Start,stop,and continue: Preliminary insight into the appeal of self-injury e-communities

Abstract

Nonsuicidal self-injury e-communication has gained heightened empirical and public interest. This is the first study to examine possible motives for nonsuicidal self-injury e-communication. A total of 68 nonsuicidal self-injury e-community members responded to open-ended questions concerning reasons for starting, temporarily stopping, and continuing nonsuicidal self-injury e-communication. Results from a thematic analysis indicated that being motivated to obtain support, get nonsuicidal self-injury help, help others, and better understand nonsuicidal self-injury represented motives for starting nonsuicidal self-injury e-communication. For some, negative interactions and accessing triggering material contributed to e-communication stoppage; these individuals continued e-communication to get support and help. Implications for research and e-outreach are discussed.

Keywords

adolescence communication information Internet mental illness

Referred to as the purposeful destruction of one’s body tissue (e.g. cutting, burning) without conscious suicidal intent, nonsuicidal self-injury (NSSI) represents a critical issue for individuals worldwide (Klonsky et al., 2011). Among adolescents and emerging adults, NSSI rates consistently range from 13.9 to 21.4 percent (Nock and Favazza, 2009), with many studies reporting higher rates (see Klonsky et al., 2011). Beyond its rates, NSSI confers risk of physical injuries, scarring, psychiatric difficulties, and suicidality (Klonsky et al., 2011, 2013). Recently, the role of e-communities, which enable individuals to connect and interact with others via the Internet, has garnered research attention in the context of NSSI. Indeed, e-communities may represent a common and preferred mode of interaction for many people who self-injure (for a review, see Lewis et al., 2012).

Several studies have examined the role of e-communities and the interactions (i.e. e-communication) occurring within them for various health-related issues, including but certainly not limited to lupus (Mazzoni and Cicognani, 2013), cancer (Chiu and Hsieh, 2012), eating disorders (Mulveen and Hepworth, 2006), and HIV/AIDS (Mo and Coulson, 2010). Findings from these studies point to the centrality of e-communities for individuals who experience these health issues; this may be especially salient for youth and young adults (Chiu and Hsieh, 2012; Mulveen and Hepworth, 2006; Teufel et al., 2011). A consistent finding across many studies is that although people make use of e-communities for a variety of reasons, obtaining needed support and accessing health information represent two primary motives for e-communication. For example, in a study involving e-communities for individuals diagnosed with lupus, most messages posted by e-community members were made to forge connections with others, get information, obtain emotional support, and give back to others in the e-community (Mazzoni and Cicognani, 2013). It has been suggested that similar reasons may underlie NSSI e-communication (Lewis et al., 2012a; Whitlock et al., 2006). However, few studies have formally examined this. Indeed, most research to date has focused on the impact that e-communication may have on those involved (see Lewis et al., 2012a).

Research examining the impact of NSSI e-communication highlights a number of risks associated with this form of online activity. Most notable are NSSI normalization and reinforcement. That is, by virtue of engaging in NSSI e-communication, individuals may be exposed to messages that contribute to NSSI maintenance and thwart help-seeking (Lewis et al., 2012a; Rodham et al., 2007; Whitlock et al., 2006). For example, individuals who share their NSSI experiences online often do so with an emphasis on emotional suffering and without hopeful messages about prognosis (Lewis and Baker, 2011; Lewis et al., 2011, 2012b) or present NSSI as an effective means to manage emotional pain (Lewis and Baker, 2011; Whitlock et al., 2006). Repeated access to these messages may foster a deleterious narrative in which NSSI is presented as a viable coping response and for which there is little hope for recovery. In addition to these messages, users of NSSI e-communities may be exposed to strategies that discourage help-seeking, including ways to self-injure, ways to hide NSSI from others (e.g. parents), and first-aid tips (Lewis and Baker, 2011; Whitlock et al., 2006). Finally, NSSI e-communication may confer risk of triggering, or heightened NSSI urges pursuant to viewing certain messages or images (Lewis and Baker, 2011; Murray and Fox, 2006).

Notwithstanding these risks, NSSI e-communication may have benefits. Researchers suggest that NSSI e-communication provides needed support to otherwise isolated individuals, which may increase feelings of validation and acceptance (Johnson et al., 2010; Lewis et al., 2012b; Murray and Fox, 2006; Rodham et al., 2007; Whitlock et al., 2006). In turn, this may increase belongingness (Johnson et al., 2010). NSSI e-communities also provide resources (e.g. coping tips) and may present encouraging, recovery-focused messages (Lewis et al., 2012a). Some have suggested that NSSI e-communication can reduce NSSI (Johnson et al., 2010; Murray and Fox, 2006). Taken together, these reports offer an interesting contrast to the above research concerning risks. Interestingly, the aforementioned benefits of NSSI e-communication seem to be tied to its underlying motives. For example, if individuals lack social support offline, they may be motivated to find it online.

Identifying motives for NSSI e-communication may shed light on why this may appeal to individuals, why it is repeated, and why it may be difficult to stop despite its potential consequences. In this regard, uses and gratification theory may have utility. Rooted in the notion that people deliberately use media in order to fulfill underlying needs (e.g. to get information or support), this theory has been useful in studying motives for media use as well as the negative and positive effects this may have. Recently, this theory has been applied to social media (Whiting and Williams, 2013), which would include e-communities.

Research investigating the appeal of NSSI e-communication is scant, and studies aimed at fostering a deeper understanding of NSSI e-communication from the vantage point of those involved have merit. Knowing what motivates NSSI e-communication may have clinical implications. According to guidelines to address problematic NSSI e-communication, it is recommended that clinicians assess what drives this (Lewis et al., 2012a; Whitlock et al., 2007). Knowing more about motives for NSSI e-communication might inform clinical approaches by illuminating questions to ask. Furthermore, these motives may highlight avenues for e-outreach, namely, ways to provide resources to those who may not seek help offline.

For many individuals, NSSI is episodic and thus may only occur in times of stress (e.g. Klonsky et al., 2011). If e-communities are used to obtain support, they may be used mostly during times of high stress versus low stress; thus, for some, e-communication may temporarily stop and later continue. Adverse online experiences may also contribute to this. NSSI e-community members have expressed concern that certain messages may trigger NSSI (Baker and Lewis, 2013). It is conceivable that if people are triggered, they temporarily avoid NSSI e-communities. No research has explored whether individuals temporarily stop NSSI e-communication and why; similarly, no research has examined whether individuals continue NSSI e-communication after temporarily stopping. In keeping with the clinical guidelines for addressing NSSI e-activity (Lewis et al., 2012a), identification of reasons for starting, temporarily stopping, and then continuing NSSI e-communication may augment approaches to address problematic NSSI e-communication.

Few efforts have examined the appeal of NSSI e-communities; studies that do chiefly rely on what individuals post online rather than asking individuals about this directly. This is the first to directly ask participants about their experiences with NSSI e-communication to understand (a) why they join NSSI e-communities, (b) why some temporarily stop using NSSI e-communities, and (c) why these latter individuals return and continue using NSSI e-communities. Obtainment of support may motivate NSSI e-communication (Lewis et al., 2012a; Whitlock et al., 2006). Research examining pro-eating disorder websites also suggests that social support may drive e-communication (Mulveen and Hepworth, 2006); parallel reports have been made for other health issues (e.g. Mazzoni and Cicognani, 2013; Mo and Coulson, 2010). Although we expected a similar theme in our data, we adopted an exploratory approach for each of the above questions; given the paucity of work in this area, we did not want to overlook other possible themes. Prior to commencing the study, our Institutional Review Board provided clearance for our investigation.

Methods

Participants

Participants (n = 68) were members of active NSSI e-communities. Individuals volunteered for the study; compensation for participation took the form of entry into a draw for four gift cards. Participants were predominantly female (83.82%); they ranged in age from 16 to 57 years (M = 24.15 years, standard deviation (SD) = 8.41 years). One participant did not indicate gender; three did not indicate age. Most participants were Caucasian (85.30%), with others reporting Hispanic (1.47%), mixed (4.41%), and other (7.35%) ethnicities. Most were from the United States (57.35%). The remaining were from Canada (16.17%), England (10.29%), Australia (5.88%), Germany (2.94%), Finland (1.47%), Ireland (1.47%), Russia (1.47%), Sweden (1.47%), and the Netherlands (1.47%). Participants indicated their sexual orientation as straight (48.53%), lesbian (4.41%), bisexual (20.59%), transgender (1.47%), questioning (13.24%), and pansexual (11.76%).

All participants had self-injured and had reported injuring at least 13 times, with some reporting over 10,000 times (M = 1030.07, SD = 2396.63). Participants used 2 to 13 NSSI methods, with most using 5 (16.18%). Cutting was most often reported (87.71%); this was followed by severe scratching and banging/hitting oneself (80.88%) and then wound interference (70.59%). Most participants wanted to stop self-injuring (58.82%), though many (39.71%) did not. Almost two-thirds reported NSSI in the past month (66.18%).

Measures

Inventory of statements about self-injury (ISAS; Klonsky and Glenn, 2009)

The ISAS is a psychometrically strong self-report questionnaire assessing NSSI history, age at onset, frequency, recency, severity, methods, desire to stop, and functions.

NSSI e-communication questions

Participants were asked three questions. First, individuals (n = 68) were asked why they started NSSI e-communication (In your own words, why did you first seek out self-injury websites or online communities (i.e. self-injury message boards, YouTube channels, Facebook groups, etc.) where others who self-injure communicate with each other?). Second, participants (n = 24) who temporarily stopped NSSI e-communication were asked why this was the case (What was the main reason for your decision to stop visiting self-injury websites or online communities?). Third, these participants were asked why they continued their e-communication again (What was the main reason for your decision to return to the self-injury websites or online communities?). Respectively, these questions are henceforth referred to as starting, stopping, and continuing NSSI e-communication.

Procedure

As a part of a larger study examining NSSI e-communication, participants were recruited using messages posted on NSSI e-communities that demonstrated activity within the past week; no e-communities explicitly mentioned being professionally moderated. Recruitment messages linked to a website on which individuals could access the study consent form. Here, participants indicated whether they wanted to enroll in the study. As a part of indicating consent, participants were asked to answer a few brief multiple-choice questions about the study (e.g. its purpose) to demonstrate their understanding of what the study entailed. They also provided an email address and were sent usernames and passwords, which granted access to the above questionnaires.

Thematic analysis

We used thematic analysis for several reasons. First, there is a dearth of research examining motives for NSSI e-communication, and we wanted an inductive approach conducive to exploring various motives from participants’ perspectives. Second, we wanted to use an approach that permitted us to understand, in depth, commonalities or patterns in participants’ responses. Third, we wanted a flexible approach that can be used by researchers from a variety of epistemological stances and theoretical viewpoints. Accordingly, we employed the following steps described by Braun and Clarke (2006):

Phase 1: data familiarization. The initial step in thematic analysis involves the reading (and re-reading) of data in order to identify potential codes/themes.

Phase 2: generation of initial codes. Next, data are organized into meaningful groups.

Phase 3: searching for themes in data. The third step involves arranging the codes into potential themes; relevant extracts for all potential themes are also collated. This stage comprises the identification of relationships between themes and level of themes (e.g. sub-levels subsumed in a broader level). Themes were identified on the basis of repetition, congruence with literature and author clinical experience, and the degree to which themes were different from one another.

Phase 4: review of themes. Here, themes are reviewed to ensure they cohere and are meaningfully distinct.

Phase 5: defining/naming themes. In the final stage, the essence of each theme is identified in order to determine what component of the data (e.g. extract) is represented by the theme.

To enhance rigor and reliability in our analysis, we engaged in note-taking during all phases to document how theme classification occurred. We also engaged in regular consultation to ensure theme names, and interpretations were collectively agreed upon.

Results

Starting NSSI e-communication (Figure 1)

When participants were asked why they initially participated in NSSI e-communities, the following five themes were identified: (1) Seeking Support, (2) Getting NSSI Help, (3) Offering NSSI Help, (4) Understanding NSSI, and (5) Indirect Discovery. Themes are presented below with corresponding participant responses (original spelling and grammar were retained).

Figure 1.

Thematic map for starting, stopping, and continuing NSSI e-communication.

Seeking Support. The importance of obtaining support emerged as a significant and frequent motive for joining NSSI e-communities. One aspect of support that seemed particularly appealing was that of anonymous support. Here, responses were brief but emphasized a need for support without having to self-identify:

Was looking to find support where no one knew me. (Participant 16)

Basically for an anonymous support system. (Participant 2)

Additionally, participant responses frequently offered a shared view that individuals who do not self-injure do not understand NSSI; they discussed how those who self-injured would understand NSSI and would thus be better suited to offer acceptance and validation:

I seeked out self-injury websites because nobody understood me. My mother screams at me when I self-harm. I need support from people who understand me. (Participant 64)

to find others who understood what I was going through, and who wouldn’t get super upset at me and demand I get help and fit myself immediately. (Participant 12)

I was tired of feeling alone and being surronded by others who didnt understand what I was going through when I would try to reach out for help. (Participant 42)

In a similar vein, individuals wrote that NSSI communities were uniquely appealing by offering a sense of belonging, thereby decreasing isolation:

Therapy and books helped but it was better to be able to talk to people who are going through the same things as you. It’s nice to see you aren’t the only one in this. (Participant 11)

I wanted to see if I could related to others and not feel so alone/insane for self injuring. (Participant 14)

Participants also discussed a desire to obtain social support in an effort to recover. They seemed to believe that by getting encouragement from others and hearing about the experiences of others, they would be in a better position to stop injuring:

I was looking to stop. I was hoping other people encouraging me to stop would help me. It was so diffucult being an adult woman and admitting to friends that I needed help stopping cutting. The internet anonymity really helped me out. I really feel like the message board helped me stop cutting so much/so often. (Participant 37)

to try to gain strength to continue not cutting through hearing other people overcoming it. (Participant 23)

Getting NSSI Help. Responses categorized as getting NSSI help were less frequent and involved explicit expressions of a desire to stop NSSI; in contrast to the previous theme, there was no mention of social support:

… I don’t feel like wanting to slit my wrists is an appropriate stress response, but it’s pervasive and I don’t know how to stop. I was looking for help. (Participant 7)

I was looking for ways to stop injuring myself, to find better coping stratergys. (Participant 28)

Offering NSSI Help. Individuals often wrote about a desire to help others as a reason for NSSI e-communication; specifically, they wanted to show others that people who self-injure are not alone:

I’ve been self harming for most of my teen, young adult life. I wanted to try and help other people know they’re not alone or have someone to talk too instead of acting out through self harm. (Participant 3)

to try to help others who were feeling like i was. (Participant 21)

Understanding NSSI. Participants also discussed a desire to enhance their NSSI knowledge, seemingly to understand their own experiences:

To learn more about what I was doing. (Participant 39)

I was seeking information and understanding of what i was going through. I had no understnading of the feeling i expeirienced before, during and after SI. (Participant 56)

Related to this, participants wanted perspective into the NSSI experiences of other e-community members:

The first time was to see how they were thinking and feeling when going through with self harm. (Participant 44)

At times, this involved not just wanting to hear about others’ experiences with NSSI but also their experiences receiving professional help for NSSI:

I first looked for an active forum after injuring myself very severly. I wanted to go to the hospital to get stitches, but I was worried that I could be commited to a psychiatric hospital against my will. I wanted to see if that was a probable outcome. I wanted to get my wound treated but not at the expense of an extended hospital stay I couldn’t afford and possible loss of my job. I wanted to find other people online who had been in my situation and see what happened to them. (Participant 31)

Indirect Discovery. Although most individuals seemed to intentionally find NSSI e-communities, some said this was unintentional. Here, participants reported finding NSSI communities accidentally (e.g. conducting a web search):

It was scary and isolating to find something so wrong that felt so good. I googled looking for an explanation, I found forums. (Participant 58)

I came across this forum [the community] by accident and read posts of others that I could relate to (i.e. no desire to stop/practical problems). (Participant 15)

Others discussed accessing NSSI e-communities after receiving recommendations from others, including both peers and professionals:

my firend directed me to [the community] when she found i was selfharming. (Participant 50)

Recommendation of psychologist—first went looking for information, then found support. (Participant 52)

Stopping NSSI e-communication (Figure 1)

For individuals who temporarily stopped NSSI e-communication, we asked why this occurred. Four themes emerged from people’s responses: (1) e-Community Stress, (2) Unmet Needs, (3) Being Triggered, and (4) Upsetting Others.

e-Community Stress. Here, participants discussed how their interaction with others in NSSI e-communities was a source of stress, conflict, and hostility and thus led to ending their e-communication:

It wasn’t productive. I was only getting negative emotions from it. (Participant 45)

I had a fight with some members about a very difficult and triggering topic. I could not stand the hostility and I was ashamed that I let myself be mean, too. (Participant 46)

Being Triggered. Individuals also stopped visiting NSSI e-communities because they were triggered as a result of e-community involvement. This was especially the case when accessing content that was graphic in nature (e.g. imagery):

Some of the graphic photos were too triggering for me. (Participant 26)

I realized visiting the site was a major trigger for me and it wasn’t helping my recovery. (Participant 34)

I thought if I stopped visiting I’d stop triggering. (Participant 22)

Unmet Needs. Some participants discussed how continued involvement with NSSI e-communities was no longer relevant or useful. They indicated that their needs were either not met or were no longer being met through their interaction with the communities:

Not focused on recovery/didn’t like the community. (Participant 48)

I felt that I did not need that level of support anymore. (Participant 67)

Upsetting Others. Beyond discussing the impact NSSI e-communication had on them, participants expressed concerns that what they posted would trigger or upset other e-community members. They seemed to be aware that material they posted online could affect others:

I was too full of my own situation and I didn’t want to trigger anyone else because I was being careless. (Participant 38)

Continuing NSSI e-communication (Figure 1)

Finally, participants who temporarily stopped NSSI e-communication were asked why they returned to NSSI e-communities. Here, four themes emerged: (1) Missing Support, (2) Needing Help, (3) Triggering Oneself, and (4) Able to Return.

Missing Support. When asked why they returned to NSSI e-communities, individuals discussed how they missed the social support received through past e-communication and how this could help address NSSI urges:

because of various triggers in my personal life i became vulnerable again and was looking for support. (Participant 23)

Others discussed how the significance of the relationships and camaraderie developed through e-communication prompted a return to NSSI e-communities:

I really liked some of the members and I missed talking to others who self-injured. (Participant 46)

Missed my friends. (Participant 8)

Needing Help. Beyond discussing the import of support and friendship, participants also described a need to access the information and resources provided by the websites as a reason for returning. This occurred even when individuals acknowledged that certain e-community content might be upsetting:

Although the website sometimes triggered me, there was also information on there that helped me. I also felt really isolated without it. (Participant 65)

Triggering Oneself. This theme comprised the desire to trigger oneself; here, accessing content that would lead to NSSI seemed to contribute to a return to NSSI e-communication:

I was beginning to “relapse” and the site was the trigger that I was looking for.(Participant 34)

Able to Return. Responses making up this theme discussed how participants’ initial reason for leaving NSSI e-communities no longer applied to them; accordingly, they reported being able to return to their original social networking activity:

For a while my urges exponentially increased so I stopped for about a week to see if that was the reason why.—It wasn’t. (Participant 19)

Discussion

This study provides a preliminary glimpse into the reasons for starting, temporarily stopping, and then continuing NSSI e-communication. Although many factors contribute to NSSI e-communication, researchers have speculated that this is largely driven by the feelings of loneliness and isolation (see Lewis et al., 2012a). Our findings support this view. Indeed, many participants discussed how these e-communities are used to obtain social support (Seeking Support); also consistent with past research (Lewis et al., 2012a; Murray and Fox, 2006; Whitlock et al., 2006), participants highlighted the import of the anonymity afforded by NSSI e-communities. In addition to social support, participants discussed the reciprocal nature of help-seeking and help provision (Getting/Offering Help). This aligns with the recent research (Rodham et al., 2013) and, as discussed below, may have implications for NSSI recovery.

The Internet has been implicated as an important means of accessing NSSI information (Lewis et al., in press). Our findings suggest that e-communities may have particular relevance in this regard (Understanding NSSI). Efforts to ensure the quality of information in e-communities may be needed. There may be utility in using people’s NSSI stories to provide NSSI information and foster recovery. Participants discussed how those who self-injure have a deeper understanding of NSSI versus those who do not and how they could learn from others’ experiences. Thus, provision of supportive and recovery-oriented messages from individuals who have overcome NSSI may be helpful in e-communities as these messages may resonate with those who presently struggle.

While there may be initial appeal to NSSI e-communities, this may not last. That is, needs previously met through NSSI e-communication may no longer be met (Unmet Needs). Adverse experiences may also contribute to temporary stoppage of NSSI e-communication (e-community Stress, Being Triggered). Indeed, individuals may have unsupportive and hostile interactions with other community members (e.g. Lewis et al., 2012b); sometimes, they may even be triggered by the content they access (Baker and Lewis, 2013; Lewis and Baker, 2011). Moderated e-communities may help safeguard against these risks and ensure individuals have supportive interactions when online (Lewis et al., 2012c). This may also address concerns that participants had about how their own messages may negatively affect those who access them (Upsetting Others).

Similar to reasons for starting e-communication, getting support and help appear to contribute to NSSI e-communication continuation (Missing Support; Needing Help). It is conceivable that these needs emerge when NSSI urges worsen (e.g. people self-injure only when acutely stressed). Hence, provision of coping resources in e-communities for individuals to use when experiencing NSSI urges and related difficulties (e.g. distress) may have merit.

Most participants report seemingly positive reasons for continuing NSSI e-communication (e.g. getting support). Curiously, however, a few returned to e-communities to trigger themselves (Triggering Oneself), a finding aligning with recent research (Baker and Lewis, 2013). This is worrisome, and efforts are needed to understand why some people report a desire to exacerbate their own NSSI.

Given our small sample size, findings may not generalize to all individuals who engage in NSSI e-communication. Our study is also exploratory, and research is needed to further validate the present findings. Use of thematic analysis, while useful in exploratory work, does not yield an integrated, overarching theory as might grounded theory. Additionally, our questions for starting, temporarily stopping, and continuing NSSI e-communication differed in wording; this might have affected how respondents answered the questions. Future work should use more consistently worded questions.

Our methodological approach precluded direct interaction with participants, meaning we could not ask follow-up questions about any responses provided; thus, we are unable to inquire about which e-communities individuals were involved with, how often they used these e-communities, or what specific aspects of e-communication they referred to when responding to our questions. We also do not know what happens to those who stop NSSI e-communication completely. Furthermore, we are unable to follow-up with participants to ask whether they agreed with our themes. These issues warrant attention in future work.

On the one hand, at least for some individuals, there may be no downside to NSSI e-communication; receiving social support and information may have a positive impact on recovery. On the other hand, it may be that although e-communication provides social support, a sense of community, among other possible benefits documented above, it may confer risk of NSSI normalization and reinforcement. This may be particularly the case if the nature of e-communication does not center on recovery (Lewis and Baker, 2011; Lewis et al., 2011, 2012b; Whitlock et al., 2006). Thus, unhelpful messages may be reinforced through repeated e-communication. It may also be difficult for some individuals to leave NSSI e-communities altogether if they identify with e-community members and/or NSSI. Taken together, NSSI e-communication may represent a “double-edged sword.” Future research ought to examine the link between specific forms of NSSI e-communication, NSSI, and recovery/help-seeking attitudes to better understand how individuals are affected by NSSI e-communication.

The current findings, in part, mirror previous research examining motives for e-communication for various health and health behavior issues (e.g. Chiu and Hsieh, 2012; Elwell et al., 2011; Mazzoni and Cicognani, 2013; Mo and Coulson, 2010; Mulveen and Hepworth, 2006). Specifically, seeking support and help from others as well as accessing health-related information may represent cardinal needs for people when using e-communities for health issues they experience. Unique to this study is the focus on not just what may motivate NSSI e-communication but also why individuals might elect to temporarily stop e-communication and, at a later date, continue it. No study that we know of has used open-ended questions to ask people about motives for starting, stopping, and continuing e-communication for other health or risk-like behaviors. Exploratory investigations, adopting similar approaches, may be helpful in the initial study of e-communication about health-related behaviors.

More work is needed to understand the nature and scope of motives for NSSI e-communication longitudinally, at different stages of e-communication (e.g. starting vs continuing e-communication), and how these motives can be understood in a broader context. Uses and gratification theory may have utility here. For example, if individuals need social support, they may start using NSSI e-communities. If support is provided (i.e. individuals’ needs are gratified), this may help to understand why e-communication continues; similarly, if e-communication stops (even temporarily), it may be that people’s needs are not gratified.

Efforts to develop a measure to assess NSSI e-communication could prove fruitful in both research and clinical domains. Currently, there is no such scale. As asking about reasons for NSSI e-activity is recommended when working with clients who self-injure (Lewis et al., 2012a; Whitlock et al., 2007), a measure may facilitate this process and attenuate focus on the motives most relevant to a client.

Akin to other topics in clinical health psychology, the Internet may represent a powerful and highly salient vehicle to reach those who self-injure—particularly those for whom offline disclosure and help-seeking is difficult or undesirable. Outreach efforts providing e-resources (e.g. research-based information, coping strategies) seem warranted. As some individuals expressed a need to learn through others’ NSSI experiences, fostering positive and recovery-focused narratives through e-communities (e.g. text, video) may be important. This may also combat harmful NSSI narratives reported in the past work (e.g. Lewis and Baker, 2011).

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Baker

Lewis

(2013) Responses to online photographs of non-suicidal self-injury: A thematic analysis. Archives of Suicide Research 17(3): 223–235.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.

Chiu

Hsieh

(2012) Communication with fellow cancer patients: Writing to be remembered, gain strength, and find survivors. Journal of Health Psychology 18(12): 1572–1581.

Elwell

Grogan

Coulson

(2011) Adolescents living with cancer the role of computer-mediated support groups. Journal of Health Psychology 16(2): 236–248.

Johnson

Zastawny

Kulpa

(2010) E-message boards for those who self-injure: Implications for e-health. International Journal of Mental Health and Addiction 8: 566–569.

Klonsky

Glenn

(2009) Assessing the functions of non-suicidal self-injury: Psychometric properties of the inventory of statements about self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment 31(3): 215–219.

Klonsky

May

Glenn

(2013) The relationship between nonsuicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology 122(1): 231–237.

Klonsky

Muehlenkamp

Lewis

. (2011) Nonsuicidal Self-Injury. Cambridge, MA: Hogrefe Press.

Lewis

Baker

(2011) The possible risks of self-injury web sites: A content analysis. Archives of Suicide Research 15(4): 390–396.

10.

Lewis

Heath

Michal

. (2012a) Non-suicidal self-injury, youth, and the Internet: What mental health professionals need to know. Child and Adolescent Psychiatry and Mental Health 6(1): 13.

11.

Lewis

Heath

Sornberger

. (2012b) Helpful or harmful? An examination of viewers’ responses to nonsuicidal self-injury videos on YouTube. The Journal of Adolescent Health 51(4): 380–385.

12.

Lewis

Heath

Denis

St . (2011) The scope of nonsuicidal self-injury on YouTube. Pediatrics 127(3): e552–e557.

13.

Lewis

Mahdy

Michal

. (in press) Googling self-injury: The state of health information obtained through online searches for self-injury. JAMA Pediatrics.

14.

Lewis

Rosenrot

Messner

(2012c) Seeking validation in unlikely places: What people ask about non-suicidal self-injury online. Archives of Suicide Research 16(3): 263–272.

15.

Mazzoni

Cicognani

(2013) Sharing experiences and social support requests in an Internet forum for patients with Systemic Lupus Erythematosus (SLE). Journal of Health Psychology. Epub ahead of print 11 March 2013. DOI: 10.1177/1359105313477674.

16.

Coulson

(2010) Living with HIV/AIDS and use of online support groups. Journal of Health Psychology 15(3): 339–350.

17.

Mulveen

Hepworth

(2006) An interpretative phenomenological analysis of participation in a pro-anorexia Internet site and its relationship with disordered eating. Journal of Health Psychology 11: 283–296.

18.

Murray

Fox

(2006) Do Internet self-harm discussion groups alleviate or exacerbate self-harming behaviour? Australian e-Journal for the Advancement of Mental Heath 5(3): 1–9.

19.

Nock

Favazza

(2009) Nonsuicidal self-injury: Definition and classification. In: Nock

(ed.) Understanding Nonsuicidal Self-Injury: Origins, Assessment, and Treatment. Washington, DC: American Psychological Association, pp. 9–18.

20.

Rodham

Gavin

Miles

(2007) I hear, I listen and I care: A qualitative investigation into the function of a self-harm message board. Suicide and Life-Threatening Behavior 37(4): 422–430.

21.

Rodham

Gavin

Lewis

. (2013) An investigation of the motivations driving the online representation of self-injury: A thematic analysis. Archives of Suicide Research 17(2): 173–183.

22.

Teufel

Schäffeler

de Zwaan

. (2011) Internet use among patients with psychosomatic disorders: What are the health-related demands and needs? Journal of Health Psychology 16(7): 1120–1126.

23.

Whiting

Williams

(2013) Why people use social media: A uses and gratifications approach. Qualitative Market Research: An International Journal 16(4): 362–369.

24.

Whitlock

Lader

Conterio

(2007) The Internet and self-injury: What psychotherapists need to know. Journal of Clinical Psychology (In Session) 63: 1135–1143.

25.

Whitlock

Powers

Eckenrode

(2006) The virtual cutting edge: The Internet and adolescent self-injury. Developmental Psychology 42(3): 407–417.