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Article Excerpt
Although only 1% to 4% of the U.S. population engages in superficial self-harm (SSH), this behavior is much more prevalent in adolescents, with estimates ranging from 14% to 39%. While current studies primarily focus on clinical interventions, few have investigated SSH from an individual's perspective, and there is little guidance for family, friends, and others who desire to provide assistance. In particular, those in close contact with youth, particularly in schools, need basic information on SSH and suggestions for responding to students at risk. One-on-one, day-to-day, practical and effective intervention is needed. This study investigated the perspectives of 96 young women with a history of SSH. Based on their responses' to an Internet survey, friends and mental health professionals were perceived as most helpful in acknowledging the individual's emotional pain and distress. Participants also wanted others to be nonjudgmental, to permit emotional expression, and to acknowledge their availability to offer help. Translated into practice, young women who engage in SSH consider an accepting supportive relationship to be a critical element in their recovery.
Self-Harming Behaviors
Individuals are hardwired to survive, to automatically seek protection, and to avoid danger and injury. However, Favazza (1996) provides examples of rituals involving self-harm and physical deprivation that are perceived to serve a purpose in certain cultures, benefiting both individual and community. For example, in Morocco one group drinks boiling water and eats spiny cacti in an attempt to produce a psychic state and create unity with a higher spiritual force. During the New Year's festival of the Ivory Coast Abidji tribe, members participate in self-harm rituals to drive away evil spirits that threaten their community; following tradition, participants go into a deep trance-like state and, in an effort to rid their bodies of evil sprits, plunge knives into their abdomen.
Though it is against the natural instinct to protect oneself, avoid pain, and ensure self-preservation, in these situations self-harm is not only viewed as socially acceptable, it is condoned. These incidents of self-harm, woven into established spiritual rituals, are not considered pathological but are perceived as expressions of personal growth, sacrifice, and enlightenment (Favazza, 1996). However, in other situations, counter to societal norms, individuals may engage in self-harm ranging from minor scratching or cutting to extremely life-threatening behaviors (Nock & Prinstein, 2005). Typically, in mainstream American culture self-harming behaviors are seen as maladaptive and indicative of underlying emotional difficulties (Muehlenkamp, 2006, 2007).
In 1987 Favazza's classic book, Bodies Under Siege: Self-Mutilation in Culture and Psychiatry, expanded research interest and promoted professional conversation. Then, in a 1995 television interview, Princess Diana discussed her private struggle in coping with emotional pain, revealing that she was a "cutter" (Purington & Whitlock, 2004; Strong, 1998). Her admission challenged the longstanding stereotype of superficial self-harm (SSH). Previously perceived as an extreme behavior of the seriously mentally ill, SSH was redefined as a problem occurring in mainstream society. However, although public awareness of SSH has increased dramatically over the past several years, evidence informing effective research-based interventions is limited, particularly for adolescents (Bums, Dudley, Hazell, & Patton, 2005; Nock & Prinstein, 2005; Nursing Standard, 2005; Ross & Heath, 2002; Whitlock, Powers, & Eckenrode, 2006).
Overview of Self-Harming Behaviors
The current Diagnostic and Statistical Manual of Mental Disorders (DSM) does not list diagnostic criteria for self-harm (American Psychiatric Association, 2000). Rather, self-harm, referred to as self-mutilation in the DSM, is listed as commonly occurring with specific disorders, such as borderline personality disorder (BPD) and eating disorders (see also Favazza, 1996; Levitt, Sansone, & Cohn, 2004; Linehan, 1993, 2000). Elsewhere self-harming behavior (SHB) is identified by various terms: self-inflicted violence (Alderman, 1998; Travia, 2003); self-mutilation (Cassano, Lattanzi, Pini, Dell' Osso, Battistini, & Cassano, 2001; Favazza), and self-injury (Favaro & Santonastaso, 2000; Muehlenkamp & Gutierrez, 2004). SHB has also been categorized into three levels of severity: superficial, stereotypic, and major (Simpson, 2001).
SSH, the most common and least severe SHB, is the focus of this study. It includes non-life-threatening scratching and cutting. Travia (2003) delineated four major elements of SSH: (a) The behavior is socially unacceptable (Haines, Williams, Brain, & Wilson, 1995), setting it apart from culturally accepted practices like piercing, tattooing, or scarring one's body for ritual or ornamental purposes; (b) the behavior is almost always a reaction to psychological crisis (Haines et al., 1995); (c) the behavior leads to tissue damage; and (d) the behavior is not based on conscious suicidal intent (Alderman, 1998; Favazza & Rosenthal, 1993).
More severe than SSH, stereotypic self-injury appears to be biologically driven (Favazza, 1996) and is often linked with more extreme developmental delays and disabilities, such as autism or intellectual deficiency (McClintock, Hall, & Oliver, 2003). From a behavioral standpoint, stereotypic self-injury is frequently associated with self-stimulation and the need for increased sensory input. Stereotypic self-injury includes intense repetitive, often rhythmic, extreme behaviors such as biting of hands, arms, or lips; head banging; eyeball pressing; and self-punching.
Major self-injury is the most severe form of SHB. It includes extreme behaviors such as amputation of limbs or genitals and eye enucleation. Extremely rare, major self-injury is typically associated with psychosis or acute intoxication and may result in serious injury or death (Favazza, 1996; Favazza & Rosenthal, 1993).
Superficial Self-Harm
Mental health professionals estimate that 1-4% of the general population engage in SHB (Alderman, 1998; Klonsky, Oltmanns, & Turkheimer, 2003), but the prevalence rate is much higher among adolescents. Some researchers have estimated that 14-39% of adolescents (Nock & Prinstein, 2005; Ross & Heath, 2002) and up to 61% of adolescent psychiatric inpatients intentionally harm themselves (DiClemente, Ponton, & Hartley, 1991).
SSH typically begins in late childhood or early adolescence and may continue 15 to 20 years or longer (Favazza & Rosenthal, 1993). Because most individuals go to great lengths to conceal their injuries and scars, prevalence rates may be underestimated (Martinson, 2000). However, it is important to recognize that not all scarring is considered SSH: many adolescents proudly display tattoos and multiple body piercings as a rite of passage into adulthood or an expression of independence and individuality (Graham & Teall, 2006; McGuinness, 2006; Roberts, Auinger, & Ryan, 2004).
In addition to developmental considerations, sex is an important demographic to consider in clarifying who engages in SSH. In particular, sex differences are noted in childhood and adolescence. According to Lieberman (2004) females account for approximately 60% of elementary-aged children and 80% of middle- and high-school-aged adolescents who self-injure. The behavior is also thought to be more common among middle- and upper-class adolescent girls and young women (Simpson, 2001).
Although SSH seems to be more common in females, Favazza (1996) noted that this generalization may be "an artifact of sampling techniques" (p. 240) and that demographics of those who self-harm vary by setting. For example, males who are incarcerated or hospitalized in psychiatric hospitals frequently inflict self-harm (e.g., cutting, self-tattooing, and burning) (Claes, Vandereycken, & Vertommen, 2007; Matsumoto, Yamaguchi, Asami, Okada, Yoshikawa, & Hirayasu, 2005). However, outside prison and psychiatric settings, the...
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