Superficial self-harm: perceptions of young women who hurt themselves.

Although only 1% to 4% of the U.S. population engages in superficial self-harm (SSH (Secure SHell) A security protocol for logging into a remote server. SSH provides an encrypted session for transferring files and executing server programs. Also serving as a secure client/server connection for applications such as database access and e-mail, SSH supports a ), this behavior is much more prevalent in adolescents, with estimates ranging from 14% to 39%. While current studies primarily focus on clinical interventions, few have investigated SSH from an individual's perspective, and there is little guidance for family, friends, and others who desire to provide assistance. In particular, those in close contact with youth, particularly in schools, need basic information on SSH and suggestions for responding to students at risk. One-on-one, day-to-day, practical and effective intervention is needed. This study investigated the perspectives of 96 young women with a history of SSH. Based on their responses' to an Internet survey, friends and mental health professionals were perceived as most helpful in acknowledging the individual's emotional pain and distress. Participants also wanted others to be nonjudgmental non·judg·men·tal  
adj.
Refraining from judgment, especially one based on personal ethical standards.

Adj. 1. nonjudgmental , to permit emotional expression, and to acknowledge their availability to offer help. Translated into practice, young women who engage in SSH consider an accepting supportive relationship to be a critical element in their recovery.

Self-Harming Behaviors

Individuals are hardwired to survive, to automatically seek protection, and to avoid danger and injury. However, Favazza (1996) provides examples of rituals involving self-harm and physical deprivation that are perceived to serve a purpose in certain cultures, benefiting both individual and community. For example, in Morocco one group drinks boiling water and eats spiny spiny

sharp spines protrude.

spiny amaranth
amaranthusspinosum.

spiny anteater
see echidna.

spiny clotburr
xanthiumspinosum.

spiny emex
see emex australis.  cacti in an attempt to produce a psychic state and create unity with a higher spiritual force. During the New Year's festival of the Ivory Coast Ivory Coast: see Côte d'Ivoire.  Abidji tribe, members participate in self-harm rituals to drive away evil spirits that threaten their community; following tradition, participants go into a deep trance-like state and, in an effort to rid their bodies of evil sprits, plunge knives into their abdomen.

Though it is against the natural instinct to protect oneself, avoid pain, and ensure self-preservation, in these situations self-harm is not only viewed as socially acceptable, it is condoned. These incidents of self-harm, woven into established spiritual rituals, are not considered pathological but are perceived as expressions of personal growth, sacrifice, and enlightenment (Favazza, 1996). However, in other situations, counter to societal norms, individuals may engage in self-harm ranging from minor scratching or cutting to extremely life-threatening behaviors (Nock nock  
n.
1. The groove at either end of a bow for holding the bowstring.

2. The notch in the end of an arrow that fits on the bowstring.

tr.v. nocked, nock·ing, nocks
1.  & Prinstein, 2005). Typically, in mainstream American culture self-harming behaviors are seen as maladaptive Maladaptive
Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.

Mentioned in: Cognitive-Behavioral Therapy  and indicative of underlying emotional difficulties (Muehlenkamp, 2006, 2007).

In 1987 Favazza's classic book, Bodies Under Siege: Self-Mutilation in Culture and Psychiatry, expanded research interest and promoted professional conversation. Then, in a 1995 television interview, Princess Diana Noun 1. Princess Diana - English aristocrat who was the first wife of Prince Charles; her death in an automobile accident in Paris produced intense national mourning (1961-1997)
Diana, Lady Diana Frances Spencer, Princess of Wales  discussed her private struggle in coping with emotional pain, revealing that she was a "cutter" (Purington & Whitlock, 2004; Strong, 1998). Her admission challenged the longstanding stereotype of superficial self-harm (SSH). Previously perceived as an extreme behavior of the seriously mentally ill, SSH was redefined as a problem occurring in mainstream society. However, although public awareness of SSH has increased dramatically over the past several years, evidence informing effective research-based interventions is limited, particularly for adolescents (Bums, Dudley, Hazell, & Patton, 2005; Nock & Prinstein, 2005; Nursing Standard, 2005; Ross & Heath, 2002; Whitlock, Powers, & Eckenrode, 2006).

Overview of Self-Harming Behaviors

The current Diagnostic and Statistical Manual of Mental Disorders Diagnostic and Statistical Manual of Mental Disorders /Di·ag·nos·tic and Sta·tis·ti·cal Man·u·al of Men·tal Dis·or·ders/ (DSM) a categorical system of classification of mental disorders, published by the American Psychiatric Association, that delineates objective  (DSM 1. DSM - Data Structure Manager.

An object-oriented language by J.E. Rumbaugh and M.E. Loomis of GE, similar to C++. It is used in implementation of CAD/CAE software. DSM is written in DSM and C and produces C as output. ) does not list diagnostic criteria for self-harm (American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. , 2000). Rather, self-harm, referred to as self-mutilation in the DSM, is listed as commonly occurring with specific disorders, such as borderline personality disorder bor·der·line personality disorder
n.
A personality disorder marked by a long-standing pattern of instability in interpersonal relationships, behavior, mood, and self-image that can interfere with social or occupational functioning or cause extreme  (BPD Borderline personality disorder (BPD)
A pattern of behavior characterized by impulsive acts, intense but chaotic relationships with others, identity problems, and emotional instability. ) and eating disorders eating disorders, in psychology, disorders in eating patterns that comprise four categories: anorexia nervosa, bulimia, rumination disorder, and pica. Anorexia nervosa is characterized by self-starvation to avoid obesity.  (see also Favazza, 1996; Levitt, Sansone, & Cohn, 2004; Linehan, 1993, 2000). Elsewhere self-harming behavior (SHB SHB Svenska Handelsbanken (Swedish bank)
SHB System Host Board (PCI Industrial Computer Manufacturers Group standard)
SHB Strictly Hard Bean (coffee)
SHB Saudi Hollandi Bank ) is identified by various terms: self-inflicted violence (Alderman ALDERMAN. An officer, generally appointed or elected in towns corporate, or cities, possessing various powers in different places.
     2. The aldermen of the cities of Pennsylvania, possess all the powers and jurisdictions civil and criminal of justices of the , 1998; Travia, 2003); self-mutilation (Cassano, Lattanzi, Pini, Dell' Osso, Battistini, & Cassano, 2001; Favazza), and self-injury (Favaro & Santonastaso, 2000; Muehlenkamp & Gutierrez, 2004). SHB has also been categorized cat·e·go·rize  
tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es
To put into a category or categories; classify.


cat  into three levels of severity: superficial, stereotypic, and major (Simpson, 2001).

SSH, the most common and least severe SHB, is the focus of this study. It includes non-life-threatening scratching and cutting. Travia (2003) delineated de·lin·e·ate  
tr.v. de·lin·e·at·ed, de·lin·e·at·ing, de·lin·e·ates
1. To draw or trace the outline of; sketch out.

2. To represent pictorially; depict.

3.  four major elements of SSH: (a) The behavior is socially unacceptable (Haines, Williams, Brain, & Wilson, 1995), setting it apart from culturally accepted practices like piercing, tattooing, or scarring one's body for ritual or ornamental purposes; (b) the behavior is almost always a reaction to psychological crisis (Haines et al., 1995); (c) the behavior leads to tissue damage; and (d) the behavior is not based on conscious suicidal intent (Alderman, 1998; Favazza & Rosenthal, 1993).

More severe than SSH, stereotypic self-injury appears to be biologically driven (Favazza, 1996) and is often linked with more extreme developmental delays developmental delay
n.
A chronological delay in the appearance of normal developmental milestones achieved during infancy and early childhood, caused by organic, psychological, or environmental factors.  and disabilities, such as autism autism (ô`tĭzəm), developmental disability resulting from a neurological disorder that affects the normal functioning of the brain. It is characterized by the abnormal development of communication skills, social skills, and reasoning.  or intellectual deficiency (McClintock, Hall, & Oliver, 2003). From a behavioral standpoint, stereotypic self-injury is frequently associated with self-stimulation and the need for increased sensory input. Stereotypic self-injury includes intense repetitive, often rhythmic, extreme behaviors such as biting of hands, arms, or lips; head banging; eyeball See eyeballs and eyeball driven.  pressing; and self-punching.

Major self-injury is the most severe form of SHB. It includes extreme behaviors such as amputation amputation (ăm'pyətā`shən), removal of all or part of a limb or other body part. Although amputation has been practiced for centuries, the development of sophisticated techniques for treatment and prevention of infection has greatly  of limbs or genitals gen·i·tals
pl.n.
Genitalia.  and eye enucleation enucleation /enu·cle·a·tion/ (e-noo?kle-a´shun) removal of an organ or other mass intact from its supporting tissues, as of the eyeball from the orbit. Enucleation
Surgical removal of the eyeball. . Extremely rare, major self-injury is typically associated with psychosis psychosis (sīkō`sĭs), in psychiatry, a broad category of mental disorder encompassing the most serious emotional disturbances, often rendering the individual incapable of staying in contact with reality.  or acute intoxication intoxication, condition of body tissue affected by a poisonous substance. Poisonous materials, or toxins, are to be found in heavy metals such as lead and mercury, in drugs, in chemicals such as alcohol and carbon tetrachloride, in gases such as carbon monoxide, and  and may result in serious injury or death (Favazza, 1996; Favazza & Rosenthal, 1993).

Superficial Self-Harm

Mental health professionals estimate that 1-4% of the general population engage in SHB (Alderman, 1998; Klonsky, Oltmanns, & Turkheimer, 2003), but the prevalence rate is much higher among adolescents. Some researchers have estimated that 14-39% of adolescents (Nock & Prinstein, 2005; Ross & Heath, 2002) and up to 61% of adolescent psychiatric inpatients intentionally harm themselves (DiClemente, Ponton, & Hartley, 1991).

SSH typically begins in late childhood or early adolescence and may continue 15 to 20 years or longer (Favazza & Rosenthal, 1993). Because most individuals go to great lengths to conceal their injuries and scars, prevalence rates may be underestimated (Martinson, 2000). However, it is important to recognize that not all scarring is considered SSH: many adolescents proudly display tattoos and multiple body piercings body piercing Body image A disruption of a mucocutaneous surface with jewelry or dangling artifices. See Tattoos.  as a rite of passage rite of passage
n.
A ritual or ceremony signifying an event in a person's life indicative of a transition from one stage to another, as from adolescence to adulthood.  into adulthood or an expression of independence and individuality (Graham & Teall, 2006; McGuinness, 2006; Roberts, Auinger, & Ryan, 2004).

In addition to developmental considerations, sex is an important demographic to consider in clarifying who engages in SSH. In particular, sex differences are noted in childhood and adolescence. According to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.  Lieberman (2004) females account for approximately 60% of elementary-aged children and 80% of middle- and high-school-aged adolescents who self-injure. The behavior is also thought to be more common among middle- and upper-class adolescent girls and young women (Simpson, 2001).

Although SSH seems to be more common in females, Favazza (1996) noted that this generalization may be "an artifact A distortion in an image or sound caused by a limitation or malfunction in the hardware or software. Artifacts may or may not be easily detectable. Under intense inspection, one might find artifacts all the time, but a few pixels out of balance or a few milliseconds of abnormal sound  of sampling techniques" (p. 240) and that demographics of those who self-harm vary by setting. For example, males who are incarcerated incarcerated /in·car·cer·at·ed/ (in-kahr´ser-at?ed) imprisoned; constricted; subjected to incarceration.
in·car·cer·at·ed
adj.
Confined or trapped, as a hernia.  or hospitalized in psychiatric hospitals psychiatric hospital
n.
A hospital for the care and treatment of patients affected with acute or chronic mental illness. Also called mental hospital.  frequently inflict self-harm (e.g., cutting, self-tattooing, and burning) (Claes, Vandereycken, & Vertommen, 2007; Matsumoto, Yamaguchi, Asami, Okada, Yoshikawa, & Hirayasu, 2005). However, outside prison and psychiatric settings, the assumption that SSH is more common in females is supported by current research (Lieberman, 2004; Whitlock, Eckenrode, & Silverman, 2006). Additionally, sex differences in SSH align with the fact that females far outnumber out·num·ber  
tr.v. out·num·bered, out·num·ber·ing, out·num·bers
To exceed the number of; be more numerous than.

outnumber
Verb

to exceed in number:  males in reporting sexual abuse and in being identified with mood disorders The mood or affective disorders are mental disorders that primarily affect mood and interfere with the activities of daily living. Usually it includes major depressive disorder (MDD) and bipolar disorder (also called Manic Depressive Psychosis). , eating disorders, and BPD (American Psychiatric Association, 2000; Levitt et al., 2004; Ross & Heath, 2002). Current research also acknowledges the impact of environmental trauma on the onset and exacerbation of SSH, though caution is recommended in interpreting male/female differences in prevalence rates due to society's feminization feminization /fem·i·ni·za·tion/ (fem?i-ni-za´shun)
1. the normal development of primary and secondary sex characters in females.

2. the induction or development of female secondary sex characters in the male.  of SSH and the greater latitude allowed females to engage in such behavior (Brickman, 2004; Rodham Rodham is an English surname which may refer to a number of persons or places. People
Family of Hillary Rodham Clinton

• Hillary Rodham Clinton, 2008 presidential candidate and current junior U.S.

, Hawton, & Evans, 2005).

In females, cutting is the most common form of SSH (Selekman, 2002). Although cutting the wrists and forearms is common, other sites include the back, thighs, genitals, and breasts. Highly visible cutting and scratching may be inflicted on the face and neck. Instruments used for cutting include razors, knives, sharp stones, broken glass, needles, and animal bones (Jacobs, 2005; Ross & McKay, 1979). Selekman (2002) noted that burning is another common form of SSH. Most burns are inflicted with cigarettes, match heads, and the repetitive friction of erasers.

Characteristics of Individuals Who Self-Harm

A number of studies have reported characteristics common among individuals who self-harm, including (a) a history of physical, sexual, or psychological abuse (Darche, 1990; Favazza, 1996; Low, Jones, MacLeod, Power, & Dugan, 2000; Van der Kolk, Perry, & Herman, 1991; Zlotnick, Shea, Pearlstein, Simpson, Costello, & Being, 1996); (b) addictive behaviors Addictive behavior is any activity, substance, object, or behavior that has become the major focus of a person's life to the exclusion of other activities, or that has begun to harm the individual or others physically, mentally, or socially. , including compulsive eating, illicit drugs illicit drug Street drug, see there , and misuse of prescribed drugs (Favaro & Santonastaso, 2000; Favazza & Conterio, 1989; Favazza & Rosenthal, 1993; Lieberman, 2004; Matsunaga et al., 1998; Simpson & Porter, 1981); (c) limited coping skills A coping skill is a behavioral tool which may be used by individuals to offset or overcome adversity, disadvantage, or disability without correcting or eliminating the underlying condition. Virtually all living beings routinely utilize coping skills in daily life.  (Favazza); (d) negative self-image and limited emotional resiliency (Simpson, 2001); (e) limited ability to verbally express feelings (Favazza & Conterio, 1989; Simpson, 2001); and (f) intense anxiety and rage (Ross & Heath, 2003).

Corresponding Mental Health Issues

Behaviors associated with SSH often co-occur with Verb 1. co-occur with - go or occur together; "The word 'hot' tends to cooccur with 'cold'"
collocate with, construe with, cooccur with, go with

accompany, attach to, come with, go with - be present or associated with an event or entity; "French fries come  such mental health disorders as generalized anxiety disorder Generalized Anxiety Disorder Definition

Generalized anxiety disorder is a condition characterized by "free floating" anxiety or apprehension not linked to a specific cause or situation. , posttraumatic stress disorder Posttraumatic stress disorder

An anxiety disorder in some individuals who have experienced an event that poses a direct threat to the individual's or another person's life.  (PTSD PTSD posttraumatic stress disorder.
PTSD
abbr.
posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) ), BPD, and antisocial personality disorder antisocial personality disorder
n.
A personality disorder characterized by chronic antisocial behavior and violation of the law and the rights of others.  (Chapman, Gratz, & Brown, 2006; Levitt et al., 2004; Linehan, 1993; Muehlenkamp, 2006, 2007; Sansone & Levitt, 2002; Walsh, 2005). In general, those who engage in SSH often struggle with depression and anxiety (Muehlenkamp, 2006; Walsh).

SSH is often exhibited by individuals struggling with eating disorders. Favazza and Conterio (1989) found that 61% of those who self-harm "now have or at some time in the past have had an eating disorder eat·ing disorder
n.
Any of several patterns of severely disturbed eating behavior, especially anorexia nervosa and bulimia, seen mainly in female teenagers and young women. " (p. 287). Similarly, Favaro and Santonastaso (2000) and Nagata, Kawarada, Kiriike, and Iketani (2000) estimated that 14-59% of patients with anorexia nervosa have engaged in SSH. More recently other authors have reported somewhat less overlap. For example, Fichter, Quadflieg, and Rief (1994) and Matsunaga et al. (1998) estimated the range of individuals struggling with bulimia nervosa bulimia nervosa

Eating disorder, mostly in women, in which excessive concern with weight and body shape leads to binge eating followed by compensatory behaviour such as self-induced vomiting or the excessive use of laxatives or diuretics.  who engage in SSH to be 15-30%.

Overwhelmed with pent-up emotions, rather than turning to others for social support individuals turn frustration and anger inward: SSH releases this tension (Favazza, 1996; Trepal & Wester, 2006, 2007). Cutting, burning, and other acts of self-harm seem to quickly provide temporary relief (Favazza). According to Favazza, "Episodic episodic

sporadic; occurring in episodes. e. falling a paroxymal disorder described in Cavalier King Charles spaniels in which affected dogs, starting at an early age, experience episodes of extensor rigidity, possibly brought on by stress. e.  self-mutilation is so prevalent [in BPD] because it works: it ends the depersonalization depersonalization /de·per·son·al·iza·tion/ (de-per?sun-al-i-za´shun) alteration in the perception of self so that the usual sense of one's own reality is temporarily lost or changed; it may be a manifestation of a neurosis or another  and mounting anxiety ... provides solace, stabilizes emotional swings, and so forth" (p. 250). Self-harm also serves as an anchor to reality, giving a sense of self-control and somehow compensating for what is missing--adaptive coping skills and a feeling of social connectedness Social connectedness is a psychological term used to describe the quality and number of connections we have with other people in our social circle of family, friends and acquaintances. These connections can be both in real life, as well as online.  (Yates, 2004).

A common factor underlying SSH is a perception of isolation, disconnectedness, and alienation from supportive social relationships (Favazza & Rosenthal, 1993; Walsh, 2005). Those who engage in SSH cite a history of failed relationships and difficulty maintaining long-term close relationships (Favazza, 1996). Social isolation combined with limited impulse control impulse control Psychology The degree to which a person can control the desire for immediate gratification or other; IC may be the single most important indicator of a person's future adaptation in terms of number of friends, school performance and future  may increase the likelihood of SSH and antisocial antisocial /an·ti·so·cial/ (-so´sh'l)
1. denoting behavior that violates the rights of others, societal mores, or the law.

2. denoting the specific personality traits seen in antisocial personality disorder.  behavior, including addictive behaviors such as alcoholism and drug addiction drug addiction
 or chemical dependency

Physical and/or psychological dependency on a psychoactive (mind-altering) substance (e.g., alcohol, narcotics, nicotine), defined as continued use despite knowing that the substance causes harm.  (Lacey & Evans, 1986; Lieberman, 2004). In fact, Ross and McKay (1979) indicated that 86% of incarcerated adolescent females in one Canadian facility reported carving their skin at least once and averaged eight incidents of SSH.

Background Summary and Statement of Purpose

Although growing concerns about young women's SSH have increased professional attention to this area, there are few research-based strategies to guide responsive intervention (Trepal & Wester, 2006, 2007; Whitlock, et al., 2006). In an attempt to identify effective interventions, Bums et al. (2005) searched electronic research databases for randomized ran·dom·ize  
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment.  clinical control trials and quasi-experimental studies related to SSH. They concluded that, first, group therapy appeared to be the only intervention demonstrating a significant reduction in repetitive SSH; and second, there was a serious lack of intervention research. Furthermore, recommended interventions focused on clinical therapeutic settings, offering limited practical guidelines for families, friends, and social support systems. This is especially problematic given that SSH is often misunderstood by those who are not professionally trained. Lacking understanding, family and friends often react negatively with anger, disgust, despair, and threats, further alienating al·ien·ate  
tr.v. al·ien·at·ed, al·ien·at·ing, al·ien·ates
1. To cause to become unfriendly or hostile; estrange: alienate a friend; alienate potential supporters by taking extreme positions.  those who self-harm (Costin, 2004; Kress, Gibson, & Reynolds, 2004).

Because very little is known about the personal perspectives of those who engage in SSH, this study investigated the perceptions of young women who engaged in SSH, particularly their views about support and how others might assist. This information will lay the groundwork for increased understanding of SSH, educating others about the feelings underlying the behavior. Ultimately, the goal of understanding is to strengthen empathy and open lines of communication "Lines of Communication" is an episode from the fourth season of the science-fiction television series Babylon 5. Synopsis
Franklin and Marcus attempt to persuade the Mars resistance to assist Sheridan in opposing President Clark. , taking the emphasis of intervention off merely controlling and stopping the behavior and redirecting efforts to_understanding the individual's point of view (Clark, 2006; Rogers, 1961).

METHODS

Recruitment of Participants

The participants, female and at least 18 years old, were recruited from three online support forums: (a) http://gabrielle.self-injury.net/; (b) http://buslist.org/phpBB/; and (c) www.shardforum.co.uk. These Web sites host members seeking support for managing or reducing their self-harm. Community members on these sites interact through on-line posted messages, providing an arena to ask questions and seek and offer support (Whitlock, et al., 2006). No compensation was offered to participants.

To keep the sample fairly homogeneous, only females who engaged in SSH were included in the study. This was accomplished by excluding participants with a history of major or stereotypic self-harm and those with limited self-awareness (e.g., those diagnosed with schizophrenia, autism, or dissociative identity disorder dissociative identity disorder: see multiple personality. dissociative identity disorder
 formerly multiple personality disorder

Rare condition indicated by the absence of a clear and comprehensive identity. ). Two screening questions were included to identify participants who self-reported these behaviors or one or more of the listed diagnoses. Data from these surveys were not analyzed.

The sample consisted of 96 females, including both those who currently superficially self-harm (n = 86) and those who previously self-harmed (n = 10). Of the participants, 47 resided in the U.S. (in 24 states), 32 in England, 5 in Canada, 3 in Australia, 2 in Scotland, and 1 in each of the following countries: Singapore, Austria, Netherlands, New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. , Slovenia, Sweden, and Switzerland. The sample was 91.7% Caucasian (n = 88) and 7.3% non-White (n = 7); one participant did not specify race/ethnicity. Ages ranged from 18 to 46 (M = 21.8, SD = 4.9). In addition, 41.7% (n = 40) of participants reported completing at least some college and 30.2% (n = 29) were currently enrolled part-time. These demographics, though limited, appear to be somewhat representative of the general population of young women who superficially self-harm (Simpson, 2001).

Survey

Initial drafts of the survey instrument were reviewed by five licensed psychologists familiar with adolescent/young adult issues, including female eating disorders and behaviors related to SSH. They provided feedback to improve the survey, particularly the wording of questions, and to help align the survey with the research concerns. The refined survey and informed consent form were then approved by the sponsoring university's Institutional Review Board and the moderators of the three online support forums for individuals who self-harm.

An introductory message, including an invitation to participate and a brief description of the study, was posted on the on-line forums. All participants were informed that the study was confidential; the researchers did not have access to their names or contact information. For those interested in participating, a Web link was listed, providing additional information and the letter of informed consent. Informed consent was assumed if the participant clicked I agree. This indicated that the individual read and understood the consent form, desired to participate, and was at least 18 years old and female.

After consenting to take part in the study, participants completed the survey, which took approximately 10 minutes. The first nine questions were demographic, asking participants to describe age, home town/country, ethnicity, current economic situation, education completed, current occupation, and current living situation (alone or with others). After the demographic section, 22 questions focused on the research. They investigated perceptions of experiences related to SSH, especially reducing SSH, and which persons, interactions, and actions participants considered helpful or harmful. The last two questions screened for serious self-injury and diagnosis of autism, schizophrenia, or dissociative identity disorder (multiple personality disorder Multiple Personality Disorder Definition

Multiple personality disorder, or MPD, is a mental disturbance classified as one of the dissociative disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). ).

Data Analysis

Because the literature provides limited insight into the perspectives of young women who engage in SSH, this initial study is exploratory and descriptive rather than comparative. For each of the research questions, percentages were calculated, providing a context in which to describe individual responses and perceptions. Participants' comments supplemented their responses.

RESULTS

Profile of Self-Harming Behaviors

Only 10.4% (n = 10) of participants met the "recovered" criterion indicating that they had not engaged in any form of SSH within the past 12 months. Participants reported a history of harming themselves for an average of 7 years (N = 96, M = 7, median = 6, SD = 4.4, range = 1-24 years). The form of SSH most frequently reported was cutting; 97.9% (n = 94) of participants reported a history of cutting. About 37% (n = 35) of them reported cutting at least several times weekly. Other forms of SSH reported, in descending order, were scratching, picking skin so it becomes wounded or cannot heal, burning, biting, biting nails very short, head banging, hair pulling, inserting items under the skin, and eating sharp or toxic items.

Perceptions of Reducing Self-Harm

What type of support is perceived as helpful? Most of the 96 participants (86%, n = 83) reported that someone acknowledging the severity of their distress was perceived as helpful and supportive. One stated it was helpful "[when they ask] how l am doing, if they just listen to me when ! talk, let me talk out all my emotions without anyone judging me or thinking I'm suicidal." They indicated that merely having someone listen helped them feel that someone was at least trying to understand their SSH. Specifically, 83% (n = 80) reported that talking about SSH and verbalizing feelings was helpful if the other person listened and withheld judgment. Feeling as though they were being judged was a common worry: "I wish they would not ... be so quick to judge self-injury as a selfish behavior." Furthermore, 81% (n = 78) of participants reported that it was helpful to simply know that someone was available and able to assist them if needed. On the other hand, all but one participant considered consequences like grounding, threatening, or punishing as not helpful.

Based on the comments, negative consequences increased stress, were perceived as punitive, and simply "made matters worse." A common reaction of participants was resistance and anger toward others who attempted to gain control by hiding razors and cutting tools; searching rooms for razors, checking arms, or forcing them to reveal new scars; making threats to leave; calling police; and ordering them to stop cutting. When others responded with crying, screaming, self-blaming, "telling me to cut them instead of myself," such reactions exacerbated urges to self-harm and were perceived as harmful rather than helpful.

Who is helpful? Participants rated their past and current perception of others' support as fitting within one of eight categories: extremely harmful, somewhat harmful, minimally harmful, neutral, minimally helpful, somewhat helpful, extremely helpful, and not applicable. Not applicable was included as an option for participants who had limited or no contact with specific individuals about the participant's SSH. Participants rated the help offered by the following individuals: mother, father, friend(s), significant other (boyfriend, girlfriend, or spouse), sibling(s), teacher(s), athletic coach, religious leader, and school psychologist/counselor. To further simplify the data, categories were also collapsed to describe individuals as helpful, neutral, or harmful. When the three helpful categories (extremely helpful, somewhat helpful, and minimally helpful) are collapsed, 59% (n = 57) of participants perceived their friends as the most helpful group in providing support and helping reduce SSH. When the three harmful categories (minimally harmful, somewhat harmful, and extremely harmful) are collapsed, a higher percentage of participants described their mothers (43%, n = 41) and fathers (39%, n = 37) as the most harmful for helping decrease SSH.

Possibly indicating limited social support beyond family and friends, 95% of coaches and 80% of religious leaders were rated as not applicable or neutral This indicated that participants either had no or minimal interaction with them or, when there was interaction, coaches and religious leaders were perceived as neither helpful nor harmful.

Who is helpful in providing specific types of support? Those who perceived specific behaviors as helpful in reducing their SSH had the option of responding to follow-up questions that asked who participants preferred for specific help. Open-ended questions A closed-ended question is a form of question, which normally can be answered with a simple "yes/no" dichotomous question, a specific simple piece of information, or a selection from multiple choices (multiple-choice question), if one excludes such non-answer responses as dodging a  expanded the response options beyond the list of relationships in the previous close-ended questions. Twenty-nine participants responded to a follow-up question: "Who would you most prefer to have directly ask you how they might be helpful?" Almost half, 41% (12 of 29), preferred a friend to ask this.

Of the 56 participants who discussed why they engaged in SSH, 41% (n = 23) preferred this type of conversation with mental health professionals, doctors, or social workers, and 32% (18 of 56) preferred having it with a friend. Similarly, when asked about discussing SSH with someone who withheld judgment and permitted oral expression of feelings, 37% of participants (25 of the 67 who responded to this question) preferred to have this type of open discussion with mental health professionals, doctors, or social workers, and 34% (23 of 67) with a friend.

Of the 83 participants who perceived others as helpful in acknowledging the severity of distress, 53 responded to the follow-up question. Regarding who they preferred to offer this type of support, 28% (15 of 53) preferred a friend and 19% (10 of 53) a mental health professional, doctor, or social worker. Participants typically described what they needed to be understood and accepted: "Listen, don't judge." "Listen to me talk out my emotions." "Acknowledge my depression before I get worse." "Understand that [SSH] is a symptom of a bigger and deeper set of problems."

Thirty-six participants who perceived having a person stay with them as helpful in reducing SSH responded to a follow-up question. Asked to identify who that person would be, 42% (15 of 36) identified a friend and 25% (9 of 36) a significant other; only 1 participant chose a pastor or religious leader. In fact, taking into account all responses to follow-up questions, only 1 participant indicated prayer as something she considered helpful in reducing SSH.

In response to questions about interactions they viewed as harmful, participants made the most negative comments about controlling relationships and interactions with parents. For instance, "[Parents] try to force me to talk about it when I have said I don't want to." "My mother ... shouts at me and expects it to motivate me to stop." "[My mother] did full body searches to make sure I hadn't self-harmed." "[My parents stepped in], dragging me to the therapist, touching my scars."

When asked to identify the single most helpful person available to offer assistance, 41% (24 of 59 participants who responded) chose a friend to be available, and 19% (11 of 59) their significant other. Asked what helpful assistance they wished others would have provided, participants commented on the need to feel loved, validated, and accepted, wanting others to verbalize and demonstrate acceptance. Parents were often the individuals participants listed as those who should provide this assistance.

DISCUSSION

Limitations

This study had several weaknesses. First, 90% of the participants failed to meet criteria for recovery, indicating they had engaged in SSH at least once within the past 12 months. Since the majority of participants continue to harm themselves, this particular sample may be less than ideal for gaining insight into who provided helpful assistance and what type of response or interaction was truly helpful in reducing SSH. Perhaps a sample limited to those who have recovered would provide more insight into factors impacting long-term recovery from SSH.

Second, it might be argued that Internet forums See forum.  attract a select group of individuals, computer-literate and from affluent backgrounds with more access to computers (Mathy, Kerr, & Haydin, 2003). Moreover, because this sample consisted primarily of Caucasian participants (approximately 92%), it may not adequately represent the general population of individuals who self-harm. However, though not ethnically diverse, participants represented a variety of cultures around the world.

Third, participants may not have responded honestly to the questions intended to screen out individuals younger than 18 and those with certain psychiatric disorders or histories of more extreme self-harm. If the responses were not truthful, the data may not accurately represent young women who engage specifically in superficial self-harm.

These considerations must be taken into account and caution taken when interpreting the results and generalizing the findings of this study. Additionally, when interpreting the data, one must consider the lack of information about the questionnaire's psychometric psy·cho·met·rics  
n. (used with a sing. verb)
The branch of psychology that deals with the design, administration, and interpretation of quantitative tests for the measurement of psychological variables such as intelligence, aptitude, and  properties. Because the questionnaire was drafted for this particular study, there are no data available about its reliability or validity. It is recommended that future studies deal with these areas of weakness.

Implications of Research Findings

Of particular frustration for participants in this study were incidents involving others who responded negatively toward SSH. They were particularly sensitive to emotionally charged interactions with individuals (typically parents and significant others) who attempted to take control by imposing mental health care, hiding razor blades ra·zor·blade also ra·zor blade  
n.
A thin sharp-edged piece of steel that can be fitted into a razor.

razor blade n → hoja de afeitar

razor blade , forcing them to reveal cuts and wounds, shaming, blaming, yelling, and threatening to leave. But they appreciated the helpfulness of those who took time to listen, express love and positive regard, and remain calm, avoiding emotionally charged interactions. Thus, in considering approaches for therapeutic intervention and practical day-to-day social support, it is useful to note that participants struggling with SSH expressed a desire to communicate feelings to those who listen and withhold judgment.

Because a major feature of BPD is the insatiable need to feel nurtured, supported, and accepted (Linehan, 1993, 2000), supportive social interactions may be most effective when aligned with a therapy recommended for BPD: dialectical di·a·lec·tic  
n.
1. The art or practice of arriving at the truth by the exchange of logical arguments.

2.
a.  behavior therapy behavior therapy or behavior modification, in psychology, treatment of human behavioral disorders through the reinforcement of acceptable behavior and suppression of undesirable behavior.  (DBT DBT Department of Biotechnology (India)
DBT Dibenzothiophene
DBT Drive-By Truckers (band)
DBT Design Basis Threat
DBT Deutscher Bundestag (German Parliament) ). DBT stresses the importance of validation, empathy, and a radical acceptance of things as they are "in the moment" (Swenson, Sanderson, Dulit, & Linehan, 2001). From both a clinical point of view and the participants' perspective, the importance of empathic em·path·ic  
adj.
Of, relating to, or characterized by empathy.

Adj. 1. empathic - showing empathy or ready comprehension of others' states; "a sensitive and empathetic school counselor"
empathetic  listening and maintaining positive emotional support cannot be overestimated.

Although family, friends, and others have opportunities to listen and support, as individuals leave home and become increasingly independent family relationships may naturally become secondary to peer and intimate relationships (Erikson, 1968). However, strained family relationships, particularly with parents, may continue to jeopardize the stability of close relationships and fuel SSH (Briere & Gil, 1998). In fact, a history of family stressors may exacerbate difficulties in forming healthy relationships (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007; Selekman, 2002).

In addition to depending on friends for support, participants also indicated a preference for mental health professionals, doctors, or social workers to "talk about why" and to "acknowledge the severity of [their] distress." Those were also the groups most often listed as people with whom participants said they would most like to talk about SSH "with someone who is nonjudgmental and lets you verbalize your feelings." In practical terms, then, participants saw the benefits of a therapeutic counseling relationship.

Retrospectively, individuals viewed disciplinary measures such as grounding, threatening, or punishing as controlling and ineffective in reducing SSH. The notion that these punitive measures exacerbate the problem is intuitive in that punishment often increases tension, anxiety, and anger (Berk, 2006; Turnbull et al., 2002).

Listening. Participants cited the importance of listening skills. Two behaviors were seen as particularly helpful: (a) someone acknowledging the severity of the participant's distress, and (b) someone encouraging the participant to verbalize her feelings. This finding is consistent with the hypothesis that individuals who self-harm have a difficult time verbalizing their feelings (Favazza & Conterio, 1989; Simpson, 2001). The young women in this study, possibly recognizing this difficulty, expressed the importance of verbalizing their feelings with a trusted other. Similarly, the findings reaffirm re·af·firm  
tr.v. re·af·firmed, re·af·firm·ing, re·af·firms
To affirm or assert again.


re  the importance of building rapport and trust in therapeutic counseling relationships (Corey, 2005), further demonstrating the potential benefits of professional counseling.

Supportive peer relationships. Friends potentially play a significant role in supporting an individual who struggles with SSH. Participants indicated that, more than anyone else, they would prefer their friends to directly ask how they might be helpful, and that they would most prefer to know that their friends are available and acknowledge the severity of their distress. Second only to mental health workers, doctors, and social workers, friends were chosen as the group (a) to whom participants would prefer to talk in a nonjudgmental way that allowed them to verbalize their feelings, and (b) with whom they would prefer to "talk about why" they inflict self-harm.

Although there are currently no published studies about the effects of friendship on self-harm, multiple studies suggest that friendship and positive peer support promote prosocial behavior (e.g., Barry & Wentzel, 2006; McGuire & Weisz, 1982). Specifically, the affective quality, stability, and frequency of interaction in a friendship are correlated with the frequency of prosocial behavior in adolescents and young adults (Barry & Wentzel). Furthermore, positive friendships counter the intense negative emotions negative emotion Any adverse emotion–eg, anger, envy, cynicism, sarcasm, etc. Cf Positive emotion.  often associated with self-harm, such as social isolation and loneliness (Favazza, 1996; Kress, Gibson, & Reynolds, 2004).

Finally, partners and ex-partners also appeared to play a significant role in the management of self-harm in young women; "partner/ex-partner" was the most common response to the question, "who is the single most helpful person to stay with you?" Participants also preferred their significant other as the person they would want available to assist.

In summary, it appears that, aside from mental health and medical professionals, young women who self-harm prefer their friends to help in the following ways: (a) acknowledging the severity of their distress; (b) directly asking how they might be helpful; and (c) offering their time and availability. These findings are consistent with past research in several areas, especially research that indicates that individuals who engage in SSH have limited ability to express their feelings (Simpson, 2001); possess limited coping skills (Muehlenkamp, 2006, 2007; Trepal & Wester, 2006); and report a sense of social isolation, loneliness, and difficulty forming close relationships (Favazza, 1996). Participants seem to recognize these weaknesses and acknowledge the potential for others to compensate for them; that is, they recognized the appropriateness of discussing feelings, utilizing this as a coping strategy rather than resorting to SSH.

Furthermore, past studies report that individuals who engage in SSH recognize the importance of developing coping skills, particularly in expressing their feelings and utilizing constructive behavior (Nelson & Grunebaum, 1971). Our findings are clearly consistent with these findings. Additionally, in Nelson and Grunebaum's study, participants most frequently reported that an accepting therapist helped them to learn to express feelings verbally and behave constructively. In the present study, mental health professionals were actually written in as preferred helpers on several points of support.

This information also has implications for counselors and psychologists who work in schools. Currently, almost 75% of mental health services health services Managed care The benefits covered under a health contract  for children and youth are provided in public schools (Burns & Hoagwood, 2002). More effort needs to be invested in educating and preparing school-based mental health workers to work with youth who exhibit SSH (Lieberman, 2004; Trepal & Wester, 2006), gearing up preventive efforts rather than responding after SSH becomes an entrenched en·trench   also in·trench
v. en·trenched, en·trench·ing, en·trench·es

v.tr.
1. To provide with a trench, especially for the purpose of fortifying or defending.

2.  coping skill. School-based services must be channeled to better meet the mental health needs of students who are struggling with SSH. Well-trained counselors must build rapport, increasing their understanding of emotional needs, rather than focusing solely on SSH behavior. They must open lines of communication with students to bolster social support.

Finally, influential adults the individual respects, such as parents, siblings, teachers, coaches, religious leaders, and others, may help keep lines of communication open by acknowledging distress and avoiding judgment and punitive measures that tend to increase anxiety. Efforts to provide basic information about self-harm to parents and support personnel would likely strengthen the confidence of those who want to assist and also help them build better rapport. All adults who work with students would benefit from basic training in listening skills, focusing on reflective nonjudgmental listening and empathic support (Clark, 2006; Rogers, 1961).

Suggestions for Future Research

Since participants in this study were primarily Caucasian, future studies should expand to include participants of other ethnic backgrounds; the nature and impact of SSH (e.g., prevalence, stigma) may differ between cultural groups. Treatment implications and helping behaviors must also be investigated to increase the specificity of treatment and align it with individual needs. To facilitate these goals, future Internet surveys should solicit specific ethnic or cultural groups, recruiting participants from culture-specific Web sites.

The benefits and drawbacks of Internet support for those engaging in SSH should be more fully explored (Whitlock, Lader, & Conterio, 2007). Counselors must evaluate the "quantity, quality, and nature of Interact use in treating self-injurious clients" (Whitlock et al., p. 1142). Adaptive coping skills should include both healthy expression of emotions and strengthening of supportive interpersonal relationships.

CONCLUSION

An estimated 14-39% of adolescents engage in SSH. Because most of them resist seeking counseling or professional assistance, clinicians must provide guidelines to educate and strengthen support of family and friends who desire to assist but may not know how to do so.

Suggestions for nonprofessionals. Based on participant feedback and incorporating information from previous research, the following suggestions are made to assist those who engage in SSH: (a) Upon discovering SSH, remain calm; (b) let the person know you are available and desire to assist; (c) permit emotional expression; (d) acknowledge the person's pain; (e) show positive regard and acceptance; (f) show concern by listening and trying to understand the person's feelings; (g) listen without judging or discounting the person's perceptions; and (h) encourage the person to seek professional help from an experienced counselor. In sum, peers and family need to emphasize the importance of counseling, understanding that SSH is a maladaptive coping mechanism coping mechanism Psychiatry Any conscious or unconscious mechanism of adjusting to environmental stress without altering personal goals or purposes  that is typically an expression of deeper emotional issues (Ross & Heath, 2002).

Suggestions for professionals. Mental health workers in school and community settings must be trained on multiple issues related to self-harm, particularly how to recognize and respond to both behavioral and emotional aspects of SSH. Professionals must stay abreast of the burgeoning research and publications informing treatment. An Internet site, The Cornell Research Program on Self Injurious in·ju·ri·ous  
adj.
1. Causing or tending to cause injury; harmful: eating habits that are injurious to one's health.

2.  Behavior in Adolescents and Young Adults (http://www.crpsib.com/ whatissi.asp), provides current information on self-injury. Associated with this site, Purington and Whitlock (2004) have created a 4-page handout that targets must-know information that is particularly helpful in a school setting. This handout boils down research findings into a format that is easy for teachers, parents, and adolescents to read and understand. For professionals working in the trenches, disseminating accurate information is critical.

It is also important for future research to work closely with practitioners to evaluate the effectiveness of interventions, better understand emotional needs, reduce SSH, and encourage positive relationships and healthy coping skills. However, in keeping with the purpose of this study, the effectiveness of these interventions must be evaluated from multiple perspectives, taking into account the viewpoints and perceptions of individuals who engage in SSH. Practitioners who work closely with them will be especially helpful in gathering this type of feedback.

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Katherine Ryan is affiliated with the Lodi Unified School District Lodi Unified School District is a school district located in San Joaquin County, California. It encompasses the cities of Stockton and Lodi and currently has roughly 28,396 students. , California. Melissa Allen Heath, Lane Fischer, and Ellie L. Young are affiliated with the School Psychology Program, Brigham Young University Brigham Young University, at Provo, Utah; Latter-Day Saints; coeducational; opened as an academy in 1875 and became a university in 1903. It is noted for its law and business schools. : Correspondence concerning this' article should be addressed to Melissa Allen Heath, School Psychology Program, Brigham Young University, Dept. Counseling Psych/Special Ed., 340-K MCKB, Provo, Utah 84602-5093. E-mail: melissa_allen@byu.edu.

We live our lives responding to the situation we are in. Our situations are complicated and have many aspects — including physical, emotional, mental, spiritual and social aspects.

We adjust to physical matters, such as how close someone is standing to us or how much oxygen is in a room; we respond emotionally to what others are saying; we use our intellect to make plans and reflect on our experience; we may have a sense of spirit or purpose or sense a lack of meaning, and we negotiate our relationships with those around us. We are continually engaging with these aspects of our lives.

Our psychology is affected by the world around us.

We also carry the past with us. We not only adjust to the world around us; we are also influenced by what we have learned and our past experiences. We often carry around with us (at least a part of) the world we grew up in. Often our early caregivers remain influential throughout our lives. In psychotherapy, the attention is usually on past trauma. This can lead to the past being seen as a bad thing. However, it also contains many resources that we draw on to respond in the present: language and other social rituals we have learned, ways of understanding, skills, friendships and much more.

Our response to the present can also be affected by our concerns, worries and plans for the future.

Our personal past and individual notions about the future mean that one person’s response in the present is likely to be different to another person’s response — even if they are responding to something reasonably simple like the enquiry, “Hi, how are you?”

In psychotherapy (and blogging) the focus is usually on the individual and what they can do. For this post, I’d like to look at the other end of the individual-social polarity and focus on our social situation.

This social world affects us. It seems likely that more people are more worried about money now than 12-18 months ago. It wouldn’t be surprising if psychotherapists are dealing with more anxiety now than 12-18 months ago.

These social changes are relatively short term. There is also longer term social change — measured in decades and centuries. One commonly cited example is: Where have all those hysterical Victorian upper class women that Freud used to treat gone to? (Are shock-jocks and some kinds of politicians in the same situation as Victorian upper class women? They seem hysterical to me.)

I’d like to spend the rest of this post giving my perceptions of how our current social situation is distinctive and the impact this is likely to have on our experience.

The Big Picture: Technology

For me the best characterisation of our society is Jacques Ellul’s The Technological Society [Amazon-US | Amazon-UK]. (Also see the International Jacques Ellul Society.) When we look at our society, and compare it to previous ages, it is striking how much technology there is. There are now lots of ways to do almost anything that we want to do. One example: if I wish to get physically fit, there are gyms, running clubs, jogging clubs, different styles of routines (like Pilates), martial arts, yoga or tai chi. I live in a relatively small city (less than half a million people) and here there are even options for what style of tai chi I would like to pursue.

The technological society consists not only of methods and software but of ways of thinking and feeling too. We can approach our lives as a series of problems or situations that are to be fixed or manipulated.

The Smaller Picture: Computers

One impact of computers is on the availability of information. Being able to google your question to find an answer — to just about any question — is quite different to needing to get to a library. Having information presented in answer to your question is different to needing to read a book and process the information (possibly presented in a quite different form) to get an answer to your question.

The second impact of computers is communication. We can be in communication with many people, widely dispersed in a variety of ways. The time taken to have pen-friend relationships is quite different to being on Facebook, phoning on your mobile, and sending email. We can be ‘in touch’ with people from most places on Earth at any time we like.

Implications

Implications of Technology

When we can do pretty much whatever we want, and have a variety of ways to do it, the question becomes what we want to do. The focus shifts to values. As individuals we are confronted with a ‘choice of values’ or even the need to create them. This is quite different to a sense of vocation — a calling has a sense of inevitability, of ‘choosing to become who we are’. We need processes where people can discover their values and gain the support they need to live in accord with them.

Implications of Information Overload

We need to become much better at how to process information so that it is useful to us — and not just ‘facts’ that we memorise (or more likely google and forget quite soon). “Data is not information, information is not knowledge, knowledge is not wisdom.”

Implications of Communication

Information is only a small part of human communication. The focus on information means that we neglect our emotions, our aesthetic sense and the time it takes to build a genuinely warm and human relationship. We need to know how to communicate with others (especially those who are not part of our sub-culture or tribe).

I’d like to hear about your experience. How do you experience your social situation and how do you respond to it? Do you think we need new kinds of counselling to respond to our different social situation?