a way of coping’.

At first glance most of the adolescents seemed to have a good understanding of their self-harm, talking about its use as a coping strategy and how it ‘relieved stress’. When asked to elaborate on this, however, the adolescents found it difficult, leading to possible questions about whether some of these explanations were given to them by professionals as a way of explaining this behaviour or were culturally accepted understandings. McAdams (1998) uses the metaphor of ‘press releases’ to indicate defensive processes seen in phrases or commonly acknowledged understandings that are highly palatable to listener but conceal the real individual story which may be painful and more complex for both storyteller and listener to understand. It seemed likely that the more complex stories about the adolescents’ difficulties were hidden by ‘neat’ superficially credible descriptions of the way in which self-harm helped them to cope. This might explain the way that the adolescents were more able to talk about their self-harm than the difficulties behind it and suggest that the conversations that the adolescents do engage in centre around normalizing self-harm behaviour rather than gaining a better understanding of the underlying difficulties. It seems interesting to consider whether it is the adolescents’ fears about what this means in terms of their identity, the fact that they are highly defended against talking about more painful experiences, or perhaps the conversations that professionals are comfortable engaging in that focuses these conversations in this way.

In a similar way, medical explanations may be seen to prevent further processing of the underlying emotions and sense making of previous traumas. Kate, for example, heard voices that told her to self-harm and had spent considerable time within the mental health service. A lot of the time the voices she heard seemed to be highlighting anxieties that were understandable in the context of her experiences, but the belief that the voices were simply a symptom of mental illness seemed to stunt further exploration of these experiences. In this way, medical understandings of issues such as self-harm or Psychosis might encourage defensive processes by suggesting that we do not need to explore the underlying difficulties. Without engaging in conversations that go past these neat explanations the adolescent cannot fully understand, story and make meaning of their experiences.

The perceived lack of understanding from others also had a significant impact on the adolescents’ relationships with others. The adolescents expressed difficulties relating to family and peers and a sense of isolation both in coping with their difficulties and more broadly. As family and peers are so important for identity development and processing of difficult experiences, this can only compound the problem. Several of the adolescents voiced a sense of agency that they experienced as a result of finding their own way of dealing with problems. Attachment literature, however, would suggest that this extreme form of independent coping where others cannot be depended on for help (perhaps suggestive of an avoidant/ambivalent attachment style) might lead to difficulties fostering supportive relationships in adulthood (McCarthy & Taylor, 1999).

Difficulty talking

The perception that others do not understand them (or their self-harm) seems very much linked to their difficulty talking. In what appears to be a vicious circle, the adolescents find it difficult to talk to others about their self-harm as they find it difficult to understand themselves. Without talking to others, however, they cannot gain support in developing more coherent and comprehensive accounts of their lives which will help to guide them in the future and are left instead with the assumption that others will not be able to understand. Unfortunately, negative reactions from others and the reality that self-harm is poorly understood within the general population can reinforce this process. This aside, these adolescents do seem to find it particularly difficult to talk and show a tendency to avoid thinking or talking about difficult issues. The adolescents describe self-harm as a preferred method to talking or having to think things through and also a way of coping because they cannot talk. The adolescents’ stories also highlight difficulties talking within the family, suggesting that their opportunities to talk are limited.

These difficulties were evident in the way in which the adolescents needed assistance in structuring their story and by the parts that were not storied. Difficulties were also apparent in the way the adolescents had difficulty constructing fully integrated narratives. For most of the adolescents their stories about self-harm seemed to stand alone, requiring assistance from the interviewer to make links between self-harm and difficult experiences or stressors and to place the story within a broader life context. Brooke’s story stood out as being more fully integrated without assistance, as did Rose’s in parts, as she spontaneously made links between difficulties such as isolation and increased self-harm. These differences could be explained by the practice that they have had in telling their stories and assistance gained from professionals in scaffolding them. Brooke and Rose are also amongst the oldest of the adolescents (aged 17 and 18 respectively), which might suggest that some of this difference is due to age related development.

The lack of true resolutions in the adolescents’ stories is unsurprising given the difficulty that most of them had in telling their story, their lack of opportunities to discuss their difficulties and the defence mechanisms in place. It seems possible that the resolutions that they do hold may be quite risky. In Alison’s case, for example, self-harm seems like a better option than aggression, as she believes that her relationship with her parents has improved, but this seems questionable. In Rose’s case her pregnancy has put self-harm on hold for a while but as a young, single mother it seems likely that her difficulties may increase due to the pressures of caring for a young baby.

These adolescents have stories with gaps, and parts that they would prefer not to re-visit. Their stories do not fit neatly together or have a satisfactory ending. The implications of this are thoughts, memories and feelings that are overwhelming; with self-harm being the only visible way to manage these.

Implications of directing anger towards self

Four of the adolescents described earlier aggressive behaviour that was met with punishment so that self-harm (perhaps not consciously) seemed a better alternative. This seems like a damaging strategy in terms of personal development but one that is easy to imagine when we consider the way that aggressive behaviour is often thought about in our culture. In Alison’s story, for example, we can understand the way in which her concern about her father’s illness and problems at school were difficult for her to understand thus leading her to lash out. The treatment that she received rather than validating her distress and teaching her to express her emotions verbally, caused her to internalize them and to believe that she is a bad person for feeling and expressing her emotions in that way. In this way punitive treatment could be seen to build on and reinforce a negative view of self that these adolescents hold as well as discouraging the expression of feelings, especially anger, which was notably missing in several of the adolescents’ interviews (Bateman & Fonagy, 2004). In the context of identity development it seems particularly damaging that not only did these adolescents not have access to relationships that enabled them to express their feelings, but they also had no access to conversations where they could process early traumas and reach an understanding that they had no control over these events (Crittenden, 2008). Our findings suggest that a combination of attachment and systemic theories are necessary to conceptualize the young people’s experiences. Abilities to develop coherent stories about our lives are intimately connected with the conversations we are encouraged to engage in with our families and other intimate relationships (Dallos & Vetere, 2006; McAdams, 1993).

Critique

This research aimed to work together with the adolescents interviewed in order to assist them in giving their account of their experiences. For this reason member validation and feedback from participants about the interview process during the interview process was very much encouraged in the hope that this would allow their views to be heard. It is impossible to counteract all power differences in the research process however, especially with those adolescents who found it very difficult to talk and those who chose not to take part in the validation process. It is important, therefore, to acknowledge the part of the researcher in the interpretation of the adolescents’ stories.

It is also a challenge to respect the individuality of each adolescent’s story while looking for commonalities. Unfortunately this inevitably results in the compromising of some elements of the individual stories in order to draw conclusions about shared experiences.

Limitations and future research

Due to time limitations it was not possible to analyze all aspects of the participants’ interviews. It would have been interesting to consider more fully the way that the adolescents told their stories by looking at the links they made between current motivations, feelings and beliefs about self and past events. Habermas & Paha (2001) suggest that the ability to link major events and single episode narratives develops in adolescence, thus allowing us to create a meaningful and coherent life story. A lack of integration and linking of events was noted in this study, making it an interesting area for further exploration.

It should also be noted that only one male participant was interviewed in this study. Although this reflects a noted increased vulnerability for self-harm in female adolescents (Hawton, Hall, Simkin, Bale, Bond, Codd & Stewart, 2003), future research could helpfully explore male perspectives on self-harm further.

Future research that could further examine the difficulties that adolescents experience in developing a secure identity as a result of unprocessed trauma would also helpfully expand the ideas put forward in this study.