The Healing Journey: Help seeking for Self-injury among a Community Population
Dr Maggie Long1, Dr Roger Manktelow2 and Dr Anne Tracey3
1
University of Ulster, Jordanstown Campus, Newtownabbey, Northern Ireland
2, 3
University of Ulster, Magee Campus, Derry, Northern Ireland
Corresponding Author:
Dr Maggie Long, University of Ulster, Institute for Research in Social Sciences (IRiSS),
School of Communication, Jordanstown Campus, Shore Road, Newtownabbey, BY37 0QB,
Northern Ireland
Email: [email protected]
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Abstract
Help seeking is known to be a complex and difficult journey for people who self-injure. In
this article, we explore the process of help seeking from the perspective of a group of people
living in Northern Ireland with a history of self-injury. We conducted 10 semi-structured
interviews and employed a grounded theory approach to data analysis. We created two major
categories from the interview transcript data: (a) “involution of feeling,” which depicts
participants’ perspectives on barriers to help seeking and (b) “to be treated like a person,” in
which participants communicate their experiences of help seeking. The findings pose
important implications for policy, practice, theory and future research, including the need to
increase the uptake of follow-up care among people who arrive at hospitals with self-injury,
self-harm or suicidal behaviors.
Keywords
Grounded theory; health seeking; health care, access to; mental health and illness; qualitative
analysis; self-injury; stigma.
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Self-harm refers to a wide range of behaviors, including self-poisoning with or without
suicidal intent and self-injury. Self-injury is defined as “the intentional and direct injuring of
one’s body tissue without suicidal intent and for purposes not socially sanctioned” (Klonsky,
May, & Glen, 2013, p. 231). Evidence from the United States suggests that the prevalence of
self-injury is around 4% among adults in the general population and 21% in clinical
populations (Briere & Gil, 1998). In the general population, rates of self-injury are much
higher among adolescents and young adults.
In one study carried out in the United States, 46% of young people reported an
episode of self-injury in the year prior to research participation, including 14% who had cut
their skin and 12% who had burned their skin (Lloyd-Richardson, Perrine, Dierker, &
Kelley, 2007). Gratz, Conrad, and Roemer (2002) found a 38% prevalence of self-injury
among college students in the United States. Evidence suggests that self-cutting is the most
commonly reported method of self-injury in studies that focus on community populations
(Hawton & Harriss, 2008; Hawton et al., 2010) and that many people who self-injure use
more than one method (Gratz, 2001).
Studies on self-injury that have focused on the experiences of the self-injuring
population have often done so within statutory settings, including psychiatric inpatient and
outpatient services (Huband & Tantam, 2004; Schoppmann, Schrock, Schnepp, & Buscher,
2007; Walker, 2009). Gratz et al. (2002) argued that it is important to understand the nature
of self-injury among a non-psychiatric population because the majority of people who selfinjure “are able to function within the community” and “remain largely hidden within
society” (p. 10). Self-injury is understood to impact communities and societies far beyond
the psychiatric population that is often the focus of research. However, it is difficult to
develop a comprehensive understanding of the nature of self-injury because it is generally a
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hidden behavior (Gratz et al., 2002; Tantam & Huband, 2009; Turp, 2003) and community
populations are difficult to access.
Help seeking is recognized to be a difficult journey for people who self-injure for a
number of reasons. Longden and Proctor (2012) have stated that people who self-injure “are
often ambivalent about help seeking due to feelings of unworthiness or shame” (p. 20). A
further disincentive to seeking help is staff attitudes: in health services, patients who selfinjure are often perceived to be particularly difficult or demanding (Schoppmann et al.,
2007). Research in the field suggests that self-injury often evokes discomfort, anger,
confusion and even disgust among care providers (Babiker & Arnold, 1997; Favazza, 1996;
Law, Rostill-Brookes, & Goodman, 2009; Shepperd & McAllister, 2003; Walsh & Rosen,
1988). Existing research indicates that when people do decide to seek help in the first
instance, they tend to do so from informal, social networks such as friends or family (Evans
Hawton & Rodham, 2005; Mental Health Foundation, 2006; Sane 2008; Wu et al., 2011;
Ystegaard et al., 2009).
The majority of existing research on help seeking for self-injury has focused more
broadly on the issue of self-harm. Moreover, previous research has often been quantitative,
determining whether people decide to seek help or not and, if they do, when and from whom
(Evans et al., 2005; Wu et al., 2011; Ystegaard et al., 2009). This approach to research has
tended to conceptualize help seeking as a staged, linear process. Evans et al. (2005) cited the
three-stage model by Saunders, Resnick, Hoberman, and Blum (1994): “recognizing there is
a problem, deciding that help is needed and seeking help” (Evans et al., 2005, p. 574).
However, help seeking is understood to be a much more complex and multi-directional
process involving an intricate web of patterns and pathways. The network-episode model of
service use (Pescosolido & Boyer, 1999; 2010) is a dynamic, process-oriented approach that
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focuses on the social context within which an individual experiences mental illness and
accesses informal sources of support and formal treatment services.
There are four main components to the network-episode model: (a) the illness career,
(b) the social support system, which consists of informal networks of support, (c) the formal
treatment system and (d) the social context (Pescosolido & Boyer, 1999; 2010). The
network-episode model posits that a person’s response to illness is influenced by social
processes and interactions, as well as individual action and choice. The model recognizes the
role of informal systems of social support that influence the illness career among people
experiencing mental health problems and their propensity to seek help from formal services.
In the network-episode model, entry into formal treatment involves dynamic patterns and
pathways through which people move in multiple directions over time rather than in a linear
progression through a staged decision-making process.
In staged models of help seeking, such as the model cited by Evans et al. (2005), the
term “help seeking” connotes a rational decision based on individual choice. In the networkepisode model, this experience is influenced by the person’s state of mind and his or her
informal support networks. Moreover, Pescosolido, Brooks Gardner, and Lubell (1998)
suggested that people’s entry into formal treatment might involve choice, coercion by either
courts or family, or “muddling through,” which describes the experiences of people who
neither seek nor resist treatment but somehow end up in health care services.
There is a paucity of qualitative research on the experiences of help seeking among
people who self-injure. Harris (2000) recruited participants outside of statutory services,
from a pen-pal network, to explore experiences in accident and emergency hospital
departments among people who cut themselves. A number of the participants in Harris’s
(2000) study related that they would not return to such formal help, irrespective of the level
of injury, because of the “hostile care” (p. 167) they were subjected to. Harris’s (2000)
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article afforded valuable understanding about the experiences of accessing medical treatment
from statutory services from the perspectives of people who self-injure. We seek to
contribute to this body of understanding by providing further insight into the process of help
seeking, including the interaction between informal support and formal care identified in the
network-episode model.
The Northern Ireland Context
Little is known about self-injury within the wider community in Northern Ireland. Reports
have been published based on hospital presentations and admissions as a result of self-harm
(Department of Health, Social Services and Public Safety in Northern Ireland (DHSSPSNI),
2009; 2010; 2012). O’Connor, Rasmussen, and Hawton (2014) conducted a survey on young
people aged 15–16 years and found a 10% lifetime prevalence of self-harm, with self-cutting
being the most commonly reported method among boys and girls. O’Connor et al. (2014)
postulated that this figure is in fact an underestimate because rates of suicide, hospital
presentations for self-harm and mental health problems are generally higher in Northern
Ireland than in other regions of the United Kingdom. Bearing these issues in mind, it is
important to gain an understanding of the experiences of people who self-injure within the
Northern Ireland context.
In Northern Ireland, people experiencing mental health problems can access
psychiatric or psychological services from the statutory sector; individuals will often be
referred to this section by a medical practitioner such as a General Practitioner (GP).
Another source of support, sometimes free at the point of delivery, is counseling. People
might be referred or self-referred to counseling (DHSSPSNI, 2002). People might access
counseling through non-statutory services in the community/voluntary sector, or through
services provided by educational institutions or employee assistance programs.
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In the current article, we strive to make a significant contribution to the existing body
of knowledge by adopting a qualitative approach to focus on the perspectives of people who
self-injure and by recruiting participants from Northern Ireland, at a community level,
independent of statutory services. The findings reported in this article form part of a larger
study, which aims to understand the experiences of self-injury and the process of seeking
and accessing help for self-injury from the perspectives of people with a history of selfinjury, community level gatekeepers and counselors. In this article, we present two
categories from the findings derived from the perspectives of people with a history of selfinjury; these categories provide an understanding of the process of help seeking among
people who self-injure.
Method
Recruitment
We recruited participants (n = 10) in two phases by advertising in non-statutory counseling
agencies and third-level education in Northern Ireland. The recruitment process involved
people who were interested in participating in the research reading the publicity leaflet and
contacting the first author by email. The first author replied to each person’s email and
enclosed a copy of the participant information sheet. The first author arranged an interview
at a time and date convenient to both parties after the participant had read the participant
information sheet, confirmed that he or she met the inclusion criteria, asked any questions or
clarified any issues and subsequently expressed a willingness to participate.
In recognition of the sensitive nature of the subject area and anticipating the
challenges of recruiting a community population with a history of self-injury, we hoped to
recruit enough participants to allow for theoretical saturation. In the first phase of data
collection, the recruitment of five participants was carried out over a six-month period.1 In
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the second phase of data collection, another five participants were recruited to the study and
interviewed. Thus, the total sample for the study was 10 individuals.
We designed the following inclusion criteria for participants: over the age of 18
years, living in Northern Ireland, with a history of self-injury, no longer engaging in selfinjury and accessing counseling at the time of research participation. The last criterion was
designed to minimize the potential for distress, based on the rationale that people engaged in
counseling would have adequate support to facilitate their participation in the research.
Some of the participants (n = 4) had a history of engaging in other methods of self-harm in
addition to self-injury. This fact was consistent with existing research (Gratz, 2001), which
suggested that many people who self-injure engage in more than one method. The sample
included two men and eight women between the ages of 19 and 42 years with a mean age of
31 years.
Data Collection
We collected data using semi-structured interviews, which we audio recorded with the
participants’ consent. All of the interviews were conducted by the first author. The duration
of the interviews ranged from 26 minutes to one hour, with a mean duration of 42 minutes.
We designed an initial interview guide based on concepts that emerged from the literature
review, which included questions about the person’s memories regarding the time his or her
self-injury began, what led him or her to self-injure, who (if anyone) was aware of his or her
self-injury, how did he or she decide who to turn to for help, what was his or her experience
of seeking help and what was his or her experience with counseling. The researcher did not
rigidly adhere to questions, but rather designed the questions to facilitate exploration and
used the questions to guide the interview process. The researcher invited participants to
expand on their responses by using follow-up and probing questions in each of the
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interviews to further illuminate particular concepts that emerged in-vivo during the interview
process.
Analysis
For the analysis process, we employed the central tenets of grounded theory (Corbin &
Strauss, 2008; Strauss & Corbin, 1998) comprising open, axial and selective coding of
categories, from which we created concepts, subcategories and categories. This process was
facilitated through the use of QSR International’s NVivo 9 qualitative data analysis software
(Richards, 2005). We commenced open coding after the first interview, through the
identification of concepts. Data collection and analysis were simultaneous processes; we
accordingly ensured that the data collection never moved too far ahead of the analysis. This
fact meant that once we had conducted an interview, we transcribed and analyzed it as soon
as possible following the recording. The process of data analysis involved conducting the
interview, transcribing the interview verbatim, printing, reading and re-reading the interview
and subsequently uploading the transcript to the computer program.
The first author began the preliminary analysis during transcription, which was a
lengthy process that took approximately six hours to transcribe a one-hour recording. This
process involved intense listening and replaying the recording to transcribe every nuance
including pauses, laughter, emphases on particular words and so forth, to accurately convey
meaning. The first author subsequently printed, read and re-read the transcript in an effort to
gain an insider’s perspective on the participant’s experience. She highlighted points and
made notes in the margins of the transcript. Next, the first author created a project in the
computer program for the findings, to which she uploaded transcripts.
The process of open coding (Corbin & Strauss, 2008) on the computer program
involved the first author creating nodes from the transcript, some of which she labeled invivo, using the participants’ language, and others she labeled based on her own constructs.
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The nodes created in the process of open coding represented concepts. Next, the first author
adjusted the interview guide to include emergent concepts, which she posed in question
format to subsequent participants. Throughout the process, the first author wrote memos to
increase her understanding of and thinking process in relation to particular nodes.
During the analysis process, we reduced each transcript to create as many nodes as
possible, which ranged from 20–50 nodes per transcript. During our analysis of each
transcript in detail to create its respective nodes, we established tentative connections
between nodes by creating parent nodes labeled using the researcher’s own constructs with
associated child nodes derived from each of the interviews. We began this process when we
had carried out four interviews because at this stage we concurred that we had collected
sufficient data to deepen the analysis process. Moreover, we created relationships in the
computer program, which allowed us to draw comparisons between the possible meanings of
nodes, without necessarily positioning them within the same node family. This process of
putting the data together again, once it has been taken apart, is known as axial coding and the
parent nodes at this stage would have been considered provisional subcategories (Corbin &
Strauss, 2008).
Following the eighth interview, we determined that we had reached theoretical
saturation because we had not created any new concepts from the data. Nonetheless, we had
collected a wealth of rich and meaningful data from the eighth participant and more people
were willing to participate in the research. Consequently, we carried out two more interviews
to ensure that saturation had occurred. We were able to deepen the analysis process and gain
insight into a wider range of experiences. We created a plethora of concepts and some
provisional subcategories, along with memos to enhance the analytic process. Collaboration
between two authors during the analysis process facilitated the conceptual leap to create
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categories that were adequately developed in terms of properties and dimensions (Corbin &
Strauss, 2008).
Once the data reached saturation, two authors worked together to pose the difficult
questions of the data, asking about the meanings of concepts and how they compared with or
differed from the meanings of other concepts. Why had parent nodes been created that
brought particular nodes together? Why were particular nodes aligned with each other and
not with another set of nodes? These types of questions facilitated the creative flow of the
analysis as the third author made notes while the first author responded to the questions,
which ensured that the analysis stemmed from the first author’s prolonged immersion in the
data (Corbin & Strauss, 2008). This process facilitated the completion of axial and selective
coding, through which the final subcategories and categories were created. In keeping with
one of the tenets of grounded theory (Corbin & Strauss, 2008), the titles of subcategories and
categories were labeled using the participants’ own language.
To enhance the credibility (Corbin & Strauss, 2008) of the analysis, we employed the
validation strategy known as member checking (Creswell & Miller, 2001; Lincoln & Guba,
1985). This strategy involves sending the transcript along with a summary of the transcript,
which identified key themes, to the relevant participant for his or her perusal and
verification, following the transcription and open coding of each interview. In addition, we
employed negative case analysis, which is an important analytic tool in grounded theory
research that “adds richness to explanation” and provides evidence that “life is not exact . . .
there are always exceptions to points of view” (Corbin & Strauss, 2008, p. 84). Hence, the
negative cases identified in the findings enhance the rigor and quality of the research.
Ethical Considerations
The university’s Research Ethics Committee granted ethical approval to our project in 2010.
We were prepared for ethical issues at each stage of the research process involving access to
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and recruitment of participants, confidentiality of personal details, write-up of findings and
ongoing sensitivity to the issue. Prior to recording the interview, the researcher invited
participants to ask questions or clarify any concerns that may have arisen between the time
he or she agreed to participate and the time of the interview. The researcher verbally
communicated all relevant information to participants and provided them with a consent
form to initial before recording the interview.
During the data collection phase, the researcher took care to create interview
conditions that would minimize the potential for distress. Prior to the interview, we
explained to participants that the researcher was not practicing as a counselor and discussed
their willingness to talk with their own counselor if any distress were to arise during the
interview. The researcher endeavored to convey sensitivity to the participants and their life
experiences, through active listening, empathy and non-judgment in every interview. The
researcher scheduled interviews deliberately to allow sufficient time to establish rapport at
the beginning and afford participants as much time as was necessary to share their story. The
researcher also took time at the end of each interview to “wind down” and allow the
participants to engage in less formal conversations before they left the interview.
To protect the anonymity of participants, we used pseudonyms throughout the
research process. Participants were invited to choose their own pseudonym or to give the
researcher permission to choose. The researcher was careful to verbally re-assure
participants that their consent was ongoing, ensuring that participants understood that they
could withdraw from the study at any time before, during or after participation without
reproach. In addition, we advised participants about the possibility of future publication of
the findings.
Findings
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The findings presented in this article include two categories and their associated
subcategories and concepts: (a) “involution of feeling”: barriers to help seeking and (b) “to
be treated like a person”: experiences of help seeking. The category labels were derived invivo from the data to ensure that the analysis was effectively grounded in the lived realities
of the participants’ experiences (Corbin & Strauss, 2008).
“Involution of feeling”: Barriers to Help Seeking
This category deepens our understanding about the participants’ perceptions and experiences
of barriers to help seeking. These barriers include external barriers such as stigma and
internal barriers such as fear. Furthermore, the functions of self-injury as a method of coping
or as a means of control forge and strengthen existing internal barriers to help seeking. The
metaphor “involution of feeling,” derived from the transcript data, pertains to the
entanglement of feelings communicated by the participants. This statement appropriately
captures the complexity of the barriers to help seeking, whereby a person might internalize
the external stigma, subsequently leading to a sense of confusion and self-doubt. For many
of the participants, this experience ultimately compounded a sense of emotional reticence,
rejecting the idea that they would want help or indeed that they would want to break out of
the spiral of self-injury.
Stigma, judgment and misunderstanding. Stigma, judgment and misunderstanding about selfinjury were identified by the participants as external barriers that hinder people who selfinjure from seeking help. The participants highlighted the level of misunderstanding in
society about self-injury and the impact this misunderstanding has in preventing people from
asking for help:
People don’t understand what self-harm is, they just think it’s either a cry for help or
just some kind of psychiatric disorder; they don’t see it as a manifestation, I suppose,
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of other things that are going on really. I think really there is an ignorance around it,
and that would stop people going for help.
The participants related that misunderstanding from others when people do seek help
or disclose self-injury can feed into an existent cycle of self-degradation and cause the
person to regress further into his or her self-injury.
Fear and confusion. Stigma, judgment and misunderstanding from society can lead to an
internal sense of confusion and self-doubt. These feelings, in turn, can contribute to feelings
of fear about help seeking and in particular the reactions of other people:
Feeling like you’re the only person in the world who [self-injures] . . . there is a sort
of like a spiral . . . like an involution of feeling, where you know that you’re not
attention-seeking because you would go to great lengths to hide it, but at the same
time you’re thinking, “am I attention-seeking by doing this and hoping that someone
will see it?” But, so you know you have a lot of arguments with yourself . . . it’s
confusing.
For some people, the fear was about a loss of control or the ripple effect that such a
hidden and private way of life may become common knowledge. Fear can co-exist with
shame, a need to hide from the view of others: “I think they’re ashamed, maybe they don’t
know why they do it and they’re just afraid to ask for help.” Thus, the participants recounted
that internalized stigma can interact with social stigma to reinforce existent obstacles to help
seeking.
Coping. This subcategory refers to the experiences shared by many of the participants that
self-injury was a coping mechanism. Self-injury enabled the participants to manage their
painful life experiences and emotional distress that were ongoing in their lives. Self-injury
14
helped when no other outlets were available and accordingly represented a fundamental
impediment to seeking external support in foregoing this, albeit maladaptive, coping
mechanism.
Although it’s obviously not a healthy thing I think it was sort of an adaptation to an
unhealthy situation . . . because I wasn’t getting adequate support elsewhere it wasn’t
like I had another way to cope.
Self-injury was not perceived to be the problem, but rather an effective part of the
solution, “a natural sort of thing.” One participant clearly distinguished the motivation for
her self-injury from that of suicide: “Em I didn’t want anyone to think I was going nuts or I
was suicidal or anything like that there, I was just for a long time trying to, it was a coping
mechanism.”
Self-injury facilitated the participants’ adaptation to an unhealthy situation by
enabling them to cope and consequently represented a significant impediment to help
seeking. In this situation, self-injury was not perceived to be a problem, which negated any
realization that external help would be required.
Control. Many of the participants used the word control when reflecting on their experiences
of self-injury. They viewed self-injury as a way to regain a sense of control in their lives
when their life circumstances were perceived to be chaotic. Hence, when the participants
perceived themselves to be in control, they did not recognize that their self-injury was a
problem and as such would not have conceived of seeking or accepting external help:
As far as I was concerned and probably still am to an extent, to me the self-harm was
my way of coping with it so it was healthy in my head, so I don’t think I ever really
wanted anybody to take it away from me cuz it was the one thing I did have control
over.
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A number of the participants who shared that control was a fundamental function of
their self-injury provided further insight into this phenomenon by relaying that over the
course of time the balance of control seemed to shift and reverse, whereby they became
controlled by the self-injury. One participant elaborated on the complexity of the function of
control, articulating that at the time of self-injuring the person may feel in control, yet in
reality the need to self-injure portrays a state of being out of control.
Self-injury provided the elusive function of control when the participants’ lives felt
beyond their control. As such, this feeling further reinforced the participants’ sense of selfinjury as a panacea to their problems, creating a significant internal barrier to help seeking.
Never wanted support. Many of the participants elucidated that they did not want support
from any external source, which posed a major obstacle to help seeking:
I know for myself there was definitely large periods of time where I didn’t want help
because I didn’t want to stop cutting because it, it made things feel better, so why
would I stop doing the one thing that made me feel better, and I really resented
attempts to get me to stop cutting because I felt like they were taking away the one
thing that was a release, an outlet for me and I had no other way. So I think you
know patient compliance that is the person who really wants that change whereas if
they don’t want it I don’t think they have any reason to ask for help.
Other participants related that they did not make a conscious decision to seek help, which
provided evidence of “muddling through” (Pescosolido et al., 1998):
Em so more or less I don’t think I ever sort of asked for support, but it sort of came
along from me just sort of saying “I can’t cope with this” from time to time.
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One of the participants deviated significantly from the others and represented the
negative case. This participant reported that he had sought help and support throughout his
life; the problem was that no suitable help was available until more recently: “if you’re
looking for help and you’re not really getting it, it makes it harder.”
The “involution of feeling” category captures the complex dimensions of barriers to
help seeking, whereby a person may internalize social stigma, subsequently leading to a
sense of confusion and self-doubt. For many of the clients, this experience ultimately
contributed to a sense of emotional reticence, rejecting the idea that they would need or want
help for their self-injury.
“To be treated like a person”: Experiences of Help Seeking
This category illustrates the participants’ experiences of overcoming the barriers to help
seeking. The category label was derived from the transcript data and pertains to the
pervasive sense from all participants of their yearning to be treated like a person when they
sought help. For some participants, this experience involved accessing help from health
services for immediate first aid, medical, psychiatric or social care and ongoing support.
Some participants reported that they initiated help seeking and some did so as the result of
either an emergency situation or discovery by others. A number of participants reached a
pivotal moment of realization when they wanted to stop self-injuring and became
incentivized to find appropriate support, from either formal or informal sources.
Stopping the fall. This subcategory captures the essence of the motivations for help seeking
shared by a number of the participants. These participants inevitably craved a way to stop the
fall and prevent themselves from spinning further and deeper into the downward spiral of
escalating self-injury:
Throughout my life there’s been like a hole waiting for me to fall into and nobody
can stop ya from falling into that hole, it’s your own sort of responsibility but if
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you’re looking to hold onto somebody to balance yourself, to stop the fall and you’re
not getting that, that is, that’s a bit hard, that makes it harder so it does.
Some participants reached out for help when their self-injury intensified to serious
levels, spiraling out of control: “looking back on it I was out of control”; “once it stopped
being something I could control I didn’t want it . . . So I wanted someone to get the control
back and I knew then I needed help.” Some participants related a turning point, an intrinsic
capacity for change, “a sudden maturity” brought about from hitting ‘rock bottom,’ which
enabled them to access support for the journey ahead.
Suicidal crisis. Four of the participants disclosed that they had either made an actual attempt to
end their lives or had experienced suicidal thoughts. For these participants, the persistent
thoughts of suicide or the attempt at suicide was almost a catalyst for their determination to
move beyond self-injury. One participant disclosed his suicidal thoughts to a social worker
who put the appropriate support in place: “at the time I’d a lot of problems with suicidal
thoughts and that, and that’s the main reason I ended up going into hospital.” Another
participant attempted to hang himself and following this event he refused to return to the
same psychiatric ward. As such, he was admitted to an alternative hospital, wherein his work
toward healing would crystallize.
One participant recalled the last occasion that she self-injured, conceding that it was
a suicide attempt. It was a year after this act before the participant felt sufficiently ready to
seek ongoing help to work through the painful life experiences that led her to self-injury:
I’m still not sure myself in my head whether it was a suicide attempt or whether it
was self-harm . . . and I went out to the kitchen and I slit my wrist, and em, was
taken to hospital . . . eh because at that point I did want to die, I wasn’t thinking
about anything else and I couldn’t even feel myself, I couldn’t even, it wasn’t sore.
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Thus, the findings demonstrate that for some of the participants, persistent thoughts
of suicide or an attempt at suicide became their lowest point, a black hole within the spiral,
from which they became motivated to propel themselves away from self-injury.
Selectively choose who you tell. This subcategory denotes the participants’ experiences of
disclosing their self-injury to others. Disclosure was recognized to be a carefully considered
decision. If disclosed inappropriately, the confidence can move swiftly, spreading far and
wide, “like letting a bag of feathers go in the wind.” For one participant, her self-injury was
discovered in school and as such the decision to disclose was no longer her own, which
posed a new set of problems for the participant in her already troubled family home. As a
result, this participant’s self-injury continued in a more covert way that would remain
undetected.
The participants suggested that it is neither appropriate nor helpful to disclose selfinjury to family members; because of their emotional proximity, family members cannot
fully understand and the self-injury causes them undue worry and distress. A number of the
participants noted the pivotal roles played by friends in providing support. Many
acknowledged friends as the first people to whom they confided their self-injury.
For two participants, their GP was an important source of professional support. A GP
provided a space for one of the participants to speak confidentially, every week, until such
time as she felt ready to meet with a counselor. However, two participants held a more
negative view of their GPs; one felt that she would be subject to judgment and another
related that “I’d a GP once that threatened to section me because I was self-harming, so that
kinda scared me.”
Out into the nowhere. This subcategory pertains to the experiences shared by some of the
participants in relation to medical treatment. Several of the participants recounted times that
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they attended either accident and emergency departments or health centers. From personal
experiences, one participant concluded that a failure to offer follow-up care means that
people are left vulnerable, possibly leading to more serious levels of self-injury, self-harm or
indeed suicide:
I’ve been to A&E [Accident and Emergency] a few times myself, with things
directly related to self-injury and . . . It’s sorta like, “aw never mind the underlying
problems, stitch you up and you’re on your way, see ya later” . . . you get let out into
the nowhere . . . and I think that’s how a lot of people get into a very bad way, where
suicide becomes a very big thing.
One participant recalled a punitive approach in medical centers when treatment
would have been delayed while others were seen before her. The participant related that
while she sought medical treatment for wounds, “I didn’t even want help; I just wanted
somebody just to treat me as a person.” After a serious episode of self-cutting, one
participant was advised by the hospital that he would receive a follow-up appointment upon
discharge, which never arrived. Another participant felt so vulnerable and paranoid when she
presented to accident and emergency that she denied that she was feeling suicidal: “the
things that I had said to cover up how I was really feeling, I was suicidal, I did need care.”
Just enough, to move on. This subcategory relates to the participants’ experiences of formal
help or support and to what extent these experiences enabled participants to move forward
with their lives. One participant articulated how the psychiatric hospitals to which she was
admitted during her teenage years were profoundly damaging: “it gave me the impression of
sort of being . . . a case, not a person but a case.” Another participant’s experiences in a
psychiatric hospital during his teenage years provided him with sufficient momentum to
move beyond self-injury: “being in hospital helped me move forward a little bit, just enough,
to get on past being depressed every day.”
20
When one participant was admitted to a different psychiatric ward after his attempted
hanging, he discovered a renewed vigor for life from the level of support he received: “And
the amount of help and support that I was, by nurses now, in [psychiatric hospital], was
brilliant, the building was clean, just everything was geared up there for people to get well.”
Wanting to be treated like a person encapsulates the inherent hope held by
participants when they embarked on their efforts to seek and access help for their self-injury.
Whether they sought interventions for immediate medical care or ongoing support from
formal or informal sources, all of the participants valued being treated like a person and
conversely were considerably damaged by being treated inhumanely.
Discussion
In this article, we have presented the findings from a unique study in which we recruited a
community population with a history of self-injury in order to understand their experiences
of help seeking. We have found that help seeking is a complex journey for people who selfinjure, constituting a range of patterns and pathways shaped by social influence. We suggest
that the network-episode model of service use (Pescosolido & Boyer, 1999; 2010) offers a
conceptual basis with which to understand the experiences of help seeking reported in the
findings.
This study was carried out in Northern Ireland, a region of the United Kingdom that
benefits from health and social care free at the point of delivery from the National Health
Service. The majority of participants in this study accessed a range of services, which might
not be available to people in countries with private or mixed health care systems where
payment is required under pre-paid or fee-for-service health care plans (Pescosolido &
Boyer, 2010). Health care systems vary across social and geographical locations and the
nature and type of service was not the primary focus of our study. We sought to probe more
deeply to understand the essence of human experience (Heidegger, 1967). Thus, the findings
21
from our study created concepts relating to self-injury and help seeking, which are
transferable beyond the Northern Ireland context. The transferability of the findings is
apparent through their applicability within the existing international evidence base.
We found that self-injury evokes a profound emotional reaction based on stigma,
fear and misunderstanding among professionals in the formal treatment system and members
of social support networks, which ultimately impacts the attitudes that people who selfinjure hold about themselves. Corrigan (2004) reflected on the interaction between social
stigma and self-stigma among people with mental illness, whereby living in a society
surrounded by prejudicial assumptions causes people to “accept these notions and suffer
diminished self-esteem, self-efficacy, and confidence in one’s future” (p. 618). We presented
evidence to support this interaction between primary social stigma and secondary self-stigma
among people who self-injure, whereby they adopt and internalize society’s prejudice and
thus begin to doubt their own sense of self. Among the participants in our study, such selflabeling impeded their willingness to disclose their self-injury or access help from informal
or formal support networks.
We identified the functions of self-injury as a coping mechanism and means of
gaining a sense of control represented internal barriers to help seeking. Self-injury enables a
person to feel a sense of control when life feels inherently chaotic (Pembroke, 1996).
Medina (2011) described this function as a “curative function” of self-injury, providing the
person with a sense of “personal agency” when he or she lives in conditions of “physical or
psychic imprisonment” (p. 2). The findings deepened insight into these ideas, where selfinjury represented the only way people could cope and thus survive experiences of trauma,
abuse and victimization. We propose that our study goes beyond other research, which
understands coping and control as functions of self-injury, by recognizing that the
functionality of the behavior represents a significant barrier to help seeking.
22
Our findings are aligned with psychiatric survivor literature (Harrison, 1997;
Pembroke, 1996; Shaw, 2002), which has conceptualized self-injury as a rational response to
harmful and debilitating social conditions such as abuse. We found that among the
participants, self-injury was not recognized to be the problem rather the panacea, albeit
temporary, to a range of painful life experiences. In our study, many of the participants
turned to self-injury to cope because they felt isolated from potential sources of support. The
participants identified self-injury to be an outlet when informal social networks were either
inadequate, through perceived or actual physical or emotional unavailability, or indeed the
cause of the underlying problems. Self-injury was the means through which the person
endeavored to cope. As such, self-injury represented the person’s initiation into the illness
career as conceptualized in the network-episode model. We would suggest that the term
“illness career” might not be appropriate in circumstances where the person does not
consider his or her behavior to be symptomatic of illness.
We found that people’s experiences of the formal treatment system can be shaped by
whether their entry into the system is voluntary or involuntary. Previous research has
debated the effectiveness of interventions that involve coercion, either in the form of
obligatory attendance at appointments or cessation of behaviors a condition of treatment
(Prochaska, DiClemente, & Norcross, 1992). Our findings reported that the help-seeking
process is more effective when the decision to disclose and ask for help is autonomous. This
finding is aligned with the results of Prochaska et al. (1992), who stated that when a person
is obligated to attend for help due to pressure from others, in the pre-contemplation stage, he
or she may desist from the behavior temporarily while others are putting him or her under
pressure: “Once the pressure is off, however, they often quickly return to their old ways” (p.
1103). When a person’s self-injury has been discovered by others and he or she is
23
subsequently obliged to access help, the level of risk may intensify as the person endeavors
to hide from scrutiny.
Existing research by Motjabai and Olfson (2008) suggests that the biggest predictor
of young people seeking help for self-injury is parental detection of the behavior. Our study
demonstrated that parental detection of self-injury was perceived to be a distressing
experience, which was particularly invalidating where control was identified as a function of
the self-injury (McMyler & Pryjmachuk, 2008; Pembroke, 1996; Shaw, 2002). Two
participants in our study experienced involuntary entry into formal treatment during their
teenage years following parental detection of self-injury. Rather than help, this treatment
aggravated their distress, further diminished their sense of autonomy and increased their selfinjurious behavior in a more hidden manner. Our study highlighted that there is the
possibility that a young person might access help following parental detection of self-injury
but this help seeking may be to maintain a façade and conform to expectations while the
behavior continues.
Our study found that people might not want to seek help because they fear this
admission of needing help will involve coercion into the cessation of the self-injurious
behavior, which ultimately defers their entry into formal care services. Our findings
supported existing evidence that has questioned the effectiveness of behavioral interventions
that aim to reduce or eliminate self-injury (Crowe & Bunclark, 2000; McAndrew & Warne,
2005; Simpson, 2006). Participants recognized behavioral interventions to be particularly
unhelpful if applied during the pre-contemplation stage of the change process (Prochaska et
al. 1992), before the person considers the behavior to be a problem. The findings support the
existing literature, which suggested that the person perceives behavioral interventions to be
punitive (McMyler & Pryjmachuk, 2008; Pembroke, 1996; Simpson, 2006; Shaw, 2002).
24
This finding is particularly notable among people who are already struggling with issues of
control (McMyler & Pryjmachuk, 2008) and might intensify the self-injurious behavior.
We found that the participants’ choice to disclose self-injury was taken carefully.
This finding contradicted interpersonal influence theory, which has been cited in clinical
literature to be a function of self-injury (Klonsky & Muehlenkamp, 2007). Our findings
reported that because self-injury is a hidden behavior, used to cope in difficult
circumstances, people often feel reluctant to confide in others (Hawton et al., 2010). Indeed,
the participants reflected on feelings of fear about the repercussions if their private behavior
became public knowledge. Similar to a range of existing research, we found that friends
provided an invaluable source of support in the person’s informal social networks (De Leo &
Heller, 2004; Evans at al., 2005; Hawton et al., 2010; Mental Health Foundation, 2006;
Sane, 2008; Ystegaard et al., 2009; Wu et al., 2011).
Our study demonstrated that when people choose to disclose their self-injury to
someone else, they might not feel ready to stop self-injuring. At this stage in the illness
career, the person recognized self-injury to be a problem that he or she was not yet ready to
relinquish. This sense of ambivalence meant that the person did not make a deliberate,
rational decision to seek help from formal services, as staged models of help seeking would
imply. Rather, we found that some participants did not know what type of help they needed
but knew that they needed something to change. In these instances, participants disclosed to
informal networks in the lay, pastoral and human-social service systems, including teachers,
social workers and friends (Pescosolido & Boyer, 1999; 2010). Thus, we found evidence of
“muddling through” (Pescosolido et al., 1998), which describes the experiences of people
who end up in formal treatment without deliberately seeking or resisting it. For two
participants, this experience was helpful, which facilitated their recovery from self-injury.
25
Our study demonstrated that for people who choose to seek help, formal services
might not be appropriately responsive to their needs. This fact echoed the research presented
in the existing literature, whereby the person who seeks help faces insurmountable obstacles
in overcoming prejudice among professionals in formal services and people in informal
social networks (Allen, 2007; Babiker & Arnold, 1997; Harris, 2000; Shaw, 2002; Simpson,
2006). This finding is particularly poignant for people who are already marginalized through
social discrimination (Babiker & Arnold, 1997).
The findings support the existing literature, which suggests that self-injury can
become increasingly entrenched where individuals do not receive adequate support, thus
progressing to such points that it reaches almost fatal levels (Tantam & Huband, 2009; Turp,
2003). For instance, following an incident where one participant cut his wrists extensively so
that he had to be operated on, he was supposed to receive a follow-up appointment from
psychiatric services, which never arrived. Following this turn of events, the participant
attempted to hang himself. This finding corresponds with the existing literature, which posits
that inadequate responses by formal statutory services might result in an escalation of the
level of injury (Pembroke, 1996; Shepperd & McAllister, 2003; Simpson, 2006).
The National Institute for Health and Clinical Excellence (NICE) Guidelines (2004)
for the management of self-harm among healthcare professionals “make clear that people
who self-harm should be treated with the same dignity and respect as any other patient” (p.
2). In our study, participants reported that they experienced discriminatory behaviors by
healthcare professionals when seeking wound care, including delayed treatment, which has
been documented in previous research (Longden & Proctor, 2012; Pembroke, 1996). We
found that these experiences were deeply invalidating for the person (Shepperd &
McAllister, 2003), negatively impacting on his or her capacity for emotional healing and
potentially in regards to future help seeking for wound care (Harris, 2000).
26
Our findings showed that when people attend accident and emergency departments
for medical treatment following an episode of self-injury, follow-up care was not offered or
the person felt too overwhelmed to avail him or herself of such support. Crucially, accident
and emergency has the potential to offer an important pathway to services for people at the
point of crisis who would otherwise decline help (Longden & Proctor, 2012). Efforts have
been made to improve follow-up care in Northern Ireland when a person presents to an
accident and emergency department with self-harming behaviors, as a result of the regional
Suicide Prevention Strategy (DHSSPSNI, 2006a/2012). A “Card before You Leave”
protocol is supposed to be in operation in all accident and emergency departments, which
offers patients an appointment for a mental health assessment the day after they present to
accident and emergency with self-harm, if they have not been assessed as in need of
immediate intervention (DHSSPSNI, 2012).
Our findings reported that when people present to accident and emergency
departments in a vulnerable mental state, they may not be emotionally equipped to take
advantage of the services offered. This finding is particularly concerning because people
who refuse help following a suicide attempt are at significantly higher risk of subsequent
completed suicide (Orbach, 1997). Our findings showed that self-injury often represents a
person’s efforts to cope rather than an attempt to end his or her life. However, our study has
demonstrated that an increase in the intensity of the behavior coupled with a lack of
appropriate support from either informal social networks or formal treatment services can
lead to suicidal crisis. Thus, we would suggest that a presentation to accident and emergency
provides an opportune moment to identify those people who are most vulnerable, in need of
immediate psychological support, and in crisis are conducive to change.
Limitations
27
A major limitation of our study was in relation to the sample. We recruited men, although
they only accounted for two individuals out of the total sample of 10. It may have been
beneficial to have recruited more male participants, which would have offered more insights
into men’s experiences of self-injury. However, considering the challenges of recruiting
from a community population of people with a history of self-injury, the sample provided a
wealth of rich data from which to gain understanding. Perhaps this study presents an
opportunity for future qualitative research on self-injury focusing specifically on the
experiences of men.
Moreover, our study was limited because we focused on the perspectives of people
who had experienced and sought help for self-injury. We could have enhanced the rigor of
the findings by exploring the perspectives of people within the participants’ social networks.
Many participants related that they confided in friends. As such, there seems to be the
potential for further research that explores dyads of people with a history of self-injury and
the friends they cite as their trusted confidantes. There are obvious challenges in relation to
access and recruitment for research of this kind, however appropriate support with a well
thought out design and implementation could afford a unique contribution to the existing
evidence base.
Implications
The aim of the current article was to provide an understanding of the process of help seeking
among people who self-injure. We found that help seeking is a complex journey for people
who self-injure. The findings produced evidence to suggest that a range of social and
psychological factors contributes to the barriers preventing people who self-injure from
seeking help. Moreover, the findings indicated that while these barriers can be overcome,
professional responses to attempts at help seeking could be enhanced. We suggest that the
network-episode model of service use (Pescosolido & Boyer, 1999, 2010) provides a
28
conceptual basis from which to understand the process of seeking help, which involves the
complex interaction between informal social networks and formal services at different stages
of the illness career.
We found that a person’s movement within the illness career mutually influences his
or her interaction with informal support networks and formal treatment services. In the
network-episode model, the term “illness career” is used to depict the point at which the
person begins to display “unusual behavior” (Pescosolido & Boyer, 1999, p. 436) and makes
efforts to cope with the onset of mental illness. We found that participants in our study used
self-injury to cope with dysfunctional and debilitating social conditions. We would suggest
that the term “illness career” might not be appropriate in circumstances where the person
does not consider his or her behavior to be symptomatic of illness. Furthermore, contrary to
the aims of the network-episode model, the term “illness career” could be perceived to
pathologize the individual by neglecting the social conditions within which self-injury
emerges. Therefore, we propose the use of the term “healing journey” to conceptualize the
person’s relationship with self-injury that influences his or her disclosure and efforts to seek
help.
The current suicide prevention strategy in Northern Ireland (DHSSPSNI, 2012) has
defined objectives for the prevention of suicide and self-harm, including addressing the level
of repeat accident and emergency attendances for those in emotional distress, increasing the
uptake of support services, implementation of NICE guidelines for the management of selfharm and training for frontline healthcare professionals on suicide awareness. This article
poses important implications for the implementation of such initiatives, indicating that
current practices are not conducive to meeting the objectives set. While our study was small
in scale, the need to gain an understanding about the experiences of people who have firsthand experience of these issues is paramount in providing at least some insight into Northern
29
Ireland’s continually elevated rates of suicide and self-harm despite the establishment of the
Suicide Prevention Strategy in 2006.
Based on the findings from this study, we propose that the provision of pastoral care
or emotional support in accident and emergency departments when a person presents with
self-injury, self-harm or attempted suicide could provide a crucial intervention at the time
when the person is most vulnerable. The provision of pastoral care in accident and
emergency could be provided by services in the community and voluntary sector.
Furthermore, we suggest that there would be merits to a cross-sector, interdisciplinary
approach to follow-up care, which considers services in both the statutory and
community/voluntary sector. Pastoral support in accident and emergency alongside medical
treatment and the potential for follow-up care outside of statutory services could enhance the
uptake of follow-up care, and thus enable more people who self-injure to make the journey
through the helping process.
In addition, statistics on self-injury in Northern Ireland are limited because they are
based more broadly on self-harm hospital presentations and admissions, reflecting only
reported incidents and thus underestimating the prevalence. Therefore, there is certainly a
call for a quantitative study to provide a more accurate estimate of the population prevalence
of self-injury in Northern Ireland to more appropriately inform policy.
Acknowledgements
We gratefully acknowledge the support of Professor Christopher Lewis in assisting with the
research design.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article
Funding
30
The authors received no financial support for the research, authorship, and/or publication of
this article.
Notes
1. We had expected this slow and steady level of recruitment because participants selfselected to participate in the study. Following this initial phase, another four months elapsed
with no potential participants making contact with the researcher. At this stage, the lull in
recruitment prompted us to submit an amendment to the university’s Research Ethics
Committee to permit us to recruit participants by an alternative method: advertising in thirdlevel education. Once the amendment was approved, we commenced the second phase of
data collection, wherein the remaining participants were recruited. In the second phase of
recruitment, responses to the advertising were considerably higher than anticipated, with a
total of 11 replies. Four people who contacted our team did not meet the inclusion criteria
for the study, which they realized once they had read the participant information sheet. We
scheduled the interviews in stages and arranged a total of seven interviews over the course of
four weeks. Two people who arranged to meet for interviews did not show up.
31
References
Allen, S. (2007). Self-harm and the words that bind: A critique of common perspectives.
Journal of Psychiatric and Mental Health Nursing, 14, 172–178. doi:
10.1111/j.1365-2850.2007.01060.x
Babiker, G. and Arnold, L. (1997). The language of injury: Comprehending self-mutilation.
Leicester: BPS Books.
Briere, J., & Gil, E. (1998). Self-mutilation in clinical and general population samples:
Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68,
609−620. doi:10.1037/h0080369
Corbin, J. and Strauss, A. (2008). Basics of qualitative research (3e). London: Sage.
Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist,
59, 614–625. doi:10.1037/0003-066X.59.7.614
Creswell, J.W. and Miller, D.L. (2000). Determining validity in qualitative research. Theory
into Practice, 39(3), 124-130. doi: 10.1207/s15430421tip3903_2
Crowe, M. and Bunclark, J. (2000). Repeated self-injury and its management. International
Review of Psychiatry, 12, 48–53. doi:10.1080/09540260074120
Department of Health, Social Services and Public Safety: Northern Ireland (2002).
Counselling in Northern Ireland: Report of the Counselling Review. Retrieved from
http://www.dhsspsni.gov.uk/counsel.pdf
Department of Health, Social Services and Public Safety: Northern Ireland (2006a). Protect
life – a shared vision: The Northern Ireland suicide prevention strategy and action
plan 2006 – 2011. Retrieved from
http://www.dhsspsni.gov.uk/phnisuicidepreventionstrategy_action_plan-3.pdf
Department of Health, Social Services and Public Safety: Northern Ireland (2006b). The
Bamford review of mental health and learning disability (Northern Ireland).
32
Retrieved from
http://www.dhsspsni.gov.uk/comprehensive_legislative_framework.pdf
Department of Health, Social Services and Public Safety: Northern Ireland (2010). Northern
Ireland registry of deliberate self-harm, Western area: Annual report 2009.
Retrieved from http://www.dhsspsni.gov.uk/selfharm_registry_2009_annual_report.pdf
Department of Health, Social Services and Public Safety: Northern Ireland (2012). Protect
life – a shared vision. The Northern Ireland suicide prevention strategy 2012 – 2014.
Retrieved from http://www.dhsspsni.gov.uk/suicide_strategy.pdf
Evans, E., Hawton, K. and Rodham, K. (2005). In what ways are adolescents who engage in
self-harm or experience thoughts of self-harm different in terms of help-seeking,
communication and coping strategies? Journal of Adolescence, 28, 573–587.
doi:10.1016/j.adolescence.2004.11.001
Favazza, A.R. (1996). Bodies under siege: Self-mutilation and body modification in culture
and psychiatry. Baltimore: John Hopkins University Press.
Gratz, K. L. (2001). Measurement of deliberate self-harm: Preliminary data on the deliberate
self-harm inventory. Journal of Psychopathology and Behavioral Assessment, 23,
253−263. doi:10.1023/A:1012779403943
Gratz, K., Conrad, S. and Roemer, L. (2002). Risk factors for deliberate self-harm among
college students. American Journal of Orthopsychiatry, 72, 128–140.
doi:10.1037/0002-9432.72.1.128
Harris, J. (2000). Self-harm: Cutting the bad out of me. Qualitative Health Research, 10,
164–173. doi:10.1177/104973200129118345
Harrison, D. (1997). Cutting the ties. Feminism and Psychology, 7, 438–440.
doi:10.1177/0959353597073027
33
Hawton, K., Bale, L., Casey, D., Shepherd, A., Simkin, S. and Harris, L. (2006). Monitoring
deliberate self-harm presentations to general hospitals. The Journal of Crisis
Intervention and Suicide Prevention, 27, 157–163. doi:10.1027/0227-5910.27.4.157
Hawton, K., Bergen, H., Casey, D., Simkin, S., Palmer, B., Cooper, J., Kapur, N., Horrocks,
J., House, A., Lilley, R., Noble, R. and Owens, D. (2007). Self-harm in England: a
tale of three cities: Multicentre study of self-harm. Social Psychiatry and Psychiatric
Epidemiology, 42, 513–521. doi:10.1007/s00127-007-0199-7
Hawton, K. and Harriss, L. (2008). The changing gender ratio in occurrence of deliberate
self-harm across the lifecycle. Crisis, 29, 4–10. doi: 10.1027/0227-5910.29.1.4
Hawton, K., Harriss, L., and Rodham, K. (2010). How adolescents who cuts themselves
differ from those who take overdoses. European Child and Adolescent Psychiatry,
19, 513–523. doi:10.1007/s00787-009-0065-0
Heidegger, M. (1967). Being and time. Oxford: Blackwell.
Huband, N. and Tantam, D. (2004). Repeated self-wounding: Women’s recollection of
pathways to cutting and of the value of different interventions. Psychology and
Psychotherapy: Theory, Research and Practice, 77, 413–428.
doi:10.1348/1476083042555370
Hume, M. and Platt, S. (2007). Appropriate interventions for the prevention and
management of self-harm: A qualitative exploration of service-users’ views. BMC
Public Health, 7, 1–9. doi:10.1186/1471-2458-7-9
Klonsky, E.D., May, A.M. and Glenn, C.R. (2013). The relationship between nonsuicidal
self-injury and attempted suicide: Converging evidence from four samples. Journal
of Abnormal Psychology, 122, 231–237. doi: 10.1037/a0030278
Law, G.U., Rostill-Brookes, H. and Goodman, D. (2009). Public stigma in health and nonhealthcare students: Attributions, emotions and willingness to help with adolescent
34
self-harm. Internal Journal of Nursing Studies, 46, 108–119.
doi:10.1016/j.ijnurstu.2008.08.014
Lincoln, Y.S. and Guba, E.G. (1985). Naturalistic inquiry. London: Sage.
Lloyd-Richardson, E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and
functions of non-suicidal self-injury in a community sample of adolescents.
Psychological Medicine, 37, 1183–1192. doi:10.1017/S003329170700027X.
Longden, E. and Proctor, G. (2012). A rationale for service responses to self-injury. Journal
of Mental Health, 21, 15–22. doi:10.3109/09638237.2011.608744
McAndrew, S. and Warne, T. (2005). Cutting across boundaries: A case study using
feminist praxis to understand the meanings of self-harm. International Journal of
Mental Health Nursing, 14, 172–180. doi: 10.1111/j.1440-0979.2005.00378.x
McLaughlin, C. (2007). Suicide-related behavior: Understanding, caring and therapeutic
responses. Chichester: John Wiley and Sons Ltd.
McLeod, J. (2001). Qualitative research in counselling and psychotherapy. London: Sage.
McMyler, C. and Pryjmachuk, S. (2008). “Do ‘no-suicide’ contracts work?” Journal of
Psychiatric and Mental Health Nursing, 15, 512–522. doi:10.1111/j.13652850.2008.01286.x
Medina, M. (2011). Physical and psychic imprisonment and the curative function of selfcutting. Psychoanalytic Psychology, 28, 2–12. doi:10.1037/a0022557
Mental Health Foundation (2006). Truth hurts: Report of the national inquiry into self-harm
among young people. Retrieved from Mental Health Foundation website:
http://www.mentalhealth.org.uk/content/assets/PDF/publications/truth_hurts.pdf?vie
w=Standard
Motjabai, R. and Olfson, M. (2008). Parental detection of youth’s self-harm behavior.
Suicide and Life-Threatening Behavior, 38, 60–73. doi:10.1521/suli.2008.38.1.60
35
National Institute for Clinical Excellence (2004). Press release: New guideline to
standardise care for people who self-harm. Retrieved from
http://www.nice.org.uk/nicemedia/live/10946/29422/29422.pdf
National Suicide Research Foundation Ireland (2006). ‘Accident and Emergency Nursing
Assessment of Deliberate Self-harm.’ Dublin; Republic of Ireland: Health Service
Executive. Retrieved from http://nsrf.ie/wp-content/uploads/reports/A+E_DSH.pdf
NVivo qualitative data analysis software; QSR International Pty Ltd. Version 9, 2010.
O’Connor, R., Rasmussen, S. and Hawton, K. (2010). Northern Ireland Lifestyle and Coping
Survey. Retrieved from http://www.dhsspsni.gov.uk/ni-lifestyle-and-coping-survey2010.pdf
O’Connor, R. C., Rasmussen, S., and Hawton, K. (2014). Adolescent self-harm: A schoolbased study in Northern Ireland. Journal of Affective Disorders, 159, 46–52.
Retrieved from http://dx.doi.org/10.1016/j.jad.2014.02.015
Orbach, I. (1997). A taxonomy of factors related to suicidal behavior. Clinical Psychology:
Science and Practice, 4, 208–224. doi: 10.1111/j.1468-2850.1997.tb00110.x
Pembroke, L.R. (Ed.) (1996). Self-harm: Perspectives from personal experience. Retrieved
from
http://www.kreativeinterventions.com/SelfHarmPerspectivesfromPersonalExperienc
e.pdf
Pescosolido, B. A. and Boyer, C. (1999). How do people come to use mental health
services? Current knowledge and changing perspectives. In: V. Horwitz and T.
Scheid (Eds.), A handbook for the study of mental health: Social contexts, theories
and systems (pp. 392–411). Cambridge: Cambridge University Press.
Pescosolido, B. A. and Boyer, C. (2010). Understanding the context and dynamic social
processes of mental health treatment. In: V. Horwitz and T. Scheid (Eds.), A
36
handbook for the study of mental health: Social contexts, theories and systems (pp.
420–438). Cambridge: Cambridge University Press.
Pescosolido, B. A., Brooks Gardner, C., and Lubell, K. M. (1998). How people get into
mental health services: Stories of choice, coercion and “muddling through” from
“first-timers”. Social Science and Medicine, 46, 275–286. Retrieved from:
http://dx.doi.org/10.1016/S0277-9536(97)00160-3
Prochaska, J. O., DiClemente, C. C. and Norcross, J. C. (1992). In search of how people
change: Applications to addictive behaviors. American Psychologist, 47, 1102–1114.
doi:10.1037/0003-066X.47.9.1102
Richards, L. (2005). Handling qualitative data: A practical guide. London: Sage.
SANE (2008) Understanding self-harm. Retrieved from:
http://www.sane.org.uk/Research/SelfHarmIntro
Schoppmann, S., Schrock, R., Schnepp, W. and Buscher, A. (2007). “Then I just showed
her my arms . . .” Bodily Sensations in moments of alienation related to self-injurious
behavior. A hermeneutic phenomenological study. Journal of Psychiatric and Mental
Health Nursing, 14, 587–597. doi: 10.1111/j.1365-2850.2007.01150.x
Shaw, S. N. (2002). Shifting conversations on girls’ and women’s self-injury: An analysis of
the clinical literature in historical context. Feminism and Psychology, 12, 191–291.
doi:10.1177/0959353502012002010
Shepperd, C. and McAllister, M. (2003). CARE: A framework for responding
therapeutically to the client who self-harms. Journal of Psychiatric and Mental
Health Nursing, 10, 442–447. doi: 10.1046/j.1365-2850.2003.00632.x
Simpson, A. (2006). Can mainstream health services provide meaningful care for people
who self-harm? A critical reflection. Journal of Psychiatric and Mental Health
Nursing, 13, 429–436. doi: 10.1111/j.1365-2850.2006.01000.x
37
Sinclair, J. and Green, J. (2005). Understanding resolution of deliberate self-harm:
Qualitative interview study of patients’ experiences. British Medical Journal, 330, 1–
9. doi:10.1136/bmj.38441.503333.8F
Strauss, A. and Corbin, J. (1998). Basics of qualitative research: Techniques and
procedures for developing grounded theory. London: Sage.
Tantam, D. and Huband, N. (2009). Understanding repeated self-injury: A multi-disciplinary
approach. Basingstoke: Palgrave Macmillan.
Turp, M. (2003). Hidden self-harm: Narratives from psychotherapy. London: Jessica
Kingsley Publishers.
Walsh, B. W. and Rosen, P.M. (1988). Self-mutilation: Theory, research and treatment.
New York: The Guildford Press.
Wu, C-Y., Stewart, R., Huang, H-C., Prince, M. and Lui, S-I. (2011). The impact of quality
and quantity of social support on help-seeking behavior prior to deliberate self-harm.
General Hospital Psychiatry, 33, 37–44. doi:10.1016/j.genhosppsych.2010.10.006
Ystegaard, M., Arensman, E., Hawton, K., Madge, N., Van Heeringen, K., Hewitt, A., Jan de
Wilde, E., De Leo, D. and Fekete, S. (2009). Deliberate self-harm in adolescents:
Comparison between those who receive help following self-harm and those who do
not. Journal of Adolescence, 32, 1–17. doi:10.1016/j.adolescence.2008.10.010
Bios
Maggie Long is a member of the Institute for Research in Social Sciences (IRiSS) and a
lecturer in counseling at the School of Communication, University of Ulster,
Jordanstown Campus, Shore Road, Newtownabbey, BY37 0QB, Northern Ireland.
Roger Manktelow is a member of the Institute for Research in Social Sciences (IRiSS) and
a lecturer in social work at the School of Sociology and Applied Social Studies,
University of Ulster, Magee Campus, Derry, BT48 7JL, Northern Ireland.
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Anne Tracey is a member of the Psychology Research Institute and lecturer in psychology
at the School of Psychology, University of Ulster, Magee Campus, Derry, BT48 7JL,
Northern Ireland.
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