Abstract
Six young adults (aged 19–21 years) with repeat self-harm for over 5 years were interviewed about their self-harm, why they continued and what factors might help them to stop. Interpretative phenomenological analysis identified six themes: keeping self-harm private and hidden; self-harm as self-punishment; self-harm provides relief and comfort; habituation and escalation of self-harm; emotional gains and practical costs of cutting, and not believing they will stop completely. Young adults presented self-harm as an ingrained and purposeful behaviour which they could not stop, despite the costs and risks in early adulthood. Support strategies focused on coping skills, not just eradicating self-harm, are required.
Self-harm, defined as self-poisoning or self-injury regardless of intent (Hawton et al., 2012b), is a particularly significant issue in late adolescence and early adulthood. Data from six hospitals in England (collected between March 2000 to August 2001; the Multicentre Study of Self-Harm) found two-thirds of presentations for self-harm were by those under the age of 35 years, and the largest groups in terms of age were 15- to 19-year-old females and 20- to 24-year-old males (Hawton et al., 2007). Suicide is the second most common cause of death in young people worldwide (Patton et al., 2009), and self-harm is strongly associated with increased risk of future suicide (Hawton et al., 2011; Owens et al., 2002). Repetition of self-harm is common (Owens et al., 2002), and given that most self-harm episodes do not come to the attention of clinical services (Hawton et al., 2012b), it is likely that repetition rates are underestimated. Data collected in the Multicentre Study of Self-harm in England (2000–2007) on all self-harm hospital presentations by individuals aged 10–18 years found repetition of self-harm was seen in 27 per cent of young people, and repetition was associated with increased age (Hawton et al., 2012a). A 6-year follow-up study of a cohort of adult patients admitted to hospital for self-harm found that 57 per cent repeated self-harm according to self-reports, and unemployment and divorce were associated with increased self-harm repetition (Sinclair et al., 2010). Targeted research with young adults is needed to better understand self-harm repetition and recovery in this age group.
There is an emerging body of qualitative research on self-harm, and a few studies have specifically explored recovery. A qualitative interview study of 20 adults who had not self-harmed in 2 years explored perceptions of how resolution of self-harm was achieved and identified the following themes: resolution of adolescent distress; recognition of the role of alcohol as a maintaining factor for self-harm; and understanding self-harm as a symptom of untreated or unrecognized illness (Sinclair and Green, 2005). An interview study with female college students in the United States focusing on self-harm cessation described stopping self-harm as a complex and dynamic process, in which the subjective meaning of self-harm to an individual is central (Shaw, 2006). For example, this study highlighted the importance of recognizing self-harm as problematic and as interfering with everyday activities in order to stop. Similarly, an analysis of Finnish adolescents’ personal descriptions of what had helped them to stop self-harm identified themes related to personal meanings given to self-cutting and also experiences of care/therapy (Rissanen et al., 2013). Finally, a survey of 54 university students examined why and how individuals naturally stop self-harm identified six themes using inductive content analysis: realization of stupidity/futility of self-harm; distress over scarring and negative attention; change for interpersonal reasons; receipt of help/support; desire for wellness; and development of alternate coping strategies (Gelinas and Wright, 2013).
Taking into consideration the existing evidence, this study focuses on young adults aged between 19 and 21 years who have repeatedly self-harmed over a number of years. This is an important age group for targeted research on self-harm for a number of reasons. First, our age group of interest falls roughly in the middle of the age cohort with the highest rates of hospital presentations for self-harm. Second, this is a time of significant life transitions such as leaving home, going to university or entering employment/training. Mental health problems, including depression and self-harm, are common and persistent among university students (Ibrahim et al., 2013; Zivin et al., 2009), but many students do not seek or access help for their difficulties (Eisenberg et al., 2007; Gulliver et al., 2010). There are also substantial concerns about mental health support during this time, not least because of problems with the transition from Child and Adolescent Mental Health Services (CAMHS) to adult mental health services (Singh et al., 2010). This study involves young adults recruited in community settings in England, most of whom were not currently supported by CAMHS or adult mental health services. Our aim is to explore reasons why young adults repeat or maintain self-harm and their perceptions of stopping self-harm/recovery, using interpretative phenomenological analysis (IPA) of in-depth semi-structured interviews. Qualitative work is needed in this area because despite self-harm being common in young adults, it is not well understood and there is only limited evidence on what types of interventions or supports can help (Townsend, 2015). By exploring young adults’ personal accounts of their self-harm, we may identify ways to improve support, particularly outside clinical settings.
Method
Participants
Participants aged between 19 and 21 years were recruited as part of a larger study of self-harm based in the East Midlands. Six participants were selected for inclusion in this analysis because they were over 18 years old, students in Higher Education or Further Education and reported repeated episodes of self-harm during adolescence. This purposive sampling provided a homogeneous group of the size considered optimal to the analysis approach of IPA (Smith et al., 2009). All participants had self-harmed in the last 6 months. They were recruited via advertising in community settings, a research project website and social media. Five participants were White British and one was Asian/Asian British Pakistani.
Data collection
The participants took part in individual semi-structured interviews with the first author, an experienced interviewer with minimal previous research experience in the field of self-harm. Participants were interviewed in 2014 in private at home, at university, or at a local volunteer centre. Participants were given an information sheet to read, had the opportunity to ask questions at any point, and were asked to sign a consent form.
The interviews were guided by an interview schedule and followed the form of open-ended questions, follow-up questions and prompts. The interview included specific questions relating to maintenance of self-harm and recovery from self-harm (e.g. ‘Why do you keep on self-harming?’, ‘What might help you to stop self-harming?’ and ‘What supports/services have been (un)helpful?’). These questions were discussed with an advisory group of young people who have lived experience of self-harm. Background information regarding age, mental health diagnoses and current services is given in Table 1. Participants were also asked to report the methods of self-harm they had used, age at which they first self-harmed, when they had most recently self-harmed and how frequently they self-harmed. The interviews were audio recorded and were transcribed verbatim. Their length ranged from 28 to 53 minutes (M = 38 minutes).
Participant characteristics and self-harm history (self-report).
CAMHS: Child and Adolescent Mental Health Services; PTSD: posttraumatic stress disorder.
This study also included emotional state ratings before and after the interviews as a way of monitoring participant well-being, particularly whether participants were becoming distressed. Participants were asked to rate current emotional state (‘How are you feeling’) on a visual analogue scale (VAS) at the start and end of the interview. The VAS was presented with numerical response options between 0 (worst possible emotional state, illustrated with a sad face) and 10 (best possible emotional state, illustrated with a happy face), with a neutral face (not sad or happy) at the midpoint of the scale. This was used to gauge whether participants experienced a change in well-being by taking part in the interviews (Biddle et al., 2013). If an individual’s emotional state VAS score had markedly lowered after the interview (or they otherwise appeared to be distressed during the research), a referral pathway was in place for participants to receive support from a qualified clinician via a local self-harm support organization. Ethical approval was given by the University of Nottingham School of Psychology Research Ethics Committee.
Analysis
The interview transcripts were analysed using IPA in accordance with published guidelines (Smith et al., 2009). IPA has previously been used to examine self-harm in adults and adolescents (Adams et al., 2005; Hunter et al., 2013) and more generally has made a notable contribution to understanding illness experience in mental health (Smith, 2011). Qualitative research into complex health phenomena such as self-harm produces rich and illustrative data and can highlight novel factors not examined in quantitative work.
The analysis was carried out on a case-by-case basis, using inductive coding within five discrete stages: (1) familiarization with the material through reading and re-reading of the transcripts; (2) noting first impressions of the account; (3) making exploratory and largely descriptive comments reflecting initial understanding of the content; (4) making conceptual/interpretative comments and identifying themes that captured the essential qualities of the account; and (5) organizing themes into a meaningful hierarchy for the account (using clusters, super- and sub-ordinate levels etc.). The analysis was an iterative process throughout these five stages, with descriptions and themes revisited several times. The themes identified in individual participants were then considered across the whole group through further organization, interpretation and structuring. The final analysis presented represents important themes across the group organized into a coherent structure. In order to maintain transparency in the analytical process, a record of decision-making and reflections during the analysis was kept. All the themes are supported by extracts from at least three participants in order to demonstrate the density of evidence for each theme, in line with recent IPA quality guidance (Smith, 2011).
Results and discussion
Details of the participants’ self-harm history are given in Table 1. The age of onset for self-harm was between 11 and 14 years old, thus the participants had been self-harming for between 6 and 10 years (average of 7 years). Methods of self-harm reported were varied but five of the six participants reported cutting. Participants were also asked an open-ended question about the frequency of self-harm, which they reported had varied over time, between self-harming daily or weekly and having periods of a few months when they did not self-harm.
The mean score on the emotional state VAS at the start of the interview was 6.08 (standard deviation (SD) = 2.38) and at the end of the interview was 6.17 (SD = 1.94). Thus, participants did not experience a change in emotional state in the interview session, and scores were at the positive end of the scale.
The themes identified in the participants’ account have significance for understanding why they repeatedly self-harm for years and why they had not yet been able to stop self-harming. Verbatim quotes from the interview transcripts are used to illustrate the themes. The themes are considered in the context of existing research, with a focus on the qualitative literature.
1. Keeping self-harm private and hidden
All participants talked about wanting to keep self-harm secret and some had kept their acts hidden for many years: ‘But then I said I wouldn’t [self-harm] but I kept doing it, and then she [mother] didn’t find out again until like four years after that’ (Daniela). In some cases, the part(s) of the body chosen for self-harm (e.g. top of legs or top of arms) was determined by the necessity of keeping self-harm hidden.
I certainly didn’t want anybody else to know, so I made sure to do it [self-harm] sort of quite high up [on my thigh] … it’s easy to stop people looking at the top of your thighs, you just don’t show yourself naked to anyone and it’s easy enough to cover up. (Eliot)
The participants emphasized that self-harm is a very private act. This, of course, counters the stereotype that self-harm is ‘just attention seeking’. ‘I’ve done it [self-harm] on somewhere that was visible and people have reacted, and I thought I don’t really like this, I don’t really want attention for it. I’d rather be able to do it in private’ (Brooke). Past, presumably negative experiences of other people’s reactions to self-harm also motivate individuals to keep self-harm hidden: ‘Like if people keep noticing, asking me about it [self-harm] and I didn’t want people …, it was uncomfortable for people to ask me about it’ (Brooke).
This motivation to keep self-harm hidden obviously has an impact on willingness not only to disclose to family and friends but also to mental health or other professionals providing support. For example, a qualitative study of service user and staff views regarding contact-based interventions for self-harm identified threats to privacy as a potential barrier in accessing support (Cooper et al., 2011). Indeed, a qualitative interview with 15- to 16-year-olds described how some young people did not want to accept offers of help from others, especially if they had been keeping self-harm secret (Klineberg et al., 2013). This study also found that self-harm being discovered by others was regarded as a negative experience, but disclosure of self-harm was, in hindsight, seen as a positive step by some of the adolescents who had received help.
2. Self-harm as self-punishment
One of the most clearly articulated reasons given for self-harming was using it as a way to punish the self: ‘… there’s like an element of like self-punishment type thing’ (Caitlyn). For example, here the trigger for self-harm was an argument with parents but the reason given for self-harm were the feelings of guilt that followed: ‘I felt a lot of guilt, because I felt really guilty for annoying my family for upsetting … and then I just wanted to hurt myself because I felt like I deserved it at the time’ (Amber). Another young person blamed himself for the negative feelings he experienced because of his inability to cope: ‘If all these feelings, all these negative things are all triggered by, you know, my idiocy, my stupidity, my inability to be able to deal with it - so, why should anything else [pause] suffer apart from me?’ (Eliot). The phrase ‘I deserved it’ was used repeatedly in the participants’ accounts of self-harm. There was also an interesting juxtaposition between self-harm serving as self-punishment and the more positive reasons given for self-harm (i.e. that it helps or makes them feel better). When asked why she keeps self-harming, Amber explains,
Ok, so, it feels like two reasons really. One, I deserve it. Two, it helps, so, they are kind of like opposite reasons. Cause I don’t – shouldn’t get help if I feel I deserve it, but at the time it helps. (Amber)
The need to self-punish has previously been identified as a reason for self-harm in qualitative interviews and in a systematic review of 18 studies examining the functions of self-harm (Brown and Kimball, 2013; Klonsky, 2007). A structured interview study of young adults who self-harmed found that self-punishment was identified as its function, but this was less relevant and considered secondary to the affect regulation function (Klonsky, 2009). In this study, self-punishment was represented as a more primary function of self-harm, as well as providing relief. Re-occurring thoughts of ‘deserving it’ (e.g. after upsetting someone or having an argument) may in part explain repetitive self-harm in this age group.
3. Self-harm provides relief and comfort
Feeling better after self-harm was a central reason given by participants for self-harm episodes and maintenance of self-harm. Specifically, the participants talked about self-harm providing relief, or a release, from intense emotions and thoughts. ‘I think it was a good release … [to] take my head out of that heightened, tense state and down to something that was a little bit more level and calm’ (Eliot). When asked what she wants to get from self-harm, Caitlyn replied ‘I suppose just like a sense of relief and stuff’ (Caitlyn). A sense of needing to relieve mounting emotional pressure came across in the accounts: ‘I always imagine it like a volcano, and there’s like all this pressure and tension building up in it; and eventually it’ll like, sort of, come on and when it does, it really gets bad [and] just erupts’ (Fern).
Affect regulation is a frequently cited reason for self-harm. There is converging evidence that negative affect precedes self-harm, and that decreased negative affect and relief are experienced after self-harm, from self-report and laboratory-based studies (Klonsky, 2007). It is, therefore, not surprising to find comfort and relief cited as reasons for self-harm repetition in this study. Self-harm as a release previously emerged from qualitative phenomenological analyses of adults’ (19–39 years) accounts (Brown and Kimball, 2013). We know that experience of negative life events (e.g. child/family adversity, abuse) is associated with self-harm (Hawton et al., 2012b) and that psychosocial stressors predict repeat acts over 6 months (O’Connor et al., 2009). It is, therefore, important to recognize the value placed on self-harm as a way of dealing with negative emotions when understanding repetition and supporting recovery. This is in line with current theoretical frameworks of self-harm such as the experiential avoidance model (Chapman et al., 2006)
Self-harm is not well understood by the public or health services (Law et al., 2009; Saunders et al., 2012), but the motivation to find relief from emotional distress is both objectively and subjectively rational. Interestingly, two of the participants explained that ‘pain can release endorphins’ (Fern) in their accounts. Offering this type of explanation may be an attempt by individuals to rationalize, perhaps even medically endorse, a behaviour that can be bewildering to people who do not have first-hand experience of self-harm.
4. Habituation and escalation of self-harm over time
As the participants talked about the nature of their self-harm throughout their teenage years, there was a sense that they had become accustomed to it. ‘Its [self-harm] just become habitual now. Like if I have something, something bothers me; my first instinct is always hurting myself’ (Amber). Caitlyn explained that over the years, she had become ‘better’ at self-harm: ‘over the past like 10 years or whatever … I like sort of like figured out even more, not really more efficient, but just like better ways of like doing stuff [self-harm]’ (Caitlyn). Some participants have found themselves needing to self-harm more severely over time: ‘it [self-harm] doesn’t really help anymore, I think. It used to, used to make me feel good but now, now it doesn’t. Unless I’ve something pretty bad, then it doesn’t really make a difference’ (Daniela). There was a recognition, however, of the increased risk that comes with escalating self-harm, ‘… the methods are definitely more life-threatening, and I want to cause more harm’ (Amber).
Two participants used the idea of addiction to explain why they keep on self-harming and also why they cannot stop, ‘I think I’m kind of addicted to it’ (Daniela).
… it [self-harm] is like an addiction, like for example if a drug user takes drugs and they get a good feel from it, they’ll do it again and again and again - but I got a good feel from it [self-harm] that one time; and when I felt bad again I did it again [pause] … and it just continued. (Fern)
Self-harm as an addictive behaviour was identified in a qualitative study on its meaning among adults, as participants compared their experience to drug addiction (Brown and Kimball, 2013). Furthermore, such addictive properties were reported to be present by the vast majority of a sample of adolescents hospitalized because of self-harm (Nixon et al., 2002). For example, 74 per cent agreed that they had increased its intensity/frequency over the years in order to achieve the same (desired) effect. These addictive features have also been cited as a barrier to stop self-harm in a survey of university students, along with ease and functionality (Gelinas and Wright, 2013). Nonetheless, research linking self-harm to the experience of addiction is generally lacking. Addiction (e.g. to alcohol or drugs) is a concept that is likely to be more easily understood and accepted by society compared to self-harm. As such, it may be a useful lay concept for individuals to use when explaining that stopping self-harm is difficult but may also shape their own beliefs regarding ability to stop.
5. Emotional gains and practical costs of cutting
When the participants talked about more recent episodes of self-harm, it was apparent that they had begun to weigh up the emotional gains of self-harm with the practical costs involved.
There was certainly a little bit of premeditation, it was just what can I do with it, you know, that will cause least amount of long-term damage but hopefully, you know, rectify all the sort of terror going on inside my head. (Eliot)
Although the participants wanted to self-harm (to feel better), there was an annoyance at the mess, and additional stress, that cutting caused:
I wanted some stress relief, but all it caused was bother. Because I was like, I’ve got blood everywhere. I’ve got to explain the scar to my boyfriend if he sees it, which he will. And, it hurts and then it’s leaking through my dry clothes, so I’ll have to change my clothes and my parents might see it. It was just really stressful. (Amber)
As young adults, the practicalities of dealing with their self-harm may become more in focus because they can no longer rely on carers to tend to wounds, provide dressings, wash stained clothes and bedding or accompany them to the hospital.
And, because I don’t like doing it anymore, and I get sick of all the blood and all the mess, and having to buy bandages and plasters and everything all the time. And having everything that I own like have blood on it as well, like, when you go out and you’re like ‘oh I’ve got my nice top, with blood on it’ and my bed sheets with blood stains on, and I’m sick of that and I don’t want to do it anymore. (Daniela)
This may act as an incentive to try and stop self-harming or may lead a person to change the method of self-harm, ‘I might overdose again. But I doubt I’ll cut again’ (Amber), to get a preferred outcome: ‘Well, if I overdose, I’m in hospital for like a few days, so it’s kind of like a break from life for a few days. I don’t need to think about anything, because I’m too ill to even think’ (Amber).
The practical costs and stress of self-care following self-harm may become more salient in early adulthood as these individuals are expected to be looking after themselves. However, it is not clear from the participants’ accounts whether these issues may increase their motivation to stop self-harming. The existing literature does not suggest that practical costs of self-harm are explicitly given as a reason for cessation, although reported reasons include concerns about scarring, unwanted attention and interference with daily life (Deliberto and Nock, 2008; Gelinas and Wright, 2013; Shaw, 2006). Practical concerns may instead lead an individual to switch self-harm method, which is a common occurrence. Data from the UK hospital admissions found that of the individuals repeating self-harm (leading to hospital attendance), one-third switched method and these were predominantly younger people (Owens et al., 2015).
6. Not believing they will stop completely
When asked about stopping self-harm, the participants generally believed that they would not be able to refrain completely. ‘Now I don’t really see myself stopping completely. Probably, cutting down a lot, but at the moment, as it stands, I probably won’t stop completely’ (Amber). Some participants felt as if they depended on self-harm, ‘I’ve been doing it too long and I’ve got too dependent on it to actually, like, to be able to stop, even though I’d like to’ (Daniela) and perceived a function of something to fall back on, ‘I don’t think I’ll like will ever be able to say like categorically that I’ve like now stopped … I think it’s just like it’s nice to have the option’ (Caitlyn). Essentially, participants were worried about how they would cope if they did not have self-harm, ‘I feel like I’d have nowhere to turn to … I wouldn’t have that [self-harm]. It’s just easy to self-harm and I wouldn’t have that’ (Amber).
These beliefs about stopping may discourage help-seeking but are also at odds with clinical services which may focus on eradicating the behaviour rather than addressing the emotional distress. A qualitative study of perceptions of interventions for self-harm in adults found a preference for approaches that acknowledge that self-harm management may not always involve prevention (Hume and Platt, 2007). Clinical assessments should consider whether an individual wants to, or believes, they can stop, which will be linked to their subjective understanding of the functions of their behaviours (e.g. Shaw, 2006). Interestingly, when participants were asked about the frequency of their self-harm, their responses indicated that they had experienced periods of a few months when they did not self-harm. Future qualitative research examining these pauses or breaks in self-harm may shed more light on what stopping self-harm means, particularly in the wider context of recovery.
Strengths and limitations
This study explored the perceptions of and experiences with self-harm in a distinct group of young adults in higher or further education who had repeated episodes of self-harm since early/mid adolescence. Qualitative findings based on targeted homogenous samples like this can be theoretically generalized to other young adults who share similar characteristics (Smith et al., 2009). The value in using IPA comes from presenting rich descriptions of a group’s experience of a particular phenomenon and how participants make sense of their experience of that phenomenon. However, IPA, by definition, is an interpretative and subjective process. As recommended, an audit trail of each step of the analysis was documented in order to maintain transparency (e.g. in development of themes from the participants’ transcripts and in decisions leading to the final theme structure) and to address the issue of validity or ‘soundness’ (Yardley, 2000). This audit trail allowed the researchers to identify any preconceptions regarding the subject of self-harm that had the potential to influence the analysis.
This study also included emotional state ratings before and after the interviews. Overall, the participants’ emotional state was not affected during the course of the interviews. This is consistent with previous research demonstrating that participating in research about self-harm and suicide does not cause distress (Biddle et al., 2013). We highly recommend use of these pre- and post-interview emotional ratings in qualitative research on self-harm as a means of monitoring distress (or lack thereof).
Conclusion
In line with current literature and models, self-harm was reported to provide relief and comfort from emotional distress but was also used to punish the self. Keeping self-harm private was very important, and this influenced the nature of self-harm and can discourage help-seeking (from friends and family but also from clinical services). Thus, there is an opportunity here to draw on expertise in health psychology to develop accessible support in community settings, including universities/colleges and online, which promotes evidence-based information on coping strategies and well-being, as well as addressing the stigma associated with self-harm. Confidentiality should be emphasized at the point of access to those resources. The young adults had self-harmed for a number of years, and during this time, self-harm had become routine and often more severe. Long-term self-harm may lead to a perceived dependency, potentially increasing risk and creating the belief that an individual cannot cope without it. Clinical services need to focus on coping with and reducing emotional distress rather than eradicating a problem behaviour. Indeed, the young adults did not believe that they could stop self-harm completely, but this makes sense as they regarded their self-harm as functional and habitual. The increasing responsibilities of adulthood can bring practical costs of self-harm into sharp focus, which may lead to a change in behaviour (for better or worse). Young adulthood is therefore a critical time for intervention, particularly if an individual is leaving CAMHS without a seamless transition to adult services. Clearly, non-specialist agencies such as universities/colleges, but also family and friends, can play an important role in supporting coping in young adulthood. Asking questions about an individual’s self-harm, in terms of perceived functions of self-harm and what it would mean to stop, is important when considering clinical services because these perceptions may feed in to beliefs about recovery. In summary, these findings underline the importance of beliefs about self-harm functions and recovery and suggest that clinical inventions that focus only on preventing or eradicating self-harm are neither sufficient nor appropriate.
Footnotes
Acknowledgements
The views expressed in this publication are those of the author(s) and not necessarily those of the Department of Health. The authors thank our participants and the ‘Listen-up!’ Advisory Group for their input in shaping this research.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This report is independent research commissioned and funded by the Department of Health Policy Research Programme (The ‘Listen-up!’ project: understanding and helping looked-after young people who self-harm, PRR5-0912-11006).