ArticlePDF Available

How Do Young People Understand Their Own Self-Harm? A Meta-synthesis of Adolescents’ Subjective Experience of Self-Harm


Abstract and Figures

What makes young people—most often young women—inflict damage on their own bodies? Epidemiological studies drawing on surveys have estimated incidence and identified risk factors, but studies that explore the individuals’ experience and understanding of self-harm, which typically comprise a small series of persons, are omitted in many reviews. We conducted a systematic database search of studies on adolescents’ (12–18 years of age) first-person experience of self-harm in clinical and non-clinical populations, and included 20 studies in a meta-synthesis. Four meta-themes were associated with the participants’ subjective experiences of self-harm: (1) to obtain release, (2) to control difficult feelings, (3) to represent unaccepted feelings, and (4) to connect with others. The meta-themes support self-harm as a function of affect-regulation, but also highlight how the action of self-harm may contain important emotional and relational content and an intention or wish to connect and communicate with others. Our findings underline the importance of relating self-harm to developmental psychological needs and challenges in adolescence, such as separation, autonomy and identity formation. Self-harm in adolescence may be a result of a conflict between a need to express affective experiences and a relational need for care.
This content is subject to copyright. Terms and conditions apply.
1 3
Adolescent Research Review
How Do Young People Understand Their Own Self-Harm? AMeta-
synthesis ofAdolescents’ Subjective Experience ofSelf-Harm
LineIndrevollStänicke1,2 · HanneHaavind2· SiriErikaGullestad2
Received: 29 October 2017 / Accepted: 17 January 2018
© Springer International Publishing AG, part of Springer Nature 2018
What makes young people—most often young women—inflict damage on their own bodies? Epidemiological studies draw-
ing on surveys have estimated incidence and identified risk factors, but studies that explore the individuals’ experience and
understanding of self-harm, which typically comprise a small series of persons, are omitted in many reviews. We conducted a
systematic database search of studies on adolescents’ (12–18years of age) first-person experience of self-harm in clinical and
non-clinical populations, and included 20 studies in a meta-synthesis. Four meta-themes were associated with the participants’
subjective experiences of self-harm: (1) to obtain release, (2) to control difficult feelings, (3) to represent unaccepted feel-
ings, and (4) to connect with others. The meta-themes support self-harm as a function of affect-regulation, but also highlight
how the action of self-harm may contain important emotional and relational content and an intention or wish to connect
and communicate with others. Our findings underline the importance of relating self-harm to developmental psychological
needs and challenges in adolescence, such as separation, autonomy and identity formation. Self-harm in adolescence may
be a result of a conflict between a need to express affective experiences and a relational need for care.
Keywords Adolescence· Meta-synthesis· Self-harm· Subjective experience· Qualitative research
Self-harm is increasing across several countries, and espe-
cially among young girls (Morgan etal. 2017). We know
that self-harm is related to different mental disorders and
increased suicide risk (Hawton etal. 2012; Nock 2014).
The question of what makes young people—most often
women—inflict damage on their own bodies is perplexing.
The increase of self-harm during adolescence raises the
question if such behavior may be related to developmental
challenges during adolescence, such as separation, auton-
omy and identity formation. Existing research has tended
to ignore ordinary developmental tasks in their analysis of
adolescent’s self-harm. One reason may be that reviews on
self-harm have mostly focused on studies with adult par-
ticipants (Edmondson etal. 2016; Klonsky 2007; Soyemoto
1998). Another reason may be that questionnaires used in
epidemiological studies are mostly developed from knowl-
edge about adult patients (Borschmann etal. 2011). Further,
current theories on the function of self-harm are primarily
based on the author’s descriptions of adult clients’ experi-
ence of self-harm, not on the self-harmers’ own descriptions
(e.g. Favazza 2011/1987). Knowledge from qualitative stud-
ies are often excluded from reviews (Klonsky 2007). There
is a need for studies enabling us to hear the adolescents’ own
voice. Qualitative studies on adolescents who harm them-
selves aim at capturing the young persons’ own statements
and descriptions of their experience, thus contributing to a
deeper understanding of their inner world and the purpose
of self-harm. A meta-synthesis of existing qualitative stud-
ies of young people’s experience of self-harm is a critical
step to synthesize knowledge on self-harm from adolescents
own perspective.
Self‑Harm—Definition, Prevalence, Methods,
andRisk Factors
Definitions of self-harm generally stipulate that the self-
injury must be intentional, but differ on whether suicidal
* Line Indrevoll Stänicke
1 Lovisenberg Hospital, Nic Waals Institute, Pb 4970 Nydalen,
0440Oslo, Norway
2 Department ofPsychology, University ofOslo, Pb 1094
Blindern, 0317Oslo, Norway
Adolescent Research Review
1 3
intent is included. In the UK, the concept of “deliberate
self-harm” (DSH) refers to “intentional self-poisoning or
self-injury, irrespective of type of motive or extent of sui-
cidal intent” (Hawton etal. 2012, p.2373). However, in the
US, the concept of “non-suicidal self-injury” (NSSI) refers
to “the deliberate destruction of one’s own bodily tissue in
the absence of suicidal intent and for reasons not socially
sanctioned” (Benley etal. 2014, p.638). Although the cen-
tral psychological qualities and method of self-harm may
vary, there seems to be agreement in the research literature
that self-harming behavior usually starts during adolescence,
around 12–13years of age (Swannell etal. 2014; Whitlock
and Selekman 2014). Thus, adolescence may represent a
critical period for understanding the development of self-
harming behaviors.
Depending on the definition used, estimates of the preva-
lence of self-harm range from 13 to 17% in nonclinical ado-
lescent samples (Swannell etal. 2014; Evans and Hurrell
2016), and 40–60% among adolescent psychiatric inpatients
(Klonsky etal. 2014). Self-harm is more common among
girls than among boys from 12 to 15years of age. Further-
more, self-harm is becoming increasingly widespread among
clients in clinical settings as well as among young people in
general (Morgan etal. 2017; Whitlock and Selekman 2014).
In epidemiological surveys, the frequency of self-harm var-
ies across participants, be it once in a lifetime, once in the
last year, or on a more regular basis. Most likely, the fre-
quency with which a person engages in self-harm influences
their experience and their psychological interpretation of
what is at stake in the personal as well as in the cultural
Self-harm includes a wide range of different behaviors;
include cutting, burning, scratching, banging, hitting, and
self-positioning. Cutting is the most common method for
self-harm by both genders, while young men are more likely
to use hitting and burning more than girls and women (Klon-
sky etal. 2014). Self-poisoning is more common among
psychiatric inpatients compared to outpatients (Hawton etal.
2012; Swannell etal. 2014). Favazza (2011/1987) catego-
rized cutting, burning, scratching, banging and hitting as
“superficial/moderate self-mutilation”, which may be obses-
sive, episodic or repetitive behavior. He distinguished super-
ficial self-mutilation from “major” (e.g., cutting one’s leg) or
“stereotypic” forms (e.g., pulling out one’s hair). Self-harm
may also be related to cultural, creative, religious or sexual
acts, which are often excluded from health studies (Favazza
The considerable number of epidemiological studies,
drawing on surveys and quantitative analyses in studies of
self-harm, has yielded valuable information about important
risk factors for self-harm at the group level (for overview
see: Hawton etal. 2012; Nock 2014). Risk factors for self-
harm include female gender, low socio-economic status,
sexual orientation, adverse childhood experience, abuse,
family history of suicide, bullying, mental disorder, impul-
sivity, poor problem solving and low self-esteem, many of
which are not very specific (Nock 2014). Although self-
harming is not a separate diagnosis in either the ICD-10
(World Health Organization 2004) or the DSM-V (American
Psychiatric Association 2013), it is often related to mental
illness as well as increased risk of death. Specifically, self-
harm is associated with mental disorders such as depressive
disorder, anxiety disorders, drug addiction, eating disorders,
post-traumatic stress disorder, autism, bipolar disorder,
psychosis, borderline personality disorder (BPD) (Hawton
etal. 2012). Klonsky and colleagues (2003) found that NSSI
occurs and is associated with psychiatric morbidity even in
non-clinical populations.
From laboratory studies, we know that people who self-
harm display elevated physiological arousal in response
to stressors, discontinue or escape stressful tasks sooner,
and report greater efforts to suppress aversive thoughts and
feelings during their day (Nock 2009). Research on physi-
ological and neurobiological factors, such as pain endur-
ance (Hooley and St. Germain 2014; Kirtley etal. 2016)
and impulse-control (Hamza etal. 2015), and on genetic
influence (Althoff etal. 2012; Maciejewski etal. 2014), is
of importance to gain further knowledge of the phenomenon
of self-harm at a group level.
Function ofSelf‑Harm
Since the initial articles on self-harm (Emerson 1913; Men-
ninger 1938), authors have proposed different functions
self-harm may serve for the individual. However, in these
articles, the reports on functions were based on the authors’
descriptions of mostly adult clients’ experience of self-harm,
not on the self-harmers’ own account (e.g., Motz 2010;
Straker 2006), and relatively few focused on adolescent cli-
ents (e.g., Brady 2014; Gvion and Fachler 2015). Soyemoto
(1998) reviewed theoretical and empirical studies, and pro-
posed “a functional model”. She argued that self-harm can
serve different functions—to be reinforced by or to avoid
punishment in the person’s environment (the environmental
model), to protect the person from suicide (the anti-suicidal
model), to satisfy sexual motives (the sexual model), to regu-
late overwhelming affects (the affect-regulation model), to
serve as a defense mechanism against a dissociate state (the
dissociation model), and/or to help the person to establish
borders against others (“the boundaries model”). Klonsky
(2007) systematically reviewed the empirical research on
the functions of DSH among adults and adolescents, and
found converging evidence for self-harm as “an affect-
regulation function”—a way of alleviating overwhelming
negative emotions associated with subsequent relief and
calmness. The study also indicated strong support for a
Adolescent Research Review
1 3
self-punishment function, and the findings were consistent
across different ages and samples.
Nock and Prinstein (2004, 2005) introduced an empiri-
cally based “four-function model”. In their study of a clinical
sample of young adults, they found support for NSSI being
reinforced automatically (i.e., intrapersonally or by oneself)
in positive ways (e.g., by making you feel good or generating
energy) as well as in negative ways (e.g., by escaping from
negative affect). They also found support for NSSI being
reinforced socially (i.e., interpersonally or by others) either
in positive (e.g., by gaining attention or access to resources)
or negative ways (e.g. to avoid punishment by others). In line
with these findings, Bentley and colleagues (2014) argue
that NSSI regulates emotional and cognitive experiences and
is a way to communicate with or influence others.
Most systematic reviews of self-harm focus mainly on
adult participants or include only a few studies with adoles-
cent participants (Klonsky 2007; Swannell etal. 2014). This
is also the case in Edmondson and colleagues (2016) review
of first-hand accounts on the reasons for self-harm other
than an intention to die. The most endorsed reason for self-
harm was to handle distress and exert interpersonal influ-
ence (for example to get attention or punish someone), but
of importance was also positive and adaptive functions like
self-validation and a personal sense of mastery. Theoretical
functional models are not explicitly based on adolescents
own understanding of their behavior. However, one excep-
tion is Jacobson and Gould’s (2007) review of self-harm
among adolescents in mixed clinical and non-clinical sam-
ples. They found that the main reason for NSSI was to regu-
late negative emotion (negative reinforcement: to end a state
of depression, tension, anxiety and/or fear and to reduce
anger). A smaller minority of participants endorsed engag-
ing in NSSI to prompt feelings when none exist (automatic
positive reinforcement), to elicit attention (social positive
reinforcement), or to remove social responsibilities (social
negative reinforcement). Still, Jacobson and Gould (2007)
and Edmondson and colleagues (2016) primarily included
data from self-report questionnaires with pre-determined
answer categories for frequency, methods, and reasons for
self-harm, and only a few studies included open-ended ques-
tions (see also Klonsky 2007). Many of the questionnaires
are thorough, but mostly customized as self-report question-
naires for adults and based on findings from adult clinical
samples (Swannell etal. 2014). There are some exceptions,
for example, Nock and Prinstein (2004, 2005) adjusted their
questionnaire after a focus group discussion with adoles-
cents both with and without self-harm experience.
Although quantitative studies have yielded important
knowledge about self-harm, qualitative studies offer a unique
opportunity to gain insight into the subjective experience
of young people who self-harm. For obvious reasons, first-
hand accounts from adolescents describing their experience
of self-harm are missing in many of the epidemiological
studies. In a phenomenological analysis of open interviews
with adolescents (18years or older) from a normal popula-
tion who harmed themselves, Brown and Kimball (2013)
presented three main themes; (1) self-harming is misun-
derstood, (2) self-harming has an important role in adoles-
cent culture and (3) advice for professionals. The adoles-
cents were concerned with themes such as differentiating
between self-harm and suicidal behavior, self-harming as
an addiction, interventions meant to help are not helpful,
self-harming reflects mental and physical pain or trauma,
and self-harming is about control or a need for punishment.
In particular, the results of qualitative research on adoles-
cents’ subjective experiences associated with intentional
self-harm offer the potential to increase our understanding
of how self-harm can become an important part of some
adolescents’—often girls—movement from adolescence
towards adulthood. Whatever the open or hidden purposes,
there could be more than just one psychological issue at
stake, and they are not necessarily the same for all persons
engaging in similar self-harming practices. In review arti-
cles, qualitative studies are often excluded due to their rela-
tively small number of cases in each study (Klonsky 2007).
Although the number of qualitative studies on self-harm is
growing, their clinical application and their contribution to
knowledge about development will be limited unless the rich
understanding collected from these interpretative studies can
be synthesized (Levitt etal. 2016; Walsh and Downe 2004).
A meta-synthesis of existing studies of young people’s expe-
rience of self-harm is a critical step in this direction.
Findings from qualitative studies serve as an essential
complement to empirical quantitative studies, which typi-
cally focus on general, context-independent knowledge to
capture different aspects of the phenomenon of self-harm.
In the clinic and in the community, clinicians meet adoles-
cents with different kinds of illness who self-harm for many
different reasons and with varying frequency and severity.
Findings from qualitative studies may contribute to a deeper
understanding of the self-harmer’s inner world and experi-
ence. Such understanding may increase clinicians’ ability to
empathize with their patients who self-harm, possibly con-
tributing to more productive treatment processes. Qualitative
studies can also serve to inform epidemiological and neuro-
physiological studies, and the ecological quality of existing
Current Study
This study provides a meta-synthesis of qualitative studies
of self-harm among young people by exploring first per-
son experiences of self-harm across relevant studies. The
research aim was to investigate the purpose of self-harm,
Adolescent Research Review
1 3
as understood by the young person herself. Furthermore,
we proposed that self-harm in adolescence might be under-
stood from a developmental perspective, i.e. as related to
challenges faced in becoming a young woman or man. Ado-
lescence is characterized by cognitive, biological, psycho-
logical and social changes (Siegel 2015). Developmental
issues like separation, affect regulation, problem solving,
autonomy, identity formation and relational fidelity are of
great importance (Erikson 1980; Siegel 2015). In this meta-
synthesis, we payed attention to how self-harm is linked
to personal experiences and cultural issues in the studies
of adolescents. Our research questions were: (1) What is
the purpose of self-harm, as understood by the young per-
son? Further, (2) Can adolescents’ experience of self-harm
be related to the developmental challenges of becoming a
young woman or man?
We applied Noblit and Hare’s (1988, 1998) meta-ethnog-
raphy method for meta-synthesis, and followed the seven
steps they described; (1) Getting started, (2) Deciding what
is relevant to the initial interest, (3) Reading the studies,
(4) Determining how the studies are related, (5) Translating
the studies into one another, (6) Synthesizing translations,
and (7) Expressing the synthesis. We included qualitative
studies focusing on adolescents’ experience of self-harm
from the field of mental health and other disciplines, with
different methodologies, and with clinical and non-clinical
populations to highlight nuances in reasons for self-harm
(Noblit and Hare 1988; Timulac 2009). Although the data
from the different studies may not be transferable to dif-
ferent contexts, we assumed that the concepts and findings
were relevant in a synthesized form. A meta-synthesis can
serve to “reveal what is hidden in individual studies and
to discover a whole among a set of parts” (Campbell etal.
2003, p.680). We have found no meta-synthesis of self-harm
among adolescents that focus on first-person experiences
and open-question interviews. As this was a secondary syn-
thesis of data, ethical approvals were not required.
Literature Search
The main author (LIS) undertook a conventional literature
search, guided by words that could connect to self-harm,
qualitative research, intention and adolescence (see Appen-
dix for details). The following databases were searched:
MEDLINE, Embase, PsycINFO, CINAHL, Web of Sci-
ence, Pep-Web, ProQuest Dissertations & Theses, ProQuest
Sociological Abstracts, Scopus, IBSS and Cochrane Library.
We searched both MeSH words and free text in the relevant
bases. The electronic search strategy identified 2300 refer-
ences. We removed 952 duplicates, and 1348 unique records
Inclusion andExclusion Criteria
The first author (LIS) screened the records against the broad
inclusion criteria ages 12–18 years, topic on self-harm, and
qualitative methodology based on title and abstracts (see
Table1 for inclusion and exclusion criteria). This step
Table 1 Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria
Study population
Participants from 12 to18years of age
Girls, boys and mixed gender
Participants younger than 12 and older than 18years of age
Topic of interest
First-person descriptions of the experience of self-harm
Studies from the field of mental health and other disciplines, with differ-
ent methodologies, nonclinical and clinical populations
Self-harm as part of a particular illness, such as psychosis, eating
disorder, personality disorder, or mental retardation
Indirect ways of self-harm, such as starving, smoking or using drugs
Qualitative methodology
Explicit qualitative method for data analysis, and data collected with
open interviews, semi-structured interviews or written text
Primarily used quantitative methods, questionnaires or presenting
theoretical models
Direct citations
Includes reports of adolescents’ direct citations No direct citations
Suicide attempt and motives for self-harm
Studies with participants who had attempted suicide if they also
described other motives for self-harming behavior
Studies with participants who primarily described suicidal intention
Articles or Ph.D. thesis
Articles written in English, published and peer-reviewed in an academic
journal or as a Ph.D. thesis
Study reported in another included article
Adolescent Research Review
1 3
excluded 1208 articles, and identified 140 articles for inde-
pendent appraisal of the abstract by all reviewers (LIS, HH
& SEG). We excluded studies with participants who primar-
ily described suicidal intention. However, we included some
studies with participants who had attempted suicide if they
also described other motives for self-harm. Studies where
self-harm was presented as the sequelae of a particular seri-
ous illness, such as psychosis, eating disorder, personality
disorder, or mental retardation, were not found to be relevant
to the meta-synthesis. The same principle for exclusion was
applied when studies only covered indirect methods of self-
harm, such as starving, smoking or using drugs. We included
articles written in English, published and peer-reviewed in
an academic journal or as a PhD thesis.
The three authors appraised the appropriateness of the
methodology using criteria adapted from Campbell and
colleagues (2003). In particular, we looked for interview
methods named as “open”, “semi-structured” or “in-depth”,
and paid attention to results presented with direct citations
and first-person accounts of self-harm from adolescents
with relevant experiences. We excluded some seminal
reviews, which primarily brought together the results from
quantitative analyses,or knowledge from adults,as well as
some books that mainly presented theoretical models (e.g.,
Adler and Adler 1998; Edmondson etal. 1916; Favazza
2011/1987; Gardner 2001; Hawton etal. 2012; Jacobson
and Gould 2007; Klonsky 2007; Nock 2014). We checked
reference lists of pertinent articles to complement the elec-
tronic search (“gray literature”). We included 41 articles
for full-text review by all reviewers (LIS, HH & SEG), and
ended with 20 articles after this phase (see Fig.1 for a flow
diagram). The first author (LIS) extracted characteristics of
the included studies (author, year, title, context, participant
characteristics, research methodology, and data analysis)
dating from 1981 to 2016 (see Table2).
The total number of participants was approximately 550
adolescents between 11 and 28years of age. We included
three studies with participants over 18years with direct
citations from those below 18years represented in every
theme (Adams etal.; Marshall and Yasdani 1999; Rissanen
etal. 2008). In four studies, the participants’ age was not
available, but the sample was based on Internet blogs for
adolescents (Adams etal. 2005; Ayerst 2005; Lewis and
Mehrabkhani 2017; McDermott etal. 2015). Eleven stud-
ies comprised samples with only women, and eight stud-
ies comprised mixed-gender samples with more than 75%
girls. Two studies did not report gender. The majority of
the studies were conducted in the US (n = 9) and the UK
(n = 5). Seven studies were based on non-clinical sam-
ples, five in a hospital setting (acute ward or long-term
treatment), four based in an outpatient unit, one based on
a mixed clinical and non-clinical sample, and four with
unknown samples (e.g., internet samples). Most authors
used the concept of self-harm (n = 7) (both from UK and
US), and some used self-mutilation (n = 5) (US and Scan-
dinavia), DSH (n = 3) (UK) and NSSI (n = 3) (US). The
most common form of self-harm among the participants
was cutting. The studies represented different qualitative
methodological traditions.
Translation andSynthesis
We read and reread the selected studies to identify first-,
second-, and third-order constructs (Britten etal. 2002).
One of the reviewers (LIS) listed the authors’ original find-
ings, using their own concepts (first-order constructs), the
authors’ interpretations of their findings (second-order con-
structs in the original studies), and looked for participants’
quotes supporting the concepts in each article (see Table3
for an example). We developed sub-categories of the data
between and within every study, and translated these find-
ings from one study to another, by generating sub-themes
(third-order constructs). Some of the sub-themes borrowed
the terminology of one of the constituent articles (e.g., the
term “feeling alive” from Ayerst’s (2005) article). The sub-
themes encompassed most of the original concepts. In the
end, we synthesized the sub-categories and sub-themes into
meta-themes (third-order constructs).
During the review process, the team met for consensus
meetings to decide on inclusion criteria and data extraction,
to enhance multiple interpretations of data, and to develop
concepts, in order to enhance the trustworthiness of our find-
ings (methodological integrity checks; Levitt etal. 2016). In
addition, we made individual discussion notes and engaged
in self-reflection to enhance reflexivity of our therapeutic
perspectives in the reading of the data (Lewitt etal. 2016).
In the following, we document and illustrate how four meta-
themes represent different ways adolescents experience self-
harm: to obtain release or relief from a burden or intense
feelings, to gain control over and cope with difficult feel-
ings, to represent unaccepted feelings, and to connect with
others. We present the sub-themes within each meta-theme,
and each sub-theme was composed of a collection of sub-
categories (see Table4). We identified all meta-themes in
the results across a majority of the studies (14 to 16 studies),
and we found the sub-themes and sub-categories in some
studies and not in others. We present the sub-categories with
a sample of the original quotes to specify and add meaning
to the four meta-themes, and to make the meta-synthesis
Adolescent Research Review
1 3
First Meta‑theme: Self‑Harm asaWay toObtain
Release orRelief fromaBurden orIntense Feelings
Ten of the studies highlighted release as the most impor-
tant experience while self-harming. This sub-theme covered
three sub-categories: (1) self-harm makes all the bad things
go away (n = 6): “I don’t always cut to make a point, I cut
because I need to…when I cut, when I see the blood, and I
feel it rushing, it’s such relief. I can feel it; it’s like every-
thing that is (bad) is just going out” (Machoian 2001, p.26).
(2) The release of pent up feelings/pressure/distress was
experienced as a necessity or else the person would go mad
Fig. 1 Flow diagram—steps and
Adolescent Research Review
1 3
Table 2 Characteristics of studies included in the meta-synthesis
Authors (year) Title Country Characteristics of
Sample size/gender Age Research design
and analysis
Data collection Concept of self-harm
Abrams and Gordon
Self-Harm Narra-
tives of Urban and
Suburban Young
US Non-clinical, urban
and suburban
6 girls 15–17 Thematic analysis
of narratives
qualitative inter-
Adams etal. (2005) Investigating the
‘self’ in deliberate
UK Online discussion
forums for self-
13 (11 girls, 2 boys) 16–25 Interpretive Phe-
Two online focus
groups and four
email interviews
Ayerst (2005) The autobiographi-
cal construction
of self-harm: A
study of adoles-
cent narratives
Canada Internet (25 narra-
Mostly girls
1 boy?
12–25 Discourse analysis/
tionist orientation
Narratives by
adolescents about
Bedenko (2001) A qualitative analy-
sis of the function
and intent of
behaviour in an
adolescent female
US Clinical, therapy 1 girl 15 Qualitative study/
Grounded herme-
neutic theory/A
single subject
Progression and
analysis of
Self -mutilative
Crouch and Wright
Deliberate Self-
Harm at an
Adolescent Unit:
A Qualitative
UK Adolescent Unit
Residential treat-
ment setting for
adolescents with
mental health
(4 girls, 2 boys)
12–16 Qualitative study/
interviews and
process notes
from observations
at the unit com-
munity meeting
Gulbas etal. (2015) An exploratory
study of non-
suicidal self-
injury and suicidal
behaviors in
adolescent Latinas
US Self-harmers with
or without suicide
from clinic
population and
from non-clinic
(18 girls)
NSSI and attempted
suicide (8 girls)
Suicide (29 girls)
11–19 years,
average 15
Exploratory mixed-
method analytic
In-depth qualitative
No suicidal
Holley (2016) The lived experi-
ence of adoles-
cents who engage
in non-suicidal
US Outpatient
Purposive sample
6 (5 girls, 1 boy) 14–17 Phenomenological
ended interviews
No suicidal self-
Adolescent Research Review
1 3
Table 2 (continued)
Authors (year) Title Country Characteristics of
Sample size/gender Age Research design
and analysis
Data collection Concept of self-harm
Lesniak (2010) The lived experi-
ence of adolescent
females who self-
injure by cutting
US Students 6 girls 15–18 Qualitative study/
cal method/The
Giorgi method
and Humanistic
Nursing Theory
Lewis and Mehrab-
khan (2016)
Every scar tells
a story: Insight
into people’s
self-injury scar
US, Europe, Aus-
tralia and New
53 online testi-
mony/posts on
a popular NSSI
message board
52 members Thematic analysis Posts online on
experiences with
scars from NSSI
Non-suicidal self-
injury (NSSI)
Machoian, L.
The possibility of
love: A psycho-
logical study of
adolescent girls’
suicidal acts and
US Private psychiatric
hospital on an
unlocked, volun-
tary adolescent
residential unit
3 girls 12–17 Case study analysis/
relational method
for data analysis,
the “Listener’s
In-depth semi-
structured clinical
Magagna, J. In
Briggs, S.,
Lemma, A., &
Crouch, W. (2008)
Attacks on life;
suicidality and
self-harm in
young people
US Clinical case 1 girl 15 Case-study Self-harm
Marshall, H. &
Yazdani, A.
Locating Culture
in Accounting
for Self-Harm
amongst Asian
Young Women
UK History of self-
7 girls 16–28 Qualitative
sive analysis
In-depth semi-
structured inter-
McAndrew, S. &
Warne, T. (2014)
Hearing the voices
of young people
who self-harm
Implications for
service providers
UK Non-clinical sample 7 girls 13–17 Qualitative
tive phenomeno-
logical analysis/
Face to face inter-
McDermott, E.,
Roen, K., & Piela,
A. (2015)
Explaining Self-
Harm: Youth
Cybertalk and
Sexualities and
Internet Online forums for
sexualities and
genders (lesbian,
gay, bisexual, and
trans (LGBT)
49 excerpts, from
290 members
16–25 Qualitative virtual
Thematic analysis
Posts online on
emotional distress
and self-harm
Adolescent Research Review
1 3
Table 2 (continued)
Authors (year) Title Country Characteristics of
Sample size/gender Age Research design
and analysis
Data collection Concept of self-harm
Moyer, M. & Nel-
son, K. W. (2007)
Investigating and
The student voice
US Students 6 (4 girls, 2 boys) 12–17 Qualitative
In-depth phe-
Nice, T. (2012) Troubled minds and
scarred bodies: a
grounded theory
study of adoles-
cent self-harm
UK Presenting to
hospital after an
episode of self-
(9 girls, 3 boys)
13–16 Grounded theory
analysis using
a narrative and
construct category
based approach
conducted after
episodes of self-
Parfitt, A. (2005) On aggression
turned against the
UK NHS outpatient
clinic, Psycho-
analytic psycho-
1 girl 17 Case-study Case-analysis Deliberate self-harm
Privé, A. A. (2007) An existential-
of self -cutting
among adolescent
US High school, large
urban school
6 girls 15–18 An existential-
investigation and/
Thematic analysis
interviews, open
ended research
Rissanen, M.-L.,
Kylmä, J., &
Laukkanen, E.
Descriptions of self-
mutilation among
Finnish adoles-
cents: a qualitative
descriptive inquiry
Finland Non-clinical adoles-
70 (69 girls, 1 boy) 12–21 A qualitative
Asked to write
descriptions of
their self-muti-
Yip., K.-S., Ngan,
M-Y., & Lam, I.
Adolescent self-
cutters in Hong
Hong Kong Secondary school 3 (2 girls, 1 boy) 14–18 Qualitative study/
Thematic analysis
In-depth interviews
about cause, pro-
cess, and pattern
Adolescent Research Review
1 3
(n = 3): “I felt I was going mad. I felt you know, I felt very
blocked up inside, I didn’t feel normal, I felt different from
everyone else. I felt angry and confused and empty, very
empty inside, so I felt I was going mad, very much. I thought
I was going mad” (Marshall & Yazdani 1999, p.421). (3)
After the release of feelings, the adolescents experienced
that they were relieved of the pain, stress, or problem (n = 1):
“It would be a relief for, basically, like, everything that was
going on, the stress. It was a kind of a relief for me because
each cut that happened was a relief from a problem” (McAn-
drew and Warne 2014, p.573).
In six articles, adolescents reported self-harm due to self-
hate. The sub-theme encompassed three sub-categories: (1)
Often, they reported hate towards themselves and a wish to
disappear (n = 4): “It (body dissatisfaction) made me really
depressed, contemplate suicide, and start self-harming”
(McDermott etal. 2015, p.880). Furthermore, “I want to
scream, I want to cut myself so much that I disappear, I
fucking hate myself” (Parfitt 2005, p.161). (2) Two articles
described how adolescents directed hate towards themselves
because they felt ugly and disgusting inside: “I’ve cut loads
recently, there’s so much shit inside me and I hate myself so
much, I’m such a bitch slut I have to be punished” (Parfitt
2005, p.161). (3) A few articles (n = 2) reported self-harm
in relation to a negative internal monologue: “I just get eve-
rything going through my head, and then just think about it,
and then I just cut myself” (Moyer and Nelson 2007, p.45).
Feeling Alive
In four articles, self-harm was described as a way to feel
alive, and this sub-theme consisted of two sub-categories:
(1) Three articles reported self-harm as a possibility to feel
alive, or just feel something: “…My harmness to myself is
an expression of emotional pain, I needed to feel something,
to know that I was still alive…” (Ayerst 2005, p.90). (2)
Another sub-category was a need to see the blood to know
that they are alive (n = 1): When I saw my blood running out
I knew I was alive (Rissanen etal. 2008, p.156).
Rush ofPositive Feelings
In four articles, the positive feelings related to self-harm
were important for the adolescents. This sub-theme included
three sub-categories; (1) Self-harm was reported as a way to
get a positive feeling and experience of themselves (n = 3):
“The bliss I felt during it was practically orgasmic. It was the
best feeling I had ever felt” (Ayerst 2005, p.84). (2) Others
described a positive feeling of a rush and calmness as an
important part of the self-harming experience (n = 1): “It’s
like a drug… It’s kinda like a rush that you get in your head
and you are like YES” (Privé 2007, p.78). (3) Some also
described the experience more like an addiction (n = 1): “I
feel I’m hooked on cutting” (Rissanen etal. 2008, p.157).
Second Meta‑theme: Self‑Harm asaWay toControl
ortoCope withDifficult Feelings
To Get Away fromDesperation andFrustration
In eleven studies, adolescents described the effect of self-
harm as an escape from desperation and frustration. Three
sub-categories were identified: (1) Adolescents described
how they used self-harm to get rid of emotional pain, such
as anxiety, depression or feeling sad or angry (n = 6). An
adolescent from Privé’s (2007) study said “I was very
upset… I was just mad…I was just angry at them… then
every time I was mad, I would just sit there…and I wouldn’t
scream, I would just cut myself” (p.75). (2) The cutting was
also done to get rid of difficult thoughts and feelings after
traumatic experiences or to end a dissociated state (n = 2),
as described by a girl in Ayerst’s (2005) study: “The pain
washes over, cleaning off the dark and hurtful things that
cling to my mind” (p.88). (3) In some studies (n = 4), self-
harm is related to getting rid of pain, which also results in
Table 3 Example of first- and second-order constructs and participant’s quote
Author, year, title E. E. Holley (2016): The lived experience of adolescents who engage in nonsuicidal self-injury
Participant’s quote “I hate anger. I can’t do it. When I show it, I try to stop it right away. I hate when people are
angry, so like whatever I hate I try not do it” (p.70)
Themes and concepts
First-order constructs “Negative emotionality”
Second-order constructs Low distress tolerance, poor affect regulation skills, and utilized NSSI to obtain temporary
emotional relief. Self-injurers are avoidant, as they supress both positive and negative emo-
tionality, and actively avoid initiating, managing, or addressing conflict
Subcategory A struggle to express feelings such as anger and sadness
Subtheme A struggle to express affective experiences and tame anger
Meta-theme Self-harm as a way to represent unaccepted feelings
Adolescent Research Review
1 3
Table 4 Meta-themes, sub-themes, and sub-categories
An experience of intolerable internal pressure with high intensity, which is overwhelming, has to end, and cannot be shown to other people. Self-
harm makes it possible to express difficult affects, and still protect others
Meta-themes Sub-themes Sub-categories
1. Self-harm as a way to obtain release or
relief from a burden or intense feelings
1.1 Release
1.2 Self-hate
1.3 Feeling alive
1.4 Rush of
positive feelings
1.1.1 All the bad things go away
1.1.2 Release of pent up feelings/the pressure/
distress related to an experience of necessity
or else become mad
1.1.3 To get rid of pain, the stress, a problem
1.2.1 Hate towards self and a wish to disappear
1.2.2 Because they felt ugly and disgusting
1.2.3A negative internal monologue
1.3.1 To get a feeling of being alive and feel
1.3.2A need to see the blood to know that they
were alive
1.4.1 To get a positive feeling and experience of
1.4.2A positive feeling of rush and calm down
1.4.3 Like an addiction
2. Self-harm as a way to gain control or cope
with difficult feelings
2.1 Get away from desperation and frustration
2.2 Control
2.3 Numbness
2.1.1 To get rid of emotional pain, such as anxi-
ety, depression or feeling sad or anger
2.1.2 To get rid of difficult thoughts and feel-
ings after traumatic experiences or ending a
dissociated state
2.1.3 To get rid of pain, which also makes the
adolescent feel guilty and shameful
2.2.1 To end feelings of alienation
2.2.2 To end specific feelings like sadness or
2.2.3 To take back control when helpless and
2.2.4A way to change emotional pain to physi-
cal pain
2.2.5A way to cope when nothing else helps
2.3.1 To reach a neutral feeling
2.3.2 Could end alienation
3. Self-harm as a way to represent unaccepted
3.1A struggle to express affective experiences
and tame anger
3.2 Protect others
3.1.1A struggle to find words and claim
3.1.2 To clear their mind and to make borders
to others
3.1.3A struggle to express feelings such as
anger or sadness
3.1.4 To be aware of their own needs and to get
3.2.1A wish to not hurt others
3.2.2 To avoid conflicting or negative feelings
in relation to or insituations with others
3.2.3 Don’t want to tell others about self-harm
4. Self-harm as a way to connect with others 4.1 Identification
4.2A wish to share and be open
4.1.1 An experiment
4.1.2 The group identity, being connected to
others with the same problems or identity - an
oppositional element
4.1.3 Searching for self-identity
4.2.1 Unresolved anger
4.2.2 To express feelings and pain to others
when other possibilities are unavailable or are
unheard by others
4.2.3 To ask for help when they experienced a
conflict between others about their problems
Adolescent Research Review
1 3
the adolescents feeling guilty and shameful: “I’m starting
to feel guilty every time. That’s the only feeling afterward
now” (Moyer and Nelson 2007, p.46). In this way, self-harm
can be seen as a method to get rid of difficult feelings, and
to find a solution to reduce tension, frustration, or pressure,
but may also contribute to additional problems, such as guilt
and shame, for some young people.
In nine of the studies, the adolescents highlighted the ele-
ment of control that self-harm provided in relation to dif-
ferent feelings and in relation to other people, and five sub-
categories were included: (1) Control is related to ending
feelings of alienation (n = 1): “For once I had a sense of
control on my body. I wanted to feel unique and I had to
cope with my feelings of alienation” (Ayerst 2005, p.93).
(2) How self-harm can end more specific feelings like sad-
ness or anger was also of importance (n = 5): It was in my
hand (the nail file), and I was thinking, “What I’m going to
do with this? I’m not going to kill myself because I do not
want to die. I want to just stop feeling angry. Inside me was
screaming. I was feeling really, really angry” (Gulbas 2015,
p.306). The necessity of taking control was associated with
difficulties showing feelings in general: “By self-mutilation,
I can avoid crying in the wrong places, stay cool” (Rissanen
etal. 2008, p.156). (3) Self-harm may also be related to a
state of helplessness and to feeling overwhelmed and rep-
resent a way to take back control (n = 3): “I hate the feeling
that other people can make me cry so it’s a relief that they
are not controlling me crying this time. I can do it myself”
(Gulbas 2015, p.306). (4) Self-harm was also mentioned
as a way to change emotional pain to physical pain, which
gave a feeling of being in control (n = 1): “Cleansing, just
getting rid of it (the pain). Every feeling you feel is going
into your cut. The pain you feel goes into that (cutting)”
(Moyer and Nelson 2007, p.46). (5) Some reported self-
harm as their last choice, but a way to cope when nothing
else helps (n = 2): “Writing didn’t help anymore, talking
didn’t help anymore… so I just got the razor blade” (Privé
2007, p.80). The experience of regaining control after being
overwhelmed is a central aspect for these adolescents.
In some of the studies (n = 6), the element of control was the
first step in a process to become neutral. Two sub-categories
were found: (1) Self-harm was a way to reach a neutral feel-
ing: “It went numb, I couldn’t feel it anymore… I couldn’t
feel anything” (Privé 2007, p.80). For some, numbness was
the goal. (2) For others, achieving numbness through self-
harm could end feelings of alienation.
Third Meta‑theme: Self‑Harm asaWay toRepresent
Unaccepted Feelings
A Struggle toExpress Affective Experiences andTame
In eight of the studies, adolescents indicated self-harm as
part of a struggle to express their own feelings and diffi-
culties. This sub-theme comprised four sub-categories: (1)
More specifically, they experienced a struggle to find words,
assert their voice, and claim efficacy (n = 4) in difficult situ-
ations and in interpersonal conflicts: “I feel extremely frus-
trated when my friend and teacher blame me. I feel crazy.
I don’t know how to scold back. I feel frustrated. I need to
do self-cutting to release my sense of emptiness” (Yip etal.
2004, p.44). (2) Self-harm may also be a way to clear one’s
mind and to establish boundaries with others (n = 1): “…
clear my mind and get everything else out. It just blocks the
whole world so it’s just me” (Moyer and Nelson 2007, p.46).
(3) Some mentioned a struggle to express feelings (n = 3),
such as anger, as a reason for self-harm: “I hate anger. I
can’t do it. When I show it, I try to stop it right away. I hate
when people are angry, so like whatever I hate I try not to
do” (Holley 2016, p.70). Others struggled to express hap-
piness; “True happiness or joy… it’s really hard to express
for me. I feel it sometimes I don’t know why I can’t show
it” (Holley 2016, p.71). (4) Some described self-harm as
a way to be aware of their own needs and especially to get
help from others (n = 2): “I think it’s a form of manipulation,
of manipulating other people, and I hate that. And I hate to
think that I do that, but I know I do… in some ways, I have
used it to get the support that I need at that moment of time.
And I think that is manipulation. And I hate that” (Machoian
1998, p.26).
To Protect Others
In five studies, adolescents described how important it was
for them to protect others (parents and friends) from their
difficult feelings in general or from the fact that they were
harming themselves. This subtheme included three sub-cat-
egories: (1) Adolescents reported an explicit wish not to hurt
others (n = 1): “I don’t take my anger out on other people.
Like some people fight to let out their anger. I don’t do that.
I hurt myself” (Moyer and Nelson 2007, p.47). (2) Others
avoided the conflicting or negative feelings in relation with
others in general (n = 4): “I have enormous amounts of rage
within and I’m afraid to express it outwardly, and by injur-
ing myself, it is a way of venting my feelings” (Ayerst 2005,
p.92). (3) They also described how they don’t want to tell
others about their self-harm (secrecy) (n = 1): “…’cos I went
for years without no-one finding out about my self-harming
and I didn’t want anyone to know about it, so that makes me
Adolescent Research Review
1 3
angry, especially when I know some people that do it for
attention” (Crouch and Wright 2004, p.194).
Fourth Meta‑theme: Self‑Harm asaWay toConnect
This sub-theme included eight articles and covered three
sub-categories related to how adolescents perceived self-
harm as part of being in a social group and of identity
construction processes: (1) In some studies, adolescents
reported starting with self-harm as an experiment (n = 2):
“When I started junior secondary school, my puberty was
beginning. At that time, I cut myself for the first time. It was
just an experiment, nothing more” (Rissanen etal. 2008,
p.156) and “I had nothing else to do” (Rissanen etal. 2008,
p.156). (2) In six studies, the group identity (n = 11) for ado-
lescents who harmed themselves was important, especially
to be a real self-harmer, not copying others, but also to see
themselves as different and having trouble: “I’m also more
f***d up in the head than most people. Looking at my cuts
this morning made me feel sick—it reminds me that I’m
screwed up, that my head doesn’t work the same as everyone
else’s” (Adams etal. 2005, p.1305). This sub-category also
included a positive experience of being connected to others
with the same problems or identity as outsiders: “It wasn’t
until I managed to persuade my mum to get the internet on
our computer that I discovered that I was far from being
the only one who liked to harm herself. I have met loads of
really fab people online through self-harm websites and chat
rooms and stuff” (Ayerst 2005, p.94). An oppositional ele-
ment was also described: “Why waste my time just so soci-
ety can think I’m a happy guy like the rest of them?” (Holley
2016, p.67). (3) The last sub-category was about self-harm
as part of a process of searching for self-identity (n = 2):
“Yeah. What I was and what I was meant to be, and where I
was happier. Taking part from then, and now reconnecting
it to my experiences and myself now. Well, it’s just moving
on. And like, I saw that as connected. Like this thing, and
like I could have gone down that path or that path, but I took
the weird one and it just eventually connected with my real
path, the one I was meant to be on” (Bedenko 2001, p.148).
The sub-theme of identity highlighted how adolescents are
conscious of self-harm as a cultural sign, and not just as a
symptom of mental illness—as an alternative to being an
outsider of the dominant culture.
A Wish toShare andBe Open
In twelve studies, adolescents described different ways self-
harm was related to expressions of feelings, and three sub-
categories were identified: (1) In three studies, self-harm was
related to unresolved anger: “I just get pissed, and whenever
I get mad, I like… throw things, and I’m like really aggres-
sive… and sometimes when I get mad, I just carve things on
myself. Whenever I was mad, it was just like a way to calm
down. So, sometimes I still do that. Like one time I was
mad at my boyfriend, and I did something wrong. And I was
sorry. He was pissed, and he didn’t want to talk to me. So, I
carved it in my arm, but you can’t see it anymore” (Abrahms
& Gordon 2003, p.437). (2) Three studies, report self-harm
as a way to express emotional pain to others: “It just makes
my pain easier to see” (Lesniak 2010, p.141). The expres-
sion of pain in this way was particularly important when
other possibilities are unavailable or felt unheard by others:
“When they see it, like actually see it (a cut), they’re like,
wow, maybe something is wrong. It’s like yes, you (exple-
tive) idiot something is wrong. I’ve only been saying it for
the last 17 years… People won’t believe that something is
wrong… It’s, it’s an actualization of pain, you know…The
most basic is that even if you tell people that something is
wrong, a lot of times…they won’t, they won’t know how
wrong. But all they’ll do is see a cut along a vein, and they
get the message right away” (Machoian 1998, p.25). (3) In
five studies, adolescents described self-harm as a way to ask
for help about their problems: “It is true that cutting is a cry
for help. I wish someone adult would see my cuts and scars
and help me. I have no words to ask for it (help)” (Rissanen
etal. 2008, p.156).
This meta-synthesis of qualitative studies of first person
accounts of self-harm supplements quantitative studies in
important ways. This is particularly so when it comes to the
conceptual modeling of the psychological functions of self-
harm. Attention is moved from “causes” and “risk factors”—
which are not very specific—to purpose and consequences.
Theories of the function of self-harm are mostly based on
the authors’ rendering of their clients’ understanding of
self-harm (Soyemoto 1998), and studies of the participants’
experience are often based on questionnaires with pre-deter-
mined categories developed from adult clients (Edmondson
etal. 2016). Consequently, we had limited knowledge about
the motives of self-injuring behavior, particularly among
Since the number of qualitative studies of subjective
experience of self-harm is growing, there was a need to syn-
thesize existing findings about young people in the phase of
life when such behaviors tend to develop. Finding twenty
highly relevant studies appeared to be a strong start. During
the analysis, it was possible to compare content and design
themes across studies including clinical as well as non-clin-
ical samples.
Adolescent Research Review
1 3
In the following, we discuss how our findings on the pur-
pose of self-harm from the adolescent’s perspective sup-
port and add nuance to our existing knowledge. We argue
that self-harm is a way to regulate affect. Furthermore, we
underline how the action of self-harm may be a way to con-
tain important emotional and relational content for the ado-
lescent, and may express an intention or wish to connect
and communicate with others. We also discuss common
elements across the meta-themes and how self-harm may
represent an insufficient solution to conflicting psychologi-
cal needs and developmental challenges in adolescence. We
highlight how the studies included in our meta-synthesis
seldom relate their findings to developmental issues in ado-
lescence, or the fact that young girls are overrepresented in
the studies on self-harm.
The Purpose ofSelf‑Harm fromtheAdolescents’
Common across the four meta-themes is an experience of
intolerable internal pressure and intense frustration, which
is overwhelming, must be brought to an end, and cannot be
shown to other people. Adolescents experience self-harm
as a way to obtain release or relief, or to gain control of
difficult and overwhelming stress and feelings. The first
and second meta-theme in our findings overlap with Klon-
sky’s (2007; Klonsky etal. 2014) and Jacobson and Gould’s
(2007) focus on self-harm as a way to regulate or activate
affect, and Edmondson and colleagues’ (2016) report on how
self-harm is a way to handle distress and establish a personal
sense of mastery. Thus, affect regulation emerges as a major
function of self-harm.
The third and fourth meta-theme in our findings nuance
our current understanding of adolescents’ experience of
self-harm. The third meta-theme shows how self-harm may
be an important way to represent unacceptable affective
experiences in general. Self-harm may be a way of becom-
ing aware of one’s own needs and difficulties. Further, self-
harm may express the struggle to represent that something
is difficult when other options are unavailable (Adams etal.
2005; Machoian 2001), or the ability of symbolization is
undeveloped (Bouchard and Lecours 2008). The concrete
action of self-harm may bring something to attention from
the individual’s inner or outer world. The fourth meta-theme
highlights how adolescent girls, and some boys, often expe-
rience self-harm in a relational context. Self-harm may serve
to express internal pain to others in a situation of conflict
or to ask for help (Adams etal. 2005; Crouch and Wright
2004). When feeling lonely and isolated, self-harm may con-
vey a wish to connect with others (Lesniak 2010; Machoian
1998) or a way to be part of a sub-group (Moyer & Nelsons
2007; Nice 2012).
Our findings underline the importance of understanding
self-harm not only as a disturbance in an individual’s capac-
ity for affect regulation, but also in connection to the ado-
lescent’s problems in finding ways to express themselves, to
communicate more freely, and to share experiences in rela-
tion to important others. Communicative and interpersonal
functions of self-harm are mentioned in Klonsky’s (2007;
Klonsky etal. 2014), Nock and Prinstein’s (2004, 2005), and
Soyemoto’s (1998) models of self-harm. Edmondson and
colleagues (2016) report that self-harm can serve to define
the self and exert interpersonal influence. Jacobson and
Gould (2007) underline that self-harm can elicit attention
and can be a way to get away from social responsibilities.
However, more specifically, adolescent girls and boys often
struggle to represent their experiences, and they may adjust
their expressions of difficult issues and harm themselves to
protect and not hurt important others. In this way, self-harm
can contain important emotional content and represent a
wish to connect, communicate with, and be understood by
others. In a clinical setting, this content may be important to
explore further in order to help the self-harming adolescent
get to know and tolerate their needs and feelings, and express
themselves more freely and less destructively.
Self‑Harm asanExpression ofaConflict
andDevelopmental Challenges
A remaining question, however, is why some adolescents
end up with a strong inclination to damage their own body-
tissue in order to handle unbearable and overwhelming feel-
ings and tensions?
In many of the studies, adolescents reported ambiva-
lence about sharing their experiences with others. They
were afraid of showing their feelings or frustration, did not
want to be judged by others, but also explicitly wished to
gain some understanding from others. In our view, self-harm
can be a way to solve a conflict between basic psychologi-
cal needs and developmental tasks, which are important in
adolescence (Erikson 1980; Siegel 2015). On the one hand,
the young girl or boy needs to represent and express affective
experiences, and on the other, they have a relational need for
attachment, safety, acceptance, and affiliation. Expressing
unbearable pressure or feelings, such as anger and frustra-
tion, may be impossible for some adolescents because of
their need to protect others from their feelings and their need
for support. Self-harm may be an expression of this inner
Furthermore, self-harm—after the immediate relief—
may evoke strong and difficult feelings and reactions in
others, and subsequent feelings of shame, loneliness, and
hopelessness in the young girl or boy. Thus, self-harm does
not release the adolescent from all of their problems. Nev-
ertheless, self-harmers return to self-harming behaviors
Adolescent Research Review
1 3
that, although insufficient, still seem to be the only possible
solution available to them now. The adolescent can hide the
issue causing distress, and yet the adolescent is still try-
ing to express him or herself and share their experience—
which could be the ultimate experiential proof of existence.
What is at stake here is the ongoing developmental process
of psychological separation towards autonomy, to become
an authentic self, to establish a boundary between self and
others, and to establish new forms of relational reciprocity
with important others. In adults, self-harm may have lost its
initial association with these issues. From this perspective,
self-harm may be a sign (Brady 2014; Motz 2010) of urgent
developmental challenges in the process of self-representa-
tion and identity formation (Erikson 1980).
Descriptions of self-harm comprise a wide range of affec-
tive experiences. Some adolescents specify difficult feelings,
thoughts or interpersonal conflicts, but others describe dif-
fuse stress or arousal. For some, self-harm is associated with
specific representations of mental content, but for others,
self-harm may be a sign of a more pervasive deficit and
disturbance in their ability to differentiate and express affect
and needs (Bouchard and Lecours 2008).
Many of the reported citations refer to problems with or
different ways to deal with anger. Some of the adolescents
do not want to experience anger at all, or do not want to
show anger to others (Bedenko 2001; Magagna 2008). Other
adolescents express relief that they can turn the anger toward
themselves and thereby protect others from their own dif-
ficult feelings (Parfitt 2005; Yip etal. 2004). Anger is one
of our basic emotions and is critical to protecting our body
and self from threats in the environment, or from difficult
inner feelings, thoughts or fantasies (Panksepp 2010). From
this perspective, the “harming” and the violent aspect of
self-harm may be related to the adolescent’s effort to tame or
express anger. Further, self-harm may be a way to establish,
or re-establish, a boundary between self and others when
they feel intruded or threatened. The harming of the body
may represent, in a concrete way, the undeveloped or insuf-
ficient solution to psychological challenges in adolescence.
Self‑Harm inaDevelopmental andCultural Context
Although the participants in the included studies were pri-
marily between 12 and 18years of age, the authors of the
studies seldom related their findings to developmental chal-
lenges in adolescence. There are some exceptions (Crouch
and Wright 2004; Machoian 2001; McDermott etal. 2015;
Parfitt 2005; Privé 2007), but often the findings are inter-
preted as being “age neutral”. In our opinion, it is important
to relate our findings to our knowledge of adolescence in
general. Impulsivity, sensation seeking, emotional instabil-
ity, risk behavior—such as self-harm—and testing of limits
are usual phenomena in adolescence (Casey etal. 2008).
For many adolescents, this behavior declines as they reach
Favazza (2011/1987) argues that the main perspective
in the research literature on self-harm is a clinical-medi-
cal perspective and that self-harm cannot be reduced to a
symptom of a mental illness (see alsoAdler & Adler 2003).
In “The coming of age of self-mutilation”, Favazza (1998)
asks whether self-mutilation has become more normalized
in recent years. Whitlock and Selekman (2014) also ask
whether the social motivation for starting to self-harm is
increasing. Among the studies included in our meta-syn-
thesis, some authors report social or existential issues as
important factors to understanding self-harm, like social
belonging and psychosocial exclusion (Abrams & Gordons
2003; Adams etal. 2005; Ayerst 2005), control and vulner-
ability (Marshall & Yazdani 1999), bullying, and cultural
differences (Gulbas 2015; McDermott etal. 2015). Self-
harm is underlined as a cultural expression of identity and
as an accepted way of coping with difficult feelings.
Participants in the included studies are mostly girls and
young women, but only a few authors discuss this gender
disparity in their articles (McDermott etal. 2015; Lesniak
2010). The findings are presented in a somewhat “gender
neutral” way. Although girls are overrepresented in the stud-
ies, it is important to remember that self-harm is not a “nor-
mal” behavior among girls in general. Still, adolescent girls
(and some boys) may struggle to find “accepted” channels to
express frustration and conflicting needs. Self-harm may be
related to a narrow and limiting pathway to adulthood in a
given cultural context, particularly for girls. Their relational
need to be accepted and cared for overrules their need for
expressing themselves. In our perspective, self-harm can
be a sign of mental illness, but may also be regarded as a
destructive “answer” or coping strategy for responding to
challenging developmental tasks like separation, autonomy
and identity formation in the process to become a young
Limitations oftheCurrent Study
Every included study consists of rich and comprehensive
data-material, and our analysis was depending on the find-
ings in every study. Therefore, a meta-synthesis cannot pre-
sent conclusions, but may serve as a working model. Still, it
is valuable to consider the various strengths and weaknesses
of the included studies.
In our meta-synthesis, we included studies with differ-
ent terminology and definitions of self-harm. However,
our focus was on the adolescent’s perspective of self-harm,
rather than a wish to die. There is also heterogeneity in the
conduct and presentation of meta-ethnography, and a lack
of consistency in reporting procedures for the meta-synthe-
sis (Evans and Hurrell 2016). We have tried to be explicit
Adolescent Research Review
1 3
concerning our methodological approach, our analytic
process, and our presentation of the findings. Despite the
limitations, the themes that emerged and their clustering and
hierarchy brought more specificity to how a young person
experience the act of self-harm and the purposes it serves.
Implications forFurther Research
The many related sub-categories highlight the diversity and
commonalities among adolescents’ descriptions and experi-
ences of self-harm. However, further studies are needed to
address hypotheses about sub-groups, which then would be
interesting to explore in more detail.
Differences in frequency, methods and mental illness are
important aspects of the individual differences among ado-
lescents who harm themselves (Hawton etal. 2012; Bentley
etal. 2014; Whitlock and Selekman 2014), but differences
in subjective experience could also be an important aspect
to study in this regard. For example, are there differences
in adolescents’ capacity to represent, symbolize and reflect
upon their affective and inner experiences? Are there impor-
tant differences in self-esteem and their representation of
self? Further, are there developmental differences (i.e., vul-
nerabilities or deficits) among adolescents when they start
to self-harm that influence their experience of self-harm,
the development of pathology such as BPD, or the degree
to which self-harm affects their life? These questions are
difficult to answer, but may be important in further research
on differences between clinical and non-clinical adolescents,
and between girls and boys.
Since self-harm seems to start in adolescence and has
increased among young people in recent years, there are
reasons to see self-harm as a phenomenon with core char-
acteristics, a set of sub-categories, and specific subjective
aims. In this meta-synthesis, we translated and integrated
findings from prior qualitative studies. The four meta-themes
that emerged represent different ways adolescents experience
self-harm—as a way to obtain release, to control feelings,
to represent unaccepted feelings, and to connect with oth-
ers. The meta-themes “to obtain release” and “to control
feelings” overlap with findings in reviews on adolescents
(Jacobson and Gould 2007) and adults using self-report
methods (Klonsky; Edmondson etal. 2016), and support
the theory of self-harm as a function of affect regulation
(Klonsky etal. 2014).
However, the meta-themes “to represent unaccepted
feelings” and “to connect with others” highlight the impor-
tance of understanding how self-harm may contain emo-
tional and relational content. Self-harm in adolescence
is closely related to a struggle to express themselves
and a wish to communicate and share experiences with
important others. Given that self-harming behavior typi-
cally emerges during adolescence, it is helpful to link
our knowledge of self-harm to the major developmental
challenges adolescents face, such as separation, identity
formation, autonomy and relational fidelity (Erikson
1980; Siegel 2015). The meta-themes and the common
theme—intolerable internal pressure—points to a psycho-
social dynamic understanding. We argue that self-harm
can be understood as a conflict between basic psychologi-
cal needs—a possibility to express frustration and still
protect important others. It may be challenging to find
ways to represent and express feelings, such as sadness,
jealousy, anger, and frustration, because of the enduring
need to be cared for in their daily life. Our findings can be
important in a clinical setting, particularly by informing
the therapist about the necessity of helping the adoles-
cent to explore and develop alternative ways to regulate
and express feelings. In addition, it may be fruitful for the
therapist, like researchers, to relate self-harm to identity
formation, and to the adolescent’s developmental need to
become an authentic self in relations with others.In this
way, self-harm does not need to be the only way to handle
overwhelming feelings, trauma, and loneliness.
Acknowledgements The authors wish to thank Glenn Karlsen
Bjerkenes and Hege Ringnes at the University of Oslo, Norway for their
assistance with the literature search, and Caryl Gay, PhD at the Uni-
versity of California, San Francisco for proof reading the manuscript.
Authors’ contributions LIS conceived of the study, participated in its
design and coordination and drafted the manuscript; HH participated
in the design and interpretation of the data; SEG participated in the
design and interpretation of the data. All authors read, helped to draft,
and approved the final manuscript.
Funding The Norwegian Extra Foundation for Health and Rehabilita-
tion and The Norwegian Council for Mental Health provided funding
for this study, FO4115. They had no role in the study design, collection,
analysis or interpretation of the data, writing the manuscript, or the
decision to submit the article for publication.
Compliance with Ethical Standards
Conflict of Interest The authors report no conflict of interests.
Research Involving Human and Animal Participants This article does
not contain any studies with human participants or animals performed
by any of the authors.
Adolescent Research Review
1 3
The electronic search strategy was developed in liaison with
information specialists at the University of Oslo in Decem-
ber 2016. The methodological search terms were informed
by technical guidance and worked examples.
MEDLINE 19.12.16
Database: Ovid MEDLINE(R) In-Process & Other Non-
Indexed Citations, Ovid MEDLINE(R) Daily and Ovid
MEDLINE(R) < 1946 to Present>.
Search strategy
1 exp Self-Injurious Behavior/or
(self-injur* or “self injur*” or
selfinjur*).tw,kw. (65,471)
2 exp Self-Mutilation/or (self-
mutilat* or “self mutilat*” or
selfmutilat*).tw,kw. (3901)
3 (Self-harm* or selfharm* or (self
adj2 harm*)).tw,kw. (4481)
4 (self-poison* or “self poison*” or
selfpoison*).tw,kw. (1693)
5 (self-injur* or “self injur*” or
selfinjur*).tw,kw. (3744)
6 ((self-destruct* or “self destruct*”
or selfdestruct*) adj2 behav*).
tw,kw. (545)
7 (self-cut* or “self cut*” or self-
cut*).tw,kw. (164)
8 (self-inflict* or “self inflict*” or
selfinflict*).tw,kw. (2005)
9 (non-suicid* or “non suicid*” or
nonsuicid*).tw,kw. (1723)
10 parasuicid*.tw,kw. (638)
11 or/1–10 (69,568)
12 exp Qualitative Research/or quali-
tative*.tw,kw. (222,264)
13 exp Grounded Theory/or
“grounded theor*”.tw,kw.
14 exp Interviews as Topic/or (inter-
view* adj3 psychol*).tw,kw.
15 exp Interview, Psychological/
16 exp Focus Groups/or “focus
group*”.tw,kw. (38,728)
17 exp Anecdotes as Topic/or anec-
dote*.tw,kw. (5997)
18 exp Personal narratives as topic/
19 exp Narration/or narrative*.tw,kw.
20 ethnograph*.tw,kw. (8408)
Search strategy
21 phenomenol*.tw,kw. (20,859)
22 “discourse analysis*”.tw,kw.
23 “thematic analysis*”.tw,kw.
24 (case adj3 stud*).tw,kw. (197,179)
25 or/12–24 (534,727)
26 exp Motivation/or motiv*.tw,kw.
27 exp Intention/or intent*.tw,kw.
28 (reason* or meaning*).tw,kw.
29 driv*.tw,kw. (344,497)
30 caus*.tw,kw. (2,232,491)
31 purpose*.tw,kw. (1,084,654)
32 function*.tw,kw. (3,248,983)
33 explanation*.tw,kw. (114,577)
34 subjectiv*.tw,kw. (117,108)
35 or/26–34 (6,813,738)
36 exp Adolescent/or adolescen*.
tw,kw. (1,945,129)
37 teen*.tw,kw. (27,277)
38 youth*.tw,kw. (64,761)
39 exp Minors/or minor*.tw,kw.
40 exp Young Adult/or “young
adult*”.tw,kw. (678,157)
41 or/36–40 (2,504,108)
42 11 and 25 and 35 and 41 (709)
*Bedenko, W. E. (2001). A qualitative analysis of the function and
intent of self-mutilative behavior in an adolescent female. (Doc-
toral dissertation). Retrieved from ProQuest Dissertations Pub-
lishing. (UMI No. 2001. 3024540).
*Crouch, W., & Wright, J. (2004). Deliberate self-harm at an ado-
lescent unit: A qualitative investigation. Clinical Child
Psychology and Psychiatry, 9(2), 185–204. https://doi.
*Gulbas, L. E., Tyler, T. R., & Zayas, L. H. (2015). An exploratory
study of nonsuicidal self-injury and suicidal behaviors in ado-
lescent Latinas. American Journal of Orthopsychiatry, 85(4),
*Abrams, L. S., & Gordon, A. L. (2003). Self-harm narra-
tives of urban and suburban young women. Affilia-Journal
of Women and Social Work, 18(4), 429–444. https://doi.
*Adams, J., Rodham, K., & Gavin, J. (2005). Investigating the ‘self’
in deliberate self-harm. Qualitative Health Research, 15(10),
Adler, P. A., & Adler, P. (2011). The tender cut. Inside the hidden world
of self-injury. New York: New York University Press.
Adolescent Research Review
1 3
Althoff, R. R., Hudziak, J. J., Willemsen, G., Hudziak, V., Bartels,
M., & Boomsma, D. I. (2012). Genetic and environmental
contributions self-reported thoughts of self-harm and suicide.
American Journal of Medical Genetics Part B: Neuropsychi-
atric Genetics, 159B(1), 120–127.
American Psychiatric Association (2013). Diagnostic and Statistical
Manual of Mental Disorders, 5th ed. American Psychiatric Asso-
ciation: Washington, DC.
*Ayerst, S. (2005). The autobiographical construction of self-harm:
A discourse-analytic study of adolescent narratives. (Doctoral
dissertation). Available from ProQuest Dissertations and Thesis
database. (UMI No. MR01787).
Bentley, K. H., Nock, M. K., & Barlow, D. H. (2014). The four-func-
tion model of nonsuicidal self-injury: Key directions for future
research. Clinical Psychological Science, 2(5), 638–656. https://
Borschmann, R. J., Hogg, R., Phillips, P., & Moran, P. (2011). Measur-
ing self-harm in adults: A systematic review. European Psychia-
Bouchard, M. A., & Lecours, S. (2008). Contemporary Approaches to
Mentalization in the Light of Freud´s project. In F. Busch (Ed.),
Mentalization: Theoretical Considerations, Research Findings,
and Clinical Implications. New York: Taylor and Francis.
Brady, M. T. (2014). Cutting the silence: Initial, impulsive self-cutting
in adolescence. Journal of Child Psychotherapy, 40(3), 287–301.
Britten, N., Campbell, R., Pope, C., Donovan, J., Morgan, M.,
& Pill, R. (2002). Using meta-ethnography to synthesize
qualitative research: A worked example. Journal of Health
Services Research & Policy, 7(4), 209–215. https://doi.
Brown, T. B., & Kimball, T. (2012). Cutting to Live: A phenomenol-
ogy of Self-Harm. Journal of Marital and Family Therapy, 39,
Campbell, R., Pund, P., Pope, C., Britten, N., Pill, R., Morgan, M., &
Donovan, J. (2003). Evaluating meta-ethnography: A synthesis
of qualitative research on lay experiences of diabetes and diabe-
tes care.. Social Science & Medicine, 56, 671–684. https://doi.
Casey, B. J., Jones, R. M., & Hare, T. A. (2008). The adolescent brain.
Annals of the New York Academy of Sciences, 1124, 111–126.
Edmondson, A. J., Brennan, C. A., & House, A. (2016). Non-suicidal
reasons for self-harm: A systematic review of self-reported
accounts. Journal of Affective Disorders, 191, 109–117. https://
Emerson, L. E. (1913). The case of Miss A: A preliminary report of a
psychoanalytic study and treatment of a case of self-mutilation.
Psychoanalytic Review, 1(1), 41–54.
Erikson, E. H. (1980). Identity and life cycle. New York: WW Norton.
Evans, R., & Hurrell, C. (2016). The role of schools in children and
young people’s self-harm and suicide: Systematic review and
meta-ethnography of qualitative research. BMC Public Health,
16, 401–416.
Favazza, A. R. (1998). The coming of age of self-mutilation. The
Journal of Nervous & Mental Disease, 186(5), 259–268. ISSN:
Favazza, A. R. (2011). Bodies under siege. Self-mutilation, nonsui-
cidal self-injury, and body modification in culture and psychia-
try (Thirdedn.). 2011. Baltimore: The John Hopkins University
Press. (/1987 ., .
Gardner, F. (2001). Self-harm: A psychotherapeutic approach. New
York: Taylor & Francis Inc.
Gvion, Y., & Fachler, A. (2015). Traumatic experiences and their rela-
tionship to self-destructive behavior in adolescence. Journal of
Infant, Child, and Adolescent Psychotherapy, 14(4), 406–422.
Hamza, C. A., Willoughby, T., & Heffer, T. (2015). Impulsivity and
nonsuicidal self-injury: A review and meta-analysis. Clini-
cal Psychology Review, 38, 13–24.
Hawton, K., Saunders, K. E. A., & O’Connor, R. C. (2012). Self-harm
and suicide in adolescents. Lancet, 379, 2373–2382. https://doi.
*Holley, E. E. (2016). The lived experience of adolescents who engage
in nonsuicidal self-injury (Doctoral dissertation). Retrieved from
Open Access Thesis and Dissertations. (Record No. oai:etd.ohi-
Hooley, J. M., & St. Germain, S. A. (2014). Nonsuicidal self-
injury, pain, and self-criticism: Does changing self-worth
change pain endurance in people who engage in self-injury?
Clinical Psychological Science, 2(3), 297–305. https://doi.
Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenome-
nology of non-suicidal self-injurious behavior among adolescents:
A critical review of the literature. Archives of Suicide Research,
11(2), 129–147.
Kirtley, O. J., O’Carroll, R. E., & O’Connor, R. C. (2016). Pain and
self-harm: A systematic review. Journal of Affective Disorders,
203, 347–363.
Klonsky, E. D. (2007). The functions of deliberate self-injury: A review
of the evidence. Clinical Psychology Review, 27, 226–239. https://
Klonsky, E. D., Oltmanns, T. F., & Turkheimer, E. (2003). Deliberate
self-harm in a nonclinical population: Prevalence and psychologi-
cal correlates. American Journal of Psychiatry, 160, 1501–1508.
Klonsky, E. D., Victor, S. E., & Saffer, B. V. (2014). Nonsuicidal
self-injury: What we know, and what we need to know. The
Canadian Journal of Psychiatry, 59(11), 565–568. https://doi.
*Lesniak, R. G. (2010). The lived experience of adolescent females
who self-injure by cutting. Advanced Emergency Nursing Journal,
32(2), 137–147.
Levitt, H., Pomerville, A., & Surace, F. I. (2016). A qualitative meta-
analysis examining clients’ experiences of psychotherapy: A new
agenda. Psychological Bulletin, 142(8), 801–830. https://doi.
*Lewis, S. P., & Mehrabkhani, S. (2017). Every scar tells a story:
Insight into people’s self-injury scar experiences. Counselling
Psychology Quarterly, 29(3), 296–310.
*Machoian, L. (2001). Cutting voices. Journal of Psychosocial Nurs-
ing & Mental Health Services, 39(11), 22–29. ISSN: 02793695.
Maciejewski, D. F., Creemers, H. E., Lynskey, M. T., Madden, P. A.,
Heath, A. C., Statham, D. J., Martin, N. G., & Verweij, K. J.
(2014). Overlapping genetic and environmental influences on
nonsuicidal self-injury and suicidal ideation: different outcomes,
same etiology? JAMA Psychiatry, 71(6), 699–705. https://doi.
*Magagna, J. (2008). Attacks on life: suicidality and self-harm in
young people. In S. Briggs & S. Lemma, A. & W. Crouch (Eds.),
Relating to self-harm and suicide: Psychoanalytic perspectives on
practice, theory and prevention (pp.109–127). New York, NY:
Routledge/Taylor & Francis Inc.
*McAndrew, S., & Warne, T. (2014). Hearing the voices of young
people who self-harm: Implications for service providers. Interna-
tional Journal of Mental Health Nursing, 23(6), 570–579. https://
*McDermott, E., Roen, K., & Piela, A. (2015). Explaining self-harm:
Youth cybertalk and marginalized sexualities and genders. Youth
Adolescent Research Review
1 3
and Society, 47(6), 873–889.
Menninger, K. (1938). Man against himself. New York: Harcourt,
BraceWorld, Inc. (/1966. .
Morgan, C., Webb, R. T., Carr, W. J., Kontopantelis, E., Green, J.,
Chew-Graham, C. A., Kapur, N., & Ashcroft, D. M. (2017). Inci-
dence, clinical management, and mortality risk following self-
harm among children and adolescents: cohort study. BMJ, 359,
Motz, A. (2010). Self-harm as a sign of hope. Psycho-
analytic Psychotherapy, 24(2), 81–92. https://doi.
*Moyer, M., & Nelson, K. W. (2007). Investigating and understanding
self-mutilation: The student voice. Professional School Coun-
seling, 11(1), 42–48. ISSN: 1096–2409.
*Nice, T. (2012). Troubled minds and scarred bodies: A grounded
theory study of adolescent self-harm (Unpublished doctoral dis-
sertation). The University of Kent.
Noblit, G. W., & Hare, R. D. (1988). Meta-ethnography. London:
SAGE Publications, Inc.
Nock, M. K. (2014). The Oxford Handbook of Suicide and Self-injury.
New York: Oxford University Press.
Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the
assessment of self-mutilative behavior. Journal of Consulting and
Clinical Psychology, 72(5), 885–890. ISSN: 0022-006X.
Nock, M. K., & Prinstein, M. J. (2005). Contextual features and
behavioral functions of self-mutilation among adolescents.
Journal of Abnormal Psychology, 114(1), 140–146. https://doi.
Panksepp, J. (2010). Affective neuroscience of the emotional Brain-
Mind: Evolutionary perspectives and implications for under-
standing depression. Dialogues in Clinical Neuroscience, 12(4),
533–545. ISSN: 1294–8322.
*Parfitt, A. (2005). On aggression turned against the self. Psy-
choanalytic Psychotherapy, 19, 160–173. https://doi.
*Privé, A. A. (2007). An existential-phenomenological investigation
of self-cutting among adolescent girls (Doctoral Dissertation).
Available from ProQuest Dissertations Publishing (UMI No.
*Rissanen, M.-L., Kylmä, J., & Laukkanen, E. (2008). Descriptions
of self-mutilation among Finnish adolescents: A qualitative
descriptive inquiry. Issues in Mental Health Nursing, 29(2), 145–
Siegel, D. J. (2015). Brainstorm: The power and purpose of the teenage
brain. New York: Jeremy P. Tarcher/Penguin.
Soyemoto, K. L. (1998). The functions of self-mutilation. Clinical
Psychology Review, 18(5), 531–554.
Straker, G. (2006). Signing with a scar: Understanding self-harm. Psy-
choanalytic Dialogues, 16(1), 93–112.
Swannell, S. V., Martin, G. E., Page, A., Hasking, P., & John, St, N.
J (2014). Prevalence of nonsuicidal self-injury in nonclinical
samples: systematic review, meta-analysis and meta-regression.
Suicide and Life-Threatening Behavior, 44(3), 273–303. https://
Timulak, L. (2009). Meta-analysis of qualitative studies: A tool
for reviewing qualitative research findings in psychother-
apy. Psychotherapy Research, 19(4–5), 591–600. https://doi.
Walsh, D., & Downe, S. (2004). Meta-synthesis method for qualitative
research: A literature review. Journal of Advanced Nursing, 50(2),
Whitlock, J. L., & Selekman, M. (2014). Non-suicidal self-injury
(NSSI) across the lifespan. In M. Nock (Ed.), Oxford Handbook
of Suicide and Self-Injury. Oxford Library of Psychology: Oxford
World Health Organization (2004). The ICD – 10 Classification of
Mental and Behavioral Disorders. Diagnostic criteria for research.
10th ed.
*Yip., K.-S., Ngan, M.-Y., & Lam, I. (2004). Adolescent self-cutters
in Hong Kong. Asia Pacific Journal of Social Work and Develop-
ment, 14(2), 33–51.
*Marshall, H., & Yazdani, A. (1999). Locating culture in account-
ing for self-harm amongst asian young women. Journal of
Community & Applied Social Psychology, 9(6), 413–433.
doi: 10.1002/(SICI)1099-1298(199911/12)9:6<413::AID-
Articles with marked with * are included in the meta-synthesis.
... In contrast, qualitative approaches offer an in-depth and direct exploration of lived experiences (Willig, 2013), presenting a unique understanding of individual perspectives which is particularly useful when exploring sensitive issues and under-researched areas (Roche, 1991). Qualitative research has provided a greater level of understanding into why adolescents SH, including the importance of developmental and environmental factors such as separation, independence, and forming of an identity (Stänicke, Haavind, & Gullestad, 2018). Resultingly, suggestions to explore SH in specific time points and contexts may allow for a greater understanding of important phenomena that contribute to SH behaviours. ...
The present study aimed to advance the literature with a qualitative exploration of self-harm amongst UK university students, providing novel insight into support provisions and help-seeking, as well as key triggers and maintenance factors of self-harm within a university context. Sixteen semi-structured interviews (81% female) were carried out with individuals who had engaged in self-harm during their time at university and were analysed using inductive thematic analysis. Three overarching themes were identified: 1) Understanding Self-Harm; 2) A New Identity – The impact of University on Self-Harm; and 3) Professional Help-Seeking at University – “A vague and confusing process”. Participants shared that whilst the function of self-harm as a means of coping remained relatively consistent, academic and social stressors were influential in either maintaining or reducing engagement in self-harm during university. Increased understanding of self-harm amongst university personnel and peers has the potential to encourage disclosure and reduce stigma. These findings have important implications for universities and their support services, specifically in relation to advertisement and awareness of services during university transitions, and the ways in which support is offered and delivered for students who self-harm. Greater recognition of views and definitions of self-harm from the perspective of those with lived experience is needed. This study highlights that the presence of university support services is not enough and that key factors including session numbers, referral pathways, and communication from services are crucial in determining a positive or negative experience of help-seeking amongst university students who self-harm.
... In this way, the present study highlights how digital involvement can be closely related to an exploration of self for the adolescent. Interestingly, knowledge of adolescents' reasons for self-harm underline how this behaviour may be an attempt to get relief and control as well as an attempt to express or share overwhelming feelings (Stänicke et al., 2018). By using the body in a concrete and harmful way, the young person may transform overwhelming inner suffering to a physical pain and, at the same time, express and represent conflictual, unknown feelings and vulnerability (Stänicke, 2021). ...
Full-text available
This article aims to explore how young adults (18–23) who have a history of self‐harm experienced involvement in self‐harm content online during adolescence. The qualitative data analysis follows the steps of Interpretative phenomenological analysis and resulted in four meta‐themes: (1) ‘Solitude during adolescence—finally found a place to fit in’, (2) ‘Tempting but dangerous—a game that never should end’, (3) ‘Searching for self—it was like an online diary’ and (4) ‘No one in charge’. Each superordinate theme characterizes essential features of subjective reasons for becoming involved in and their way out of self‐harm content online. Digital involvement is discussed in light of developmental challenges during adolescence—such as exploration of borders, autonomy and self‐identity formation. For lonely people, online involvement with self‐harm content may enable ‘a potential space’ in between reality and fiction sufficient for relational and personal exploration. Involvement in self‐harm content online may cover a need to belong, to express and share problems, and for support. This knowledge should inform clinicians to ask patients about involvement in risk content online and motivate decision‐makers to develop ways to detect and support vulnerable adolescents online and offline.
... Viewed with hindsight, self-harm had become part of their story. These reflections appear to chime with the idea that self-harm may coincide with developmental challenges in adolescence that begin to resolve in adulthood (33). Other qualitative accounts have similarly highlighted the way people make sense of self-harm as a formative experience within their personal narrative (34,35). ...
Full-text available
Engagement in self-harm, defined as intentional self-poisoning or self-injury irrespective of the apparent purpose of the act, is increasing, particularly among girls and young women. Understanding the behavior from the perspective of those who self-harm is, therefore, vital in designing effective interventions and treatments. The current brief research report presents a key theme from an Interpretative Phenomenological Analysis of the experience of self-harm among eight young women, aged between 18 and 29. The theme Is Self-Harm Bad? concerns the way in which participants both acknowledged and resisted a negative conception of self-harm that was often constructed from other people's attitudes. Three subthemes explore the reasons why participants were reluctant to endorse self-harm as bad: Self-Harm is the Symptom, Self-Harm Works (Until it Doesn't) and Self-Harm is Part of Me. The findings highlight the disparity between the characterization of self-harm as a highly risky behavior and the lived experience of self-harm as a functional means of emotion regulation. From a clinical perspective, the findings explored in this brief report suggest that highlighting the risks of self-harm may not be a sufficient deterrent. The recently revised draft National Institute for Health and Care Excellence (NICE) guidance recommends that everyone presenting to hospital following self-harm should be given a comprehensive psychosocial assessment, of which the function is, in part, to understand why the person has self-harmed. The current study underlines the importance of seeing past the behavior to the underlying causes and exploring the meaning of self-harm to the individual in order to implement effective preventative interventions.
... According to some, suicide can be an extreme consequence of the experience of love addiction (Fisher, 2014) or result from the traumatic ending of a significant love relationship (Crepet, 1993;Guerreschi, 2011). Self-harm -which can be defined as compulsively or impulsively hurting oneself, or inflicting wounds on one's own body, in order to cope with psychological distress or to regain a sense of emotional balance (McHale & Felton, 2010) -may also be, in some cases, identified as a dysfunctional coping strategy in face of relational issues (Nock & Kessler, 2006;Stänicke, Haavind, & Gullestad, 2018) and it is among the most significant predictors of future suicidal attempts (Carroll, Metcalfe, & Gunnell, 2014;Cavanagh, Carson, Sharpe, & Lawrie, 2003;Hawton, Saunders, & O'Connor, 2012;Klonsky, May, & Glenn, 2013). ...
Love addiction is a debated concept, generally considered as an addiction toward an object of love and can lead to deeply negative consequences, among which are self-harm and suicidal ideation. Our study aims to provide empirical evidences about love addiction etiology and characteristics, and to analyze its relation to suicidality. Our result confirmed the phenomenological depiction of love addiction that so far has mainly been hypothesized in literature, also providing a deeper understanding of its characteristics. An association with suicidal and parasuicidal behaviors has been observed, highlighting the dramatic consequences love addiction can have and the importance of preventing them.
... Qualitative research may therefore provide a better understanding of the individual experiences and processing of shame (e.g., Chapple et al., 2004;Rørtveit et al., 2010). While research (e.g., Harris, 2000;Stänicke & Haavind, 2018) suggests the potential importance of shame for people who self-injure, we are not aware of studies that have focused specifically on the experience of this emotion within the context of self-injury. ...
Full-text available
Background: Shame can be a powerfully aversive emotion that is associated with a wide variety of mental health difficulties including non-suicidal self-injury (NSSI). This study used a novel mixed-methods design (Qualitative Experiential Sequence Tracking; QUEST) to investigate the experiences of shame in a sample of individuals who self-injure. Methods: Six participants received prompts to complete brief online diaries three times per day over a period of 2 weeks. These diaries captured information about the experience of negative emotions, especially shame. Participants then underwent an individualised qualitative interview about their experiences over the previous 2 weeks. Results: Thematic analysis suggested that participants experienced shame as a social and relational emotion. Further themes included shame being associated with feelings of failure, being trapped, dangerous or contaminated, and hidden or exposed. The phenomenology of shame, and coping with shame, were also themes. NSSI could occur as a response to shame, but often shame was triggered or exacerbated by the responses of others to NSSI. Conclusions: Consistent with previous research, shame was described as an aversive emotion occurring within interpersonal and broader societal contexts and involving a negative self-focus. A lack of compassion or understanding in response to NSSI, or anticipation of negative responses from others often triggered more intense shame than the NSSI itself. Future studies could use QUEST methodology with more diverse samples or different populations to further investigate experiences of shame.
... The function of self-harm as a means of emotional release and a way of expressing feelings and difficulties in interpersonal relationships has been found in previous research (e.g., Stanicke et al., 2018). Self-harm in adolescence may be underpinned by difficulties in parent-child communication (e.g., Tulloch et al, 1997) which, it is possible gets replayed in peer relationships and managed through self-harm. ...
Full-text available
Background Self-harm is a significant public health concern during adolescence. Most cases of self-harm do not come to the attention of professional services, however, where adolescents do disclose self-harm, the majority confide in their friends. Objective Therefore, more needs to be understood about the protective function and risks friends may pose in the context of self-harm and personal implications of this behaviour. This review synthesises current research in this area. Methods A systematic search of five healthcare databases was conducted, yielding nine papers, comprising of ten studies. Most studies recruited participants from schools. Papers were appraised using three quality appraisal tools relevant to study designs. Results The synthesis found that friends act as first-line support for adolescents who self-harm, demonstrating emotional and physical availability and acting as a vehicle for terminating this behaviour and disclosure to adults. However, supporting friends who self-harm can be all-consuming, negative peer dynamics may perpetuate self-harm and group and personal vulnerability factors may increase risk of friends engaging in self-harm themselves. Conclusions: There are some indications that adolescents who self-harm may self-select friendship groups in which this behaviour is known to occur. The synthesis suggests adolescents need to be empowered to support peers who self-harm through mental health promotion and awareness-raising training at universal levels (e.g., whole school approaches). Leads for mental health in schools may also be important contact points for adolescents to disclose concerns to and seek personal support. Further practice and research implications are considered.
... Self-harm is a maladaptive behaviour that often serves several intrapersonal and interpersonal functions for adolescents [4]. A meta-synthesis of twenty qualitative studies which focused on the experience of self-harm for young people identified four primary functions of self-harm [5]. This included self-harm as a way to feel relief from intolerable emotions and to experience a feeling of being alive, to control difficult emotions and experiences, to express difficult feelings and protect others from anger, and to identify and connect with others. ...
Full-text available
Adolescent self-harm is a significant public health issue. We aimed to understand how parent stress response styles to their child’s self-harm affects their wellbeing and functioning and the wider family. Thirty-seven participants in Australia (parents; 92% female) completed a mixed methods survey regarding their adolescent child’s self-harm. We conducted Pearson zero-order correlations and independent t-tests to examine the impact of parent response style on their quality of life, health satisfaction, daily functioning, and mental health. We also used thematic analysis to identify patterns of meaning in the data. Two-thirds of participants reported mental ill health and reduced functional capacity due to their adolescent’s self-harm. Parents with a more adaptive response style to stress had better mental health. Qualitative analyses revealed parents experienced sustained feelings of distress and fear, which resulted in behavioural reactions including hypervigilance and parental mental health symptoms. In the wider family there was a change in dynamics and parents reported both functional and social impacts. There is a need to develop psychological support for the adolescent affected and parents, to support more adaptive response styles, and decrease the negative effects and facilitate the wellbeing of the family unit.
... Compounding these difficult emotions, the public health responses to the pandemic (e.g., social distancing, school closures, stay-at-home orders) prevented many adolescents from engaging in their typical ER strategies, such as seeking support from peers, maintaining a consistent routine, exercising, and spending time outdoors (Demkowicz et al., 2020;Dunton et al., 2020;Lee, 2020). In such circumstances, adolescents may be particularly drawn to DSH because it provides a clear and controllable way of expressing their emotions and regaining a sense of agency or predictability (see Stänicke et al., 2018, for a review). Given the possibility of another pandemic in the future, it will be important to develop or increase access to interventions that bolster adaptive ER skills among youth. ...
Full-text available
The objective of this study was to conduct an ecologically valid test of etiological models of deliberate self-harm (DSH) during the COVID-19 pandemic. Using a sample of Canadian adolescents, we investigated: (1) the association between COVID-19-related stress and DSH; (2) whether emotion regulation (ER) difficulties mediated/moderated this association, including whether these effects differed by age; and (3) whether the mediating/moderating effects of ER difficulties were stronger among socially distanced youth. Canadian adolescents (N = 809) aged 12-18 were recruited on social media and completed an online survey. COVID-19-related stress was associated with recent DSH. Nonacceptance of emotional responses and limited access to ER strategies fully mediated this association. The indirect effect through nonacceptance of emotional responses was stronger among more socially distanced youth, whereas the indirect effect through limited access to ER strategies was stronger among older and more socially distanced youth. COVID-19-related stress and ER difficulties did not interact to predict DSH, nor did age or social distancing moderate these interactions. These results align with etiological models proposing central roles for stress and ER difficulties in DSH. Furthermore, this study underscores a need to support adolescents, particularly older teens with reduced in-person interactions, in adaptively coping with pandemic-related stress.
Full-text available
Self-harm is a major problem among young adults, and many do not seek help from health care services. Little is known about how patients who harm themselves experience positive encounters with health care workers. Blogs are a way of communicating personal experiences to a broader public and may provide an immediate expression of such experiences. We conducted a thematic analysis of blog entries written by ten patients who carry out self-harm, in order to answer the question: How do young adults who blog about their self-harming describe positive encounters with health care workers? The analysis revealed four meta-themes: 1) I feel cared for, 2) I am treated like a fellow human, 3) I can talk about everything, and 4) I feel that the helper takes charge. Emotion regulation skills emerged as the most valued specific therapeutic ingredient. These findings are relevant for making young adults who self-harm feel understood and cared for.
Full-text available
Background Self-harm is defined as intentional self-injury without the wish to die. People who self-harm report feeling poorly treated by healthcare professionals, and nurses wish to know how best to respond to and care for them. Increased understanding of the meaning of self-harm can help nurses collaborate with young people who self-harm to achieve positive healthcare outcomes for them. Aim This review aimed to synthesise qualitative research on young peoples’ experiences of living with self-harm. Method A literature search in CINAHL, PubMed, and PsycINFO resulted in the inclusion of 10 qualitative articles that were subjected to metasynthesis. Results The results show that young people’s experiences of living with self-harm are multifaceted and felt to be a necessary pain. They used self-harm to make life manageable, reporting it provided relief, security, and a way to control overwhelming feelings. They suffered from feeling addicted to self-harm and from shame, guilt, and self-punishment. They felt alienated, lonely, and judged by people around them, from whom they tried to hide their real feelings. Instead of words, they used their wounds and scars as a cry for help. Conclusion Young people who harm themselves view self-harm as a necessary pain; they suffer, but rarely get the help they need. Further research is necessary to learn how to offer these people the help they need.
Full-text available
Cancer is not just one disease, but a large group of almost 100 diseases. Its two main characteristics are uncontrolled growth of the cells in the human body and the ability of these cells to migrate from the original site and spread to distant sites. If the dispersion is not controlled, cancer can outcome in death. One out of every four deaths in the United States (US) is from cancer. It is second only to heart disease as a cause of death in the US. About 1.2 million Americans are diagnosed with cancer per annum; apart from 500,000 die of cancer every year.Palliative care is a well-established approach to maintaining quality of life in end-stage cancer patients. Palliative care nurses have to complete basic diploma/degree/post-graduation in nursing with special training/experience in palliative care. Palliative care nurses often work in collaboration with doctors, allied health professionals, social workers, physiotherapists, and other multidisciplinary clinical care. There is a unique body of knowledge with direct application to the practice of palliative care nursing. This includes pain and symptom management, end-stage disease processes, spiritual and culturally sensitive care of patients and their families, interdisciplinary collaborative practice, loss and grief issues, patient education and advocacy, ethical and legal considerations, and communication skills, etc. The Need for the Palliative Care Nurse is a model that is persistent with basic nursing values, which combines caring for patients and their families behindhand of their culture, age, socioeconomic status, or diagnoses, and engaging in caring relationships that transcend time, circumstances, and location.
Full-text available
Objectives To examine temporal trends in sex and age specific incidence of self harm in children and adolescents, clinical management patterns, and risk of cause specific mortality following an index self harm episode at a young age. Design Population based cohort study. Setting UK Clinical Practice Research Datalink—electronic health records from 647 general practices, with practice level deprivation measured ecologically using the index of multiple deprivation. Patients from eligible English practices were linked to hospital episode statistics (HES) and Office for National Statistics (ONS) mortality records. Participants For the descriptive analytical phases we examined data pertaining to 16 912 patients aged 10-19 who harmed themselves during 2001-14. For analysis of cause specific mortality following self harm, 8638 patients eligible for HES and ONS linkage were matched by age, sex, and general practice with up to 20 unaffected children and adolescents (n=170 274). Main outcome measures In the first phase, temporal trends in sex and age specific annual incidence were examined. In the second phase, clinical management was assessed according to the likelihood of referral to mental health services and psychotropic drug prescribing. In the third phase, relative risks of all cause mortality, unnatural death (including suicide and accidental death), and fatal acute alcohol or drug poisoning were estimated as hazard ratios derived from stratified Cox proportional hazards models for the self harm cohort versus the matched unaffected comparison cohort. Results The annual incidence of self harm was observed to increase in girls (37.4 per 10 000) compared with boys (12.3 per 10 000), and a sharp 68% increase occurred among girls aged 13-16, from 45.9 per 10 000 in 2011 to 77.0 per 10 000 in 2014. Referrals within 12 months of the index self harm episode were 23% less likely for young patients registered at the most socially deprived practices, even though incidences were considerably higher in these localities. Children and adolescents who harmed themselves were approximately nine times more likely to die unnaturally during follow-up, with especially noticeable increases in risks of suicide (deprivation adjusted hazard ratio 17.5, 95% confidence interval 7.6 to 40.5) and fatal acute alcohol or drug poisoning (34.3, 10.2 to 115.7). Conclusions Gaining a better understanding of the mechanisms responsible for the recent apparent increase in the incidence of self harm among early-mid teenage girls, and coordinated initiatives to tackle health inequalities in the provision of services to distressed children and adolescents, represent urgent priorities for multiple public agencies.
Full-text available
Background: A growing body of research has explored altered physical pain threshold and tolerance in non-suicidal self-injury (NSSI) and suicidal self-harm. The evidence, however, is inconsistent such that the nature of the relationship is unclear, and whether or not this effect is also present in suicidal self-harm is equivocal. Methods: A keyword search of three major psychological and medical databases (PsycINFO, Medline and Web of Knowledge) was conducted, yielding 1873 records. Following duplicate removal and screening, 25 articles were quality assessed, and included in the final systematic review. Results: There is strong evidence for increased pain tolerance in NSSI, and some evidence for this in suicidal individuals, but notably, there were no prospective studies. The review found a lack of substantive focus on psychological correlates of altered pain tolerance in this population. Several candidate explanatory mechanisms were proposed within the reviewed studies. Limitations: The current review was a narrative systematic review; methods used to assess pain were considered too heterogeneous to conduct a meta-analysis. Conclusions: The evidence suggests that there is elevated pain tolerance among those who engage in NSSI. Future prospective research should determine if altered pain tolerance is a cause or a consequence of the behaviour. The identification of psychological correlates of increased pain tolerance is a neglected area of research. It could provide opportunities for treatment/intervention development, if mediating or moderating pathways can be identified. Too few studies have directly investigated candidate explanatory mechanisms to draw definitive conclusions.
Full-text available
Background Evidence reports that schools influence children and young people’s health behaviours across a range of outcomes. However there remains limited understanding of the mechanisms through which institutional features may structure self-harm and suicide. This paper reports on a systematic review and meta-ethnography of qualitative research exploring how schools influence self-harm and suicide in students. Methods Systematic searches were conducted of nineteen databases from inception to June 2015. English language, primary research studies, utilising any qualitative research design to report on the influence of primary or secondary educational settings (or international equivalents) on children and young people’s self-harm and suicide were included. Two reviewers independently appraised studies against the inclusion criteria, assessed quality, and abstracted data. Data synthesis was conducted in adherence with Noblit and Hare’s meta-ethnographic approach. Of 6744 unique articles identified, six articles reporting on five studies were included in the meta-ethnography. Results Five meta-themes emerged from the studies. First, self-harm is often rendered invisible within educational settings, meaning it is not prioritised within the curriculum despite students’ expressed need. Second, where self-harm transgresses institutional rules it may be treated as ‘bad behaviour’, meaning adequate support is denied. Third, schools’ informal management strategy of escalating incidents of self-harm to external ‘experts’ serves to contribute to non-help seeking behaviour amongst students who desire confidential support from teachers. Fourth, anxiety and stress associated with school performance may escalate self-harm and suicide. Fifth, bullying within the school context can contribute to self-harm, whilst some young people may engage in these practices as initiation into a social group. Conclusions Schools may influence children and young people’s self-harm, although evidence of their impact on suicide remains limited. Prevention and intervention needs to acknowledge and accommodate these institutional-level factors. Studies included in this review are limited by their lack of conceptual richness, restricting the process of interpretative synthesis. Further qualitative research should focus on the continued development of theoretical and empirical insight into the relationship between institutional features and students’ self-harm and suicide.
Full-text available
Many therapists who treat adolescents encounter patients who frequently hurt themselves. Although this generates concern and anger in those around them, these teenagers often appear to be quite indifferent to the consequences of their maladaptive behaviors. This article introduces Noshpitz’s theory of self-destructive behavior and its relationship to trauma. Noshpitz emphasizes the need to define the influence of what he terms the “negative ego ideal” on self-destructive behavior in adolescents. He claims that the negative ego ideal and trauma work together to strengthen self-destructive behavior. He identifies numerous similarities between the torturous thoughts that occur after being exposed to a traumatic event, and the torturous thoughts that derive from the negative ideal. Thus, the traumatic encounter undergoes a new interpretation within the superego when it is interpreted by the negative ideal ego. Noshpitz’s emphasis on the negative ideal ego can shed light on many manifestations of self-destructive behaviors, and can contribute to work with adolescents and young adults who have lived through some type of traumatization. Two vignettes are presented that illustrate these tenets, including the transference-countertransference dynamics involved.
The purpose of this study was to explore the meanings that self-mutilating behaviors have to adolescents. Phenomenological interviews of six students resulted in the development of seven core themes. The data provided valuable insight into the world of self-mutilation at its beginning stages. Implications for school counselors are discussed.
This article argues that psychotherapy practitioners and researchers should be informed by the substantive body of qualitative evidence that has been gathered to represent clients' own experiences of therapy. The current meta-analysis examined qualitative research studies analyzing clients' experiences within adult individual psychotherapy that appeared in English-language journals. This omnibus review integrates research from across psychotherapy approaches and qualitative methods, focusing on the cross-cutting question of how clients experience therapy. It utilized an innovative method in which 67 studies were subjected to a grounded theory meta-analysis in order to develop a hierarchy of data and then 42 additional studies were added into this hierarchy using a content meta-analytic method-summing to 109 studies in total. Findings highlight the critical psychotherapy experiences for clients, based upon robust findings across these research studies. Process-focused principles for practice are generated that can enrich therapists' understanding of their clients in key clinical decision-making moments. Based upon these findings, an agenda is suggested in which research is directed toward heightening therapists' understanding of clients and recognizing them as agents of change within sessions, supporting the client as self-healer paradigm. This research aims to improve therapists' sensitivity to clients' experiences and thus can expand therapists' attunement and intentionality in shaping interventions in accordance with whichever theoretical orientation is in use. The article advocates for the full integration of the qualitative literature in psychotherapy research in which variables are conceptualized in reference to an understanding of clients' experiences in sessions. (PsycINFO Database Record
Cutting, burning, branding, and bone-breaking are all types of self-injury, or the deliberate, non-suicidal destruction of ones own body tissue, a practice that emerged from obscurity in the 1990s and spread dramatically as a typical behavior among adolescents. Long considered a suicidal gesture, The Tender Cut argues instead that self-injury is often a coping mechanism, a form of teenage angst, an expression of group membership, and a type of rebellion, converting unbearable emotional pain into manageable physical pain. Based on the largest, qualitative, non-clinical population of self-injurers ever gathered, noted ethnographers Patricia and Peter Adler draw on 150 interviews with self-injurers from all over the world, along with 30,000-40,000 internet posts in chat rooms and communiqués. Their 10-year longitudinal research follows the practice of self-injury from its early days when people engaged in it alone and did not know others, to the present, where a subculture has formed via cyberspace that shares similar norms, values, lore, vocabulary, and interests. An important portrait of a troubling behavior, The Tender Cut illuminates the meaning of self-injury in the 21st century, its effects on current and former users, and its future as a practice for self-discovery or a cry for help.