Running head: UNDERSTANDING SELF-HARM 1

Adolescents and Deliberate Self-Harm: An Increasing Risk Among Young People

Abstract
Running head: UNDERSTANDING SELF-HARM 2

Deliberate self-harm among adolescents can take many forms. Some adolescents cut, bite, ingest

pills, and punch themselves. If deliberate self-harm or DSH is not resolved these adolescents

may continue to self-harm or it may lead to suicide. The incidence of self-harm has increased at

an alarming rate internationally and many researchers are now taking a closer look at the causes

of DSH. This paper includes the most current definition for DSH and identifies potential causes.

Most research information is based on adolescents who are in the clinical setting. Research

shows there is a larger population of self-harmers who are unidentified. School counselors,

teachers, nurses, and school administrators are in a unique position to help identify adolescents

who are at risk of being self-harmers. Interviews with school personnel have shown that they

feel unprepared and in some cases unwilling to deal with adolescents who self-harm. More

information and research is necessary to develop appropriate identification and prevention of

DSH in adolescence.

Deliberate self-harm in adolescence is gaining attention in the media and those who work

with adolescents are concerned regarding the best method to follow when helping adolescents in
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crisis. This literature review will examine several aspects of adolescent self-harm. First, there is

no clear definition of self-harm. Research studies look at aspects of self-harm, but the results are

fragmented and apply only to the issue being studied. There is a lack of empirical data to

support comprehensive treatment programs. Next, this review will examine the prevalence of

deliberate self-harm and the characteristics that these adolescents have in common. Research

provides several approaches to treating those who self-harm and this literature review will give a

brief overview of the latest trends. Finally, teachers, school counselors, and administrators are

encountering more youth who have inflicted self-harm. The last section of this literature review

will look at what school personnel can do to help adolescents who self-harm.

There are many definitions of self-harm. Some use the terms, self-harm, self-mutilation,

self-cutting, and self-injury. These terms are used interchangeably (Laye-Gindhu, & Schonert-

Reichl, 2005). Self-harm includes but is not limited to cutting, burning, hitting, hair pulling,

scratching, pinching, biting, skin picking, wound picking, and inserting objects under the skin

(Hilt, Cha,& Nolen-Hoeksema, 2008). Research also includes violent self-harm such as self-

battery like jumping and hanging as well as shooting. (Madge, Hewitt, Hawton, DeWilde,

Corcoran, Fekete, Van Heeringen, DeLeo, & Ystgaard, 2008). Overdose has also been studied

as deliberate self-harm, because it can be a precursor to suicide. Suicidal adolescents provide

statistical data because they are usually seen in the clinical setting. (Madge et al., 2008). All of

the previously mentioned forms of deliberate self-harm are included in much of the current

research.

Researchers are finding that there is an increase in repeated episodes of self-harm

(Webb, 2002). Many adolescents who engage in cutting, or other forms of self-mutilation go

undetected. They wear clothing that will hide their wounds and scars, and without effective
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treatment they continue to self-harm. Researchers feel that all forms of self-harm share a suicidal

pathway of increasing hopelessness, anger, and suicidal ideation. Without effective primary

prevention after a self-harming episode, DSH individuals will engage in self-harm again. Many

studies reveal that DSH individuals will try other methods of self-harm (Webb 2002,). Research

so far has focused on prevention of repetitive episodes and the escalation of self-destructive

behaviors, but more research should be focused on prevention of self-harm and understanding

the root of the problem (Webb, 2002).

Erikson’s theory of adolescent development indicates that they are in a crisis of identity

vs. role confusion (Santrock, 2009). Adolescents are learning to define themselves. They are

deciding where they fit in their families, in their schools, and in their circle of friends.

Adolescents develop maladaptive coping mechanisms when they are unable to resolve the inner

conflict. Researchers suggest that DSH is one way that adolescents choose to deal with the

unresolved conflict. (Webb, 2002).

Family dysfunction, psychological factors, and repetition of DSH were examined (Webb,

2002). Social factors illustrated a significantly higher rate of problems between DSH individuals

and their families, friends, boy/girlfriends, and school. DSH individuals perceived that their

parents did not understand them, and felt they were under extreme parental criticism.

DSH individuals showed a higher rate of poor parent-child communication, family

adaptability and cohesion, childhood depression, and lack of control over family life events

(Webb, 2002). Families that practiced better communication and cohesion provided support to

their adolescents and there was less incidence of DSH.

Depression and hopelessness were the major forms of psychological factors found to

influence DSH. Individuals who suffer from depression, hopelessness, anger, and poor problem-
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solving ability showed higher incidence of repeated acts of DSH (Webb, 2002). Identifying and

treating depression was a crucial factor in a successful prognosis. Adolescents who were

depressed also showed impaired problem-solving ability. Several studies showed differences in

gender, but nothing conclusive has been identified. Cutting and overdose was strongly

associated with girls, while boys were more likely to engage in deliberate recklessness and self-

battery (Webb, 2002).

More studies need to be conducted to look at specific types of self-harm and the

underlying issues that may be key to preventing DSH. One study was limited to a public high

school in Canada. This study determined that more screening of adolescents in a non clinical

setting should be done for self-harm behaviors (Laye-Gindu, & Schonert-Reichl, 2005). There is

a large population of adolescents that are going undiagnosed. Most empirical data is focused on

adolescents in the clinical setting. All self-harmers would be screened for suicidal tendencies

there. Self-harmers are more likely to engage in other risky behaviors such as drugs, alcohol,

body piercing and tattoos.

Self-harmers reported engaging in the activity to reduce depression, relieve anxiety or

stress, and to express self-hatred and anger. The motivators varied between boys and girls. Boys

tended to self-harm in front of their peers. Boys also engaged more in hitting, biting, and

punching. They chose self-harm behaviors that showed male toughness. Girls engaged in self-

harm in private. They chose forms of self-harm such as ingesting pills and eating disorders.

Self-harm can take many forms. The motivation is different with each adolescent.

Developing appropriate treatment approaches will depend on the cause of the self-harm.

Understanding the individual’s needs, motivations, and behavior is essential to helping those

who engage in self-harm. Because self-harm is associated with psychological distress, effective
Running head: UNDERSTANDING SELF-HARM 6

treatment should include emotion-focused coping strategies. Intervention and prevention should

focus on teaching and encouraging positive and constructive problem solving.

This research study accomplished several goals. The study provided more information

about the non clinical population of adolescents who may engage in self-harm behaviors. The

study also examined potential cognitive processes that may exacerbate the self-harming

situations. The study also examined the functions of self-harm. Some participants admitted to

engaging in self-harm to self-punish, relieve tension, escape boredom, get attention, and

communicate desperation. The information from this study can be used to motivate additional

research and develop appropriate interventions for adolescents.

Another study examined DSH on a global scale. Different forms of deliberate self-harm

are increasing internationally. By examining the reasons for DSH, clinicians can select

appropriate treatments and suggest alternative coping strategies, and hopefully prevent future

suicidal behavior (Scoliers, Portzky, Madge, Hewitt, Hawton, DeWilde, Ystgaard, Arensman,

DeLeo, Fekete, & Van Heeringen, 2009). This study included seven countries (Australia,

Belgium, England, Hungary, Ireland, the Netherlands, and Norway. It included 30,477

adolescents between the ages of 14 to 17. This study was conducted using an anonymous self-

report questionnaire. One part of the study asked questions about DSH. The researchers wanted

information regarding attempted DSH and the underlying reasons for the episode. The subjects

of this study answered open-ended questions which required the respondents to give reasons for

their actions. The motives for DSH at any time regardless of one episode or multiple episodes

show that “I wanted to get relief from a terrible state of mind” was the most common response

(Scoliers et al., 2009). The next most common response was “I wanted to die”. These two

statements were true for males and females. Females had a higher incidence of saying they
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wanted to show how desperate they were feeling, and that they wanted to punish themselves.

Both males and females stated that they engaged in DSH because they wanted to see if someone

loved them, to get attention, or to frighten someone. The researchers wanted to determine if the

act of DSH was a cry for help or a cry of pain. Five of the reasons adolescents gave for DSH

included acts of desperation, wanting to frighten someone, wanting to seek revenge, wanting to

see if someone loved them, and wanting to get attention. These five reasons are interpersonal

and communicative and display a cry for help. Three other reasons adolescents gave for DSH

included wanting to die, wanting to punish self, and wanting relief from an impossible situation.

These three responses are directed inwardly and are seen as a cry of pain (Scoliers et al., 2009).

Adolescents, who engage in DSH often do so as both a cry of pain and a cry for help.

There is concern about the adolescents who wish to die. Some feel that they use that explanation

to obtain sympathy and social acceptability after the event (Scolier et al., 2009). Even though

adolescents claim they want to die, the motivation is often fueled by feelings of distress and a

desire to escape a troubling situation. Many DSH adolescents are not looking for professional

help, but are seeking helpful and caring responses from the people already in their lives (Scoliers

et al., 2009)

Another European study examined adolescents in the high school setting. Researchers

were trying to gain more information on DSH in the general population instead of only those

who are in the clinical setting (Madge et al., 2008). This research project confirms earlier

findings that the true rate of self-harm is much higher than earlier reports had indicated. Their

study concludes that many adolescents harm themselves, usually at home, but do not seek

medical attention or tell anyone (Madge et al., 2008). Many adolescents who are self-harmers

regard secrecy as the sign of a ‘genuine self-harmer’. DSH is a private matter and adolescents do
Running head: UNDERSTANDING SELF-HARM 8

not share their behavior with friends or family. This seems contradictory since previous studies

found that adolescents who engage in DSH do so to see if someone cares about them and to seek

attention. This illustrates that the reasons for DSH are very complicated and unique to each

individual.

Thinking about DSH is not a direct substitute for carrying it out (Madge et al., 2008).

Even though adolescents indicated DSH ideation in the self-report questionnaires, many

adolescents do not follow through with it. More research should be conducted to determine

“why” adolescents have these thoughts and what factors prevent them from actually following

through with DSH. This may lead to some preventative ideas for the adolescents in the future

who think about DSH.

There is a fine line between DSH and suicide. The two acts are related, but very

different. While the terms self-harm, attempted suicide, and parasuicide are used

interchangeably, the difference is in the person’s attitude towards life and death, and the attitudes

are varied and complex (Madge et al., 2008). Even though wanting to die or get relief from a

terrible state of mind were the two main reasons given by both males and females, some

adolescents gave both reasons at the same time. Females were especially ambivalent, and

significantly less likely than males to say they wanted to die.

Adolescents studied had either engaged in DSH once or repetitively (Madge et al., 2008).

Many of the youth who had been cutters, were cutters repeatedly. Those who had overdosed

were less likely to overdose again. The adolescents who said they wanted to punish themselves

also engaged in DSH repetitively. More research should be conducted on the different types of

DSH and individual treatment options that are successful for the different forms of DSH (Madge

et al., 2008)
Running head: UNDERSTANDING SELF-HARM 9

Previous studies suggest that males and females have differences when it comes to DSH,

but these differences are only slight (Webb, 2002). Studies have been conducted to examine

young adolescents who have engaged in DSH. Girls who show perfectionist tendencies are more

likely to engage in DSH (Hilt et al., 2008). Depressive symptoms are also closely related to

perfectionism and feelings of inadequacy. Internal distress such as depression, perfectionism, and

inadequacy may lead to maladaptive coping mechanisms.

Not all girls resort to maladaptive coping mechanisms. The researchers of this study

wanted to examine possible negative and positive reinforcement in DSH. They believe that the

girls who resort to DSH as a way of dealing with distress have poor emotional skills. These girls

have difficulty in emotion-regulation. Rumination is the tendency to brood and continually

reflect on one’s past behaviors. A person who ruminates will exhibit self-doubt and possibly

become depressed. Rumination has been linked to other automatic reinforcement behaviors such

as binge eating. The researchers of this study expected to find a correlation between rumination,

depressive symptoms, and DSH (Hilt et al., 2008).

Interpersonal relationships can also create distress for adolescent girls. Peer victimization

has been related to depressive symptoms among boys and girls. Girls are especially sensitive to

emerging body changes, weight, and teasing. Communication and trust is essential to developing

positive support systems for girls with a history of DSH (Hilt et al., 2008). The girl’s responses

to DSH were grouped into four basic categories. There was an automatic negative response,

which meant that DSH is used to relieve the feeling of emptiness or numbness. An automatic

positive reinforcement meant the girls engaged in DSH to feel something, even if it is pain.

Negative reinforcement meant DSH is used to avoid being with people. The social positive

reinforcement meant the girls engaged in DSH to get attention (Hilt et al., 2008). Girls need
Running head: UNDERSTANDING SELF-HARM 10

assistance in developing awareness into their own feelings about themselves. The girls need

other positive coping mechanisms when dealing with depression and rumination.

Communication with peers is very important in adolescence. Most interpersonal issues lessen if

they feel more connected to others. The girls will develop positive behaviors by socializing and

getting attention for positive activities.

Prevention and treatment of DSH depends on emotional regulation of the adolescent and

the family emotional climate (Sim, Adrian, Zeman, Cassano, & Friedrich, 2009). Parental

responses to their children’s emotional displays have a significant effect on their subsequent

awareness, expression, regulation and coping with emotions. If adolescents perceive that their

parents invalidate their emotional climate, then the adolescent will resort to maladaptive

behaviors. Parental denial of emotions, invalidation, and emotional neglect are considered

predictors of the inability to regulate emotions and avoid DSH (Sim et at., 2009). One major

difference between suicidal deliberate self-harmers and non-suicidal deliberate self-harmers is

the family climate. Those who came from a supportive family that was willing to communicate

and promote healthy emotional and psychological development were less likely to be suicidal

(Sim et al., 2009).

Teachers, school counselors, nurses, and school administrators are in a unique position to

identify and offer assistance to adolescents who engage in DSH. School faculty should know

what to look for and how to respond if they suspect a student may be engaging in self-harm. One

episode of DSH may lead to more episodes of DSH and eventual suicide if a caring adult does

not intervene. In the United Kingdom, teachers are trained to deal with bullying, bereavement,

and child abuse, but they feel uncomfortable dealing with DSH (Best, 2006).
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Many cases of DSH in schools go undetected. Teachers, nurses, counselors, and

administrators were interviewed to determine the prevalence of DSH. Due to the secrecy of

DSH, it was difficult to determine the exact number of cases. DSH takes many forms and is

usually not an isolated occurrence (Best, 2006).

Many teachers are aware of DSH, but feel inadequately prepared to deal with students

who engage in DSH. One school administrator provided training to her entire staff after a

suicide of a student (Best, 2006). This training heightened awareness and taught the teachers

better communication skills and active listening. This way the teachers felt empowered to

provide primary positive responses to the students. Before this many teachers referred these

students to the counselor. In some situations this left the student feeling abandoned and lonely

because they were reaching out for help and they were referred to someone else.

However, several members of the school personnel felt like teachers should not be put in

position to offer counseling or pastoral care to adolescents who engage in DSH (Best, 2006).

Teachers are already under pressure to meet testing standards and that working with students

who engage in DSH is better left to the counselor or nurse. This view was shared by more than

one colleague, and they expressed desire to not become aware, because of massive anxieties that

would be raised if DSH was acknowledged.

Raising awareness of DSH can cause problems of labeling and confidentiality (Best,

2006). Many schools have opted to function on a “need to know” basis. Only teachers who have

direct contact with a student are informed of difficulties involving DSH. They can then prepare

themselves to respond appropriately and give support to the student if the issue should come up.

Many teachers needed time to prepare themselves emotionally to deal with a student who has

engaged in DSH. Their initial response is one of alarm, panic, anxiety, shock, and of being
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scared, distressed, upset, taken aback, freaked out, repulsed, and frustrated, so many teachers feel

powerless to help these students. School personnel are afraid they might say or do something

wrong, especially if there is a threat of suicide along with DSH (Best, 2006). Several teachers

expressed intense feelings of anxiety and they wished to pass the problem on to someone else. In

these situations, the DSH student is referred to the appropriate school counselor, nurse, or

administrator.

Schools need to be alert and equipped to cope with students who engage in DSH.

Teachers and others in caring roles who work with students that experience bereavement,

isolation, and domestic violence may feel sadness, sympathy, and concern, and in cases of abuse

they may feel angry. However, when cases of DSH are involved these teachers and caring

people may feel anxiety, panic, shock and revulsion. Successful schools provide helpful and

supportive responses to the students who exhibit DSH (Best, 2006). Part of this process is

keeping teachers informed. When teachers are informed and aware they can work to reduce their

anxiety and this is conveyed to the students. Counselors and administrators provide a support

system for classroom teachers and convey a sense of teamwork, so teachers feel supported too.

If everyone is informed in how to promote a healthy self-concept this will equip the students

with the confidence and skills necessary to handle difficult situations without experiencing

overwhelming anxiety.

References

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Guidance & Counseling, 34, 161-175.

Running head: UNDERSTANDING SELF-HARM 13

Hilt, L.M., Cha, C.B., & Nolen-Hoeksema, S. (2008). Nonsuicidal self-injury in young

adolescent girls: Moderators of the distress function relationship. Journal of

Consulting & Clinical Psychology, 76, 63-71.

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