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A qualitative exploration of student self-harm and experiences of support-seeking within a UK university setting
Counselling Psychology Quarterly
Abstract
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.
... This increases demand on university counselling and welfare services, as well as academic staff, to offer well-being support (Hughes et al, 2018;Hughes and Byrom, 2019;Hubble and Bolton, 2020). In addition, many university students and family members are providing 'informal'/unpaid support and care for their friends and loved ones (referred to as 'carers' in the current article [Yeandle et al, 2017]), highlighting the uniqueness of caregiving in a university setting (Laws and Fiedler, 2012;Byrom, 2019;Hazell et al, 2021;Edwards-Bailey et al, 2022). In 2013, the Carers Trust conducted research specifically focusing on the experiences of young adult carers attending a UK college or university (N = 101) (Sempik and Becker, 2014). ...
... Studies exploring student experiences of seeking professional support at university, including counselling and well-being services, have highlighted key gaps and limitations in existing provisions (for example, the availability and quality of care) (Baik et al, 2019). Resultingly, students engaging in SH often receive support from multiple sources, including friends, family and other students (Edwards-Bailey et al, 2022). This may present a unique group of 'non-identified potential carers', a term suggested in the literature to describe individuals aged 15-24 who share a household with an individual who may need support with their self-care, communication and well-being (Hill et al, 2009). ...
... Semi-structured interviews allow for an in-depth exploration of individual experiences while ensuring researchers can maintain focus on the aims of the research (Low, 2013). The interview guide was developed through consideration of previous findings specific to SH (see, for example, Wadman et al, 2018;Edwards-Bailey et al, 2022) and team discussions, with gaps in the existing literature on carers -for example, the influence of compassion (Schulz et al, 2007) -used to tailor the interview schedule. Given limited understanding of university caring roles, initial questions were designed to explore what the role meant and what this involved for the individual (see Table 2). ...
University provides a unique context for carers and care workers; however, there is a paucity of research aimed at understanding experiences of caring, specifically for self-harm, within this setting. This article reports on 24 interviews with informal carers and professional care workers (aged 18–55 years) with experience of supporting students who self-harm during their time at a UK University. Identifying with the role of care, understanding self-harm and the challenges of providing support in a university environment were explored. Findings highlight key areas for universities and student support to address in order to support students, family members and professionals in caring roles.
... These include a wish to continue self-injuring, feelings of embarrassment and shame, fear of stigmatisation and concern about burdening others. 11,12 Challenges specific to formal support are also reported, such as long waiting times, difficulties in accessing services, understaffed facilities, a lack of tailored and cooperative care and perceptions of self-harm not being serious enough. [11][12][13][14] Rationale for the current study ...
... 11,12 Challenges specific to formal support are also reported, such as long waiting times, difficulties in accessing services, understaffed facilities, a lack of tailored and cooperative care and perceptions of self-harm not being serious enough. [11][12][13][14] Rationale for the current study ...
Background
Self-harm is a significant problem in university students because of its association with emotional distress, physical harm, broader mental health issues and potential suicidality. Research suggests that fewer than half of students who have self-harmed seek professional help when at university.
AimsThis study aimed to explore the help-seeking journeys of university students who had engaged in self-harm, to identify perceived facilitators and barriers to securing both formal and informal support.
Method
Participants comprised 12 students who had self-harmed during their university tenure. Engaging in two semi-structured interviews over the academic year, they shared insights into their help-seeking behaviours and proposed enhancements to local services. Data underwent reflexive thematic analysis within a critical realist framework.
ResultsThe analysis identified four themes: ‘The initial university phase poses the greatest challenge’, ‘Perceived criteria for “valid” mental health problems’, ‘Evading external judgements, concerns and consequences’ and ‘The pivotal role of treatment options and flexibility in recovery’.
Conclusions
Students felt isolated and misunderstood, which amplified self-harming tendencies and diminished inclinations for help-seeking. A prevalent belief was that for self-harm to be deemed ‘valid’, it must manifest with a certain severity; however, concurrent fears existed around the ramifications of perceived excessive severity. Participants expressed a desire for streamlined pathways to mental health resources, encompassing both university and external mental health services. Insights from this study could guide future research and inform current service paradigms within academic and healthcare systems.
... Meskipun begitu, riset terkait topik NSSI masih minim terutama dikaitkan dengan help-seeking behavior. Riset terhadap perilaku mencari bantuan pada individu dengan NSSI sebagian besar diteliti pada sampel remaja di negara Barat (Bond et al., 2023;Edwards-Bailey et al., 2023;Ghinea et al., 2020;Lustig et al., 2021). Riset terdahulu ini hanya mampu menggali fenomena tersebut dalam konteks tertentu saja. ...
Nonsuicidal self-injury (NSSI) is a common mental health issue found among young adults. This study explored the experiences of help-seeking among Indonesian young adults with NSSI, as well as the supporting and inhibiting factors in the process. The approach used in this study is qualitative with a phenomenological research design. NSSI assessments, semi-structured interviews, and photo elicitation techniques were conducted on three participants through purposive sampling with the criteria being aged 18-24 who were indicated to have previously engaged in NSSI. The results of the interpretative phenomenological analysis revealed two themes in the participants’ help-seeking experiences: experiences that initiate seeking help and personal and professional support. Factors influencing help-seeking behavior were also identified, including perceptions of NSSI, perceptions of helpers and received support, public stigma, and social construction. The implications of this research focus on mental health education and the development of mental health service options in addressing negative stigmas and issues related to NSSI.Nonsuicidal self-injury (NSSI) merupakan isu kesehatan mental yang umum ditemui pada dewasa muda. Penelitian ini mengeksplorasi pengalaman mencari bantuan pada dewasa muda di Indonesia dengan NSSI, serta faktor pendukung dan penghambat dalam prosesnya. Pendekatan penelitian ini adalah kualitatif dengan desain penelitian fenomenologi. Dilakukan asesmen NSSI, wawancara semi terstruktur dan teknik photo elicitation pada tiga partisipan melalui purposive sampling dengan kriteria usia 18-24 tahun dan terindikasi pernah melakukan NSSI. Hasil interpretative phenomenological analysis menemukan dua tema dalam pengalaman partisipan mencari bantuan, yaitu: pengalaman yang menginisiasi mencari bantuan dan bantuan personal dan profesional. Ditemukan juga faktor yang memengaruhi perilaku mencari bantuan, berupa: persepsi terhadap NSSI, persepsi terhadap helper dan bantuan yang diterima, stigma publik, dan konstruksi sosial. Implikasi penelitian berfokus pada edukasi kesehatan mental serta pengembangan opsi layanan kesehatan mental dalam menghadapi isu dan stigma negatif terhadap NSSI.
Young people are suffering increased psychological disturbances that deteriorate and threaten their integrity. Harming self is one significant factor to emphasize. The purpose of this study was to assess the psychological predictors of deliberate self-harm controlling for socio-demographic and life style factors among university students in Jordan. A cross-sectional, correctional design was used to collect data from 374 university students in Jordan. Self-reported format was used to collect data. The majority of students (> 60%) thought of harming self, almost one-third had moderate to severe depression, 50% suffering moderate to high level of anxiety, and 67% (n = 251) of them have a likelihood to have social anxiety. Using six-step multiple hierarchical regression analysis, social anxiety (social phobia) was the only significant predictor of deliberate self-harm (Beta = .311, p < .001), while depression and anxiety were associated weakly and not found to be significant predictors (p >.05). No differences found in deliberate self-harm in relation to socio-demographic and life style factors except for alcohol use. University students are psychologically overwhelmed, and self-harm leading to threat of life was observed. Academics, administrators, and mental health professionals are sharing responsibilities towards maintaining mental wellbeing of university students and minimize deliberate self-harm.
Background
People use healthy and unhealthy coping strategies to reduce distress. Understanding the relationship between healthy and unhealthy coping strategies and overwhelming distress is essential to inform formulation and intervention. This study explored the interdependencies between healthy and unhealthy coping strategies using Bayesian network (BN) modelling, a robust risk assessment tool.
Methods
509 college students (Mean age = –22.9 years; 66% Female) completed a web-based survey of psychological distress, mental illness, and coping in 2018–19. BN models were used to explore the interplay of healthy and unhealthy coping strategies driven by psychological distress (at extremely low, moderate, or extremely high levels).
Result
At extremely low distress, self-soothing and social support were the most likely coping strategies used. At moderate levels, there was an increased likelihood of using professional support, as well as the increasing use of all unhealthy coping groups of strategies. At extremely high levels of distress, all unhealthy coping strategies were used frequently, including suicidality; however, healthy coping strategies were also used often.
Conclusions
These findings support a coping continuum model, from low intensity or low harm to high intensity and high harm, with a high degree of accuracy. Importantly, it shows that overwhelming distress does not necessarily occur in the absence of healthy coping strategies. Furthermore, unhealthy coping strategies are increasingly adopted when healthy strategies are inadequate or unavailable. These findings raise important implications for healthcare targets for people in distress.
A meta-analysis was conducted to examine the relative rates of youth mental health service utilization across settings among the general population and among those with elevated mental health symptoms or clinical diagnoses. Rates of school-based mental health were compared to outpatient, primary care, child welfare, juvenile justice, and inpatient. Nine studies presented rates of mental health service use for general-population youth in the U.S., and 14 studies presented rates for youth with elevated symptoms or clinical diagnoses. Random effects meta-analysis was used to calculate mean proportions of youth receiving care in each sector. Of general population youth, 7.28% received school mental health services. Rates for other sectors are as follows: 7.26% in outpatient settings, 1.76% in primary care, 1.80% in inpatient, 1.35% in child welfare, and 0.90% juvenile justice. For youth with elevated mental health symptoms or diagnoses, 22.10% of youth were served by school-based mental health services, 20.56% outpatient settings, 9.93% primary care, 9.05% inpatient, 7.90% child welfare, and 4.50% juvenile justice. Schools and outpatient settings are the most common loci of mental health care for both the general population and samples of youth with elevated symptoms or clinical diagnoses, although substantial amounts of care are also provided in a range of other settings. Results hold potential for informing resource allocation, legislation and policy, intervention development, and research. Given that mental health services are delivered across many settings, findings also point to the need for interconnection across child-serving sectors, particularly schools and outpatient clinics.
There are concerns about high levels of mental ill-health amongst university students, but little is known about the mental health of students compared to non-students over time. Using data on young people (16–24) from three UK National Psychiatric Morbidity Surveys (2000, 2007, and 2014), we found no evidence that the overall prevalence of common mental disorder (CMD), suicide attempts, or non-suicidal self-harm (NSSH) differed between students and non-students, although there was an indication that CMDs rose markedly in female students between 2007 and 2014. A rise in NSSH is apparent in both students and non-students.
Objective:
This study evaluated a brief psychological intervention aimed at improving distress tolerance and decreasing future admissions for individuals presenting to a mental health service in the context of crisis or self-harm.
Methods:
Eighty-five participants completed The Crisis Intervention Package at the point of contact with the mental health service. The outcome of the intervention was evaluated through pre- and post-scores on the Distress Tolerance Scale and future hospital admissions.
Results:
Participants showed a significant improvement in Distress Tolerance Scale scores ( P < 0.001) indicating an increase in ability to tolerate distressing emotions. Additionally, there was a significant decrease in hospital admissions 6 months pre-test to 6 months post-test.
Conclusions:
The results demonstrate the potential effectiveness of structured, brief interventions aimed at increasing distress tolerance and self-management skills for individuals presenting to a mental health service in crisis.
Background
Suicide attempts and non-suicidal self-harm (NSSH) are major public health concerns that affect millions of young people worldwide. Consequently, there is a strong need for up-to-date epidemiological data in this population.
Aims
To provide prevalence and trend estimates of suicidal thoughts and behaviours and NSSH thoughts and behaviour in university students.
Method
Data are from a 2018 national health survey for higher education in Norway. A total of 50 054 full-time students (69.1% women) aged 18–35 years participated (response rate 31%). Suicidal ideation, suicide attempts and NSSH were assessed with three items drawn from the Adult Psychiatric Morbidity Survey, and thoughts of NSSH were assessed with one item from the Child and Adolescent Self-Harm in Europe study.
Results
Lifetime suicidal thoughts were reported by 21.0%, and 7.2% reported having such thoughts within the past year. In total, 4.2% reported a suicide attempt, of whom 0.4% reported attempting suicide within the past year. The prevalence of lifetime NSSH behaviour and thoughts was 19.6% and 22.6%, respectively. All four suicidal behaviour and NSSH variables were more common among students who were single, living alone and with a low annual income, as well as among immigrants. There was an increase in suicidal thoughts from 2010 (7.7%) to 2018 (11.4%), which was evident in both men and women.
Conclusions
The observed high and increasing prevalence of suicidal thoughts and NSSH among college and university students is alarming, underscoring the need for further research, preferably registry-linked studies, to confirm whether the reported prevalence is representative of the student population as a whole.
Declaration of interest
None.
Background
There is evidence that several intervention types, including psychotherapy, reduce repeat suicide attempts. However, these interventions are less applicable to the heterogeneous patients admitted to emergency departments (EDs). The risk of a repeat suicide attempt is especially high in the first 6 months after the initial attempt. Therefore, it is particularly important to develop effective ED interventions to prevent repeat suicide attempts during this 6-month period.
Methods
We systematically reviewed randomized controlled trials of ED-initiated interventions for suicidal patients admitted to EDs using the databases MEDLINE, PsychoINFO, CINAHL, and EMBASE up to January 2015 in accordance with an a priori published protocol (PROSPERO: CRD42013005463). Interventions were categorized into four types, including active contact and follow-up interventions (intensive care plus outreach, brief interventions and contact, letter/postcard, telephone, and composite of letter/postcard and telephone), and a meta-analysis was conducted to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of a repeat suicide attempt within 6 months.
Results
Of the 28 selected trials, 14 were active contact and follow-up interventions. Two of these trials (n = 984) reported results at 6 months (pooled RR = 0.48; 95% CI: 0.31 to 0.76). There were not enough trials of other interventions to perform meta-analysis. Some trials included in the meta-analysis were judged as showing risk of bias.
Conclusion
Active contact and follow-up interventions are recommended for suicidal patients admitted to an ED to prevent repeat suicide attempts during the highest-risk period of 6 months.
Systematic review registration
PROSPERO CRD42013005463 (27 August 2013).
Electronic supplementary material
The online version of this article (10.1186/s12888-019-2017-7) contains supplementary material, which is available to authorized users.
Background
Adolescent self‐harm is a major public health concern. To date there is a limited evidence‐base for prevention or intervention, particularly within the school setting. To develop effective approaches, it is important to first understand the school context, including existing provision, barriers to implementation, and the acceptability of different approaches.
Methods
A convenience sample of 222 secondary schools in England and Wales were invited to participate in a survey, with a 68.9% (n = 153) response rate. One member of staff completed the survey on behalf of each school. Participants responded to questions on the existing provision of adolescent self‐harm prevention and intervention, barriers to delivery, and future needs.
Results
Adolescent self‐harm is an important concern for senior management and teachers. However, emotional health and well‐being is the primary health priority for schools. Health services, such as Child and Adolescent Mental Health Services, and on‐site counselling are the main approaches schools currently use to address adolescent self‐harm, with counselling cited as the most useful provision. Fifty‐two per cent of schools have received some staff training on adolescent self‐harm, although only 22% rated the adequacy of this training as high. Where schools do not have existing provision, respondents stated that they would like staff training, specialist student training, external speakers, posters and assemblies, although the latter four options were infrequently ranked as the most useful approaches. Key barriers to addressing adolescent self‐harm were: lack of time in the curriculum; lack of resources; lack of staff training and time; and fear of encouraging self‐harm amongst adolescents.
Conclusions
Adolescent self‐harm is a priority for schools. Intervention might focus on increasing the availability of training to teaching staff.
A review of literature from the past 30 years establishes psychological distress as both a longstanding and current issue affecting university students worldwide. Poorer academic outcomes and problematic health behaviours are linked to students’ distress, and these wider implications also highlight the need for appropriate policies and services to support students during what is clearly a challenging time. Further review identified various socio-demographic, situational and academic factors as potential bases of students’ distress. Undoubtedly, the demands of the university lifestyle are inherently stressful; yet experiencing these as distressing is not inevitable. Rather, a review of links between university students’ psychological attributes and psychological distress indicates such attributes might be ideal points of intervention to ensure students are best equipped to manage the stressors of university, and greater attention in this area is recommended.
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.
Background
A high proportion of individuals with Autism Spectrum Disorder (ASD) also meet criteria for anxiety disorders. Few studies have explored the experience and impact of anxiety in autistic adults using qualitative methods.
Methods
Seventeen semi-structured interviews with either autistic adults (n = 10) or the supporters of adults with a diagnosis of ASD (n = 7) were conducted. The data were analysed using thematic analysis.
Results
Three main themes were identified: ‘contributing and mitigating factors to anxiety’, ‘consequences of anxiety’, and ‘management of anxiety’.
Discussion
Findings highlighted the role that uncertainty plays in anxiety in autism, supporting existing theoretical accounts. Implications for clinical practice were discussed. These included ensuring that communication differences are minimised, and highlighting the importance of meaningfully including autistic people throughout the development and evaluation process of interventions for mental health.
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.
University is a pivotal period in a young adult's life; however, for some, university may be a recipe for disaster due to the stress and pressures that come along with university education. The purpose of the present study was to examine students' feelings of stress, loneliness, and levels of learning burnout in order to determine if these factors are related to students' academic experience, including academic coping ability, overall academic performance, and educational engagement. An online self-report questionnaire was administered to 150 undergraduate students recruited from the Psychology participant pool at a medium-sized Canadian University. There were no significant gender differences in academic stress; however, females showed higher levels of social support coping. Feelings of loneliness and learning burnout negatively influenced students' overall academic experience and their perceptions of stress. Academic coping ability did not have a mediating effect on the relation between feelings of loneliness and learning burnout; however, avoidance and approach coping ability mediated the relation between loneliness and academic performance among students. Findings from this study may inform the development of intervention and prevention programs to help students more effectively manage academic stressors, which may affect their educational experience.
Research has identified more than a dozen functions of non-suicidal self-injury (NSI), but the conceptual and empirical overlap among these functions remains unclear. The present study examined the structure of NSI functions in two large samples of patients receiving acute-care treatment for NSI. Two different measures of NSI functions were utilized to maximize generalizability of findings: one sample (n = 946) was administered the Inventory of Statements About Self-injury (ISAS; Klonsky and Glenn in J Psychopathol Behav Assess 31:215-219, 2009), and a second sample (n = 211) was administered the Functional Assessment of Self-Mutilation (FASM; Lloyd et al. in Self-mutilation in a community sample of adolescents: descriptive characteristics and provisional prevalence rates. Poster session at the annual meeting of the Society for Behavioral Medicine, New Orleans, LA, 1997). Exploratory factor analyses revealed that both measures exhibited a robust two-factor structure: one factor represented Intrapersonal functions, such as affect regulation and anti-dissociation, and a second factor represented Social functions, such as interpersonal influence and peer bonding. In support of the two-factor structure's construct validity, the factors exhibited a pattern of correlations with indicators of NSI severity that was consistent with past research and theory. Findings have important implications for theory, research, and treatment. In particular, the two-factor framework should guide clinical assessment, as well as future research on the implications of NSI functions for course, prognosis, treatment, and suicide risk.
In our globalized world the necessity for student flexibility is increasing. Psychological problems and mental disorders are frequent, and students seek help at the places where they study. This special issue presents data on the prevalence of complaints and disorders reported by students around the world. Examples of counseling services and the methods they employ are given. Proposals for the structure and the methods of mental health services for students are derived from international perspectives.
Aims
This review will focus on the rates, clinical characteristics, risk factors and methods of self-harm and suicide in different ethnic groups in the United Kingdom, providing an update synthesis of recent literature.
Methods
Studies that met the inclusion criteria between 2003 and 2013 were reviewed using the following databases: MEDLINE, PsycINFO, EMBASE and CINAHL. The methodological quality of each study was then assessed using a structured scoring system.
Results
A total of 2,362 articles were retrieved, 10 of which matched the inclusion criteria were reviewed. Significant differences were found in the rates of self-harm between ethnic groups with Asian males being least likely to self-harm and Black females being most likely to self-harm. Also, Black and South Asian people were less likely to repeat self-harm. Factors that may help protect or predispose individuals to self-harm or attempt suicide (such as religion, mental health and coping styles) also differ between ethnic groups.
Conclusions
There are clear ethnic differences in self-harm and suicide, which may be affected by factors such as cultural pressures and prevalence of mental illness. An awareness of these differences is vital to help prevent further attempts of self-harm and suicide. Further research into differences between ethnic and cultural groups and self-harm continues to be important.
For decades, knowledge about nonsuicidal self-injury (NSSI) was limited to only a small handful of empirical studies. However, the last 10 to 15 years have witnessed an explosion of research and significant advances in knowledge about NSSI. We now understand much about the classification, prevalence, correlates, forms, and functions of NSSI, and have dispelled many misconceptions. It is time for NSSI researchers to apply this basic knowledge to develop empirically grounded theoretical models and effective treatments. This In Review on NSSI was developed to help the field of mental health move forward in these 2 areas. First, this editorial briefly reviews what we now know about NSSI. Next, Margaret S Andover and Blair W Morris describe an emotion regulation model for understanding and potentially treating NSSI and for explaining the emotion regulation function of NSSI in terms of basic emotion models. Finally, Brianna J Turner, Sara B Austin, and Alexander L Chapman provide a systematic review of NSSI treatment outcome research, and note the need for new treatment approaches specifically tailored to target NSSI. We hope that this In Review not only provides state-of-the-art knowledge but also motivates and facilitates future efforts to better understand and treat NSSI.
Objective:
Self-harm is common in adolescence, but most young people who self-harm do not seek professional help. The aim of this literature review was to determine (a) the sources of support adolescents who self-harm access if they seek help, and (b) the barriers and facilitators to help-seeking for adolescents who self-harm.
Method:
Using a pre-defined search strategy we searched databases for terms related to self-harm, adolescents and help-seeking. Studies were included in the review if participants were aged 11-19 years.
Results:
Twenty articles met criteria for inclusion. Between a third and one half of adolescents who self-harm do not seek help for this behaviour. Of those who seek help, results showed adolescents primarily turned to friends and family for support. The Internet may be more commonly used as a tool for self-disclosure rather than asking for help. Barriers to help-seeking included fear of negative reactions from others including stigmatisation, fear of confidentiality being breached and fear of being seen as 'attention-seeking'. Few facilitators of help-seeking were identified.
Conclusions:
Of the small proportion of adolescents who seek help for their self-harm, informal sources are the most likely support systems accessed. Interpersonal barriers and a lack of knowledge about where to go for help may impede help-seeking. Future research should address the lack of knowledge regarding the facilitators of help-seeking behaviour in order to improve the ability of services to engage with this vulnerable group of young people.
Individuals often avoid or delay seeking professional help for mental health problems. Stigma may be a key deterrent to help-seeking but this has not been reviewed systematically. Our systematic review addressed the overarching question: What is the impact of mental health-related stigma on help-seeking for mental health problems? Subquestions were: (a) What is the size and direction of any association between stigma and help-seeking? (b) To what extent is stigma identified as a barrier to help-seeking? (c) What processes underlie the relationship between stigma and help-seeking? (d) Are there population groups for which stigma disproportionately deters help-seeking? Method Five electronic databases were searched from 1980 to 2011 and references of reviews checked. A meta-synthesis of quantitative and qualitative studies, comprising three parallel narrative syntheses and subgroup analyses, was conducted.
The review identified 144 studies with 90��189 participants meeting inclusion criteria. The median association between stigma and help-seeking was d��=�������0.27, with internalized and treatment stigma being most often associated with reduced help-seeking. Stigma was the fourth highest ranked barrier to help-seeking, with disclosure concerns the most commonly reported stigma barrier. A detailed conceptual model was derived that describes the processes contributing to, and counteracting, the deterrent effect of stigma on help-seeking. Ethnic minorities, youth, men and those in military and health professions were disproportionately deterred by stigma.
Stigma has a small- to moderate-sized negative effect on help-seeking. Review findings can be used to help inform the design of interventions to increase help-seeking.
Published prevalence estimates of nonsuicidal self-injury (NSSI) among nonclinical samples are highly heterogeneous, raising concerns about their reliability and hindering attempts to explore the alleged increase in NSSI over time. Accordingly, the objectives of this study were to investigate the influence of methodological factors on heterogeneity in NSSI prevalence estimates, explore changes over time, and estimate overall international NSSI prevalence. Results showed that methodological factors contributed over half (51.6%) of the heterogeneity in prevalence estimates, and, after adjusting for these factors, NSSI prevalence did not increase over time. Overall, pooled NSSI prevalence was 17.2% among adolescents, 13.4% among young adults, and 5.5% among adults. Clearly, development of standardized methodology in NSSI research is crucial if accurate estimates are desired.
To investigate the prevalence and associated psychosocial factors of occasional and repetitive direct self-injurious behavior (D-SIB), such as self-cutting, -burning, -biting, -hitting, and skin damage by other methods, in representative adolescent samples from 11 European countries.
Cross-sectional assessment of adolescents was performed within the European Union funded project, Saving and Empowering Young Lives in Europe (SEYLE), which was conducted in 11 European countries. The representative sample comprised 12,068 adolescents (F/M: 6,717/5,351; mean age: 14.9 ± 0.89) recruited from randomly selected schools. Frequency of D-SIB was assessed by a modified 6-item questionnaire based on previously used versions of the Deliberate Self-Harm Inventory (DSHI). In addition, a broad range of demographic, social, and psychological factors was assessed.
Overall lifetime prevalence of D-SIB was 27.6%; 19.7% reported occasional D-SIB and 7.8% repetitive D-SIB. Lifetime prevalence ranged from 17.1% to 38.6% across countries. Estonia, France, Germany, and Israel had the highest lifetime rates of D-SIB, while students from Hungary, Ireland, and Italy reported low rates. Suicidality as well as anxiety and depressive symptoms had the highest odds ratios for both occasional and repetitive D-SIB. There was a strong association of D-SIB with both psychopathology and risk-behaviors, including family related neglect and peer-related rejection/victimization. Associations between psychosocial variables and D-SIB were strongly influenced by both gender and country. Only a minor proportion of the adolescents who reported D-SIB ever received medical treatment.
These results suggest high lifetime prevalence of D-SIB in European adolescents. Prevalence as well as psychosocial correlates seems to be significantly influenced by both gender and country. These results support the need for a multidimensional approach to better understand the development of SIB and facilitate culturally adapted prevention/intervention.
In this article, the authors describe how they used a hybrid process of inductive and deductive thematic analysis to interpret raw data in a doctoral study on the role of performance feedback in the self-assessment of nursing practice. The methodological approach integrated data-driven codes with theory-driven ones based on the tenets of social phenomenology. The authors present a detailed exemplar of the staged process of data coding and identification of themes. This process demonstrates how analysis of the raw data from interview transcripts and organizational documents progressed toward the identification of overarching themes that captured the phenomenon of performance feedback as described by participants in the study.
Guidelines for determining nonprobabilistic sample sizes are virtually nonexistent. Purposive samples are the most commonly used form of nonprobabilistic sampling, and their size typically relies on the concept of “saturation,” or the point at which no new information or themes are observed in the data. Although the idea of saturation is helpful at the conceptual level, it provides little practical guidance for estimating sample sizes, prior to data collection, necessary for conducting quality research. Using data from a study involving sixty in-depth interviews with women in two West African countries, the authors systematically document the degree of data saturation and variability over the course of thematic analysis. They operationalize saturation and make evidence-based recommendations regarding nonprobabilistic sample sizes for interviews. Based on the data set, they found that saturation occurred within the first twelve interviews, although basic elements for metathemes were present as early as six interviews. Variability within the data followed similar patterns.
Counsellors working with students or other young adults may encounter individuals who have self-harmed, either with suicidal or non-suicidal intent. Recent US studies reported rates of self-injury of up to 37% of the student population, but studies in the UK have focussed primarily on younger adolescents. This study examined reported self-harm incidents (scratching, cutting, poisoning, overdose etc) from a sample of 617 university students. A total of 27% reported at least one incident of self-harm, with almost 10% having harmed themselves while at university. Gender differences were not significant but psychology students reported significantly more self-harm than other students. Participants reporting self-harm scored significantly higher on maladaptive coping styles, rumination, and alexithymia (specifically difficulty in identifying emotions) and these differences were most marked for students reporting repetitive and recent self-harm. Rumination and Alexithymia factor 1 (difficulty identifying feelings) emerged as the most robust factors predicting self-harm status. Comments from students who self-harmed at university highlighted the importance of accessible services and academic staff support. The implications of these findings for counselling interventions are discussed, including challenging negative rumination tendencies and developing mindfulness skills.
The transition from high school to university was used as the context for examining the relationship between emotional intelligence and academic achievement. During the first month of classes 372 first-year full-time students at a small Ontario university completed the short form of the Emotional Quotient Inventory (EQ-i:Short). At the end of the academic year the EQ-i:Short data was matched with the student's academic record. Predicting academic success from emotional intelligence variables produced divergent results depending on how the former variable was operationalized. When EQ-i:Short variables were compared in groups who had achieved very different levels of academic success (highly successful students who achieved a first-year university GPA of 80% or better versus relatively unsuccessful students who received a first-year GPA of 59% or less) academic success was strongly associated with several dimensions of emotional intelligence. Results are discussed in the context of the importance of emotional and social competency during the transition from high school to university.
Objectives
To compare emergency department (ED) visit rates for suicidal ideation and/or self-harm among youth by urban-rural location of residence.
Study design
Retrospective analysis of ED visits for suicidal ideation and/or self-harm by youth age 5-to-19 years (N=297,640) in the 2016 Nationwide Emergency Department Sample, a representative sample of all U.S. ED visits. We used weighted Poisson generalized linear models to compare population-based visit rates by urban-rural location of patient residence, adjusted for age, sex, and U.S. Census region. For self-harm visits, we compared injury mechanisms by urban-rural location.
Results
Among ED visits for suicidal ideation and/or self-harm, the median age was 16 years, 65.9% were female, 15.9% had a rural location of patient residence, and 0.1% resulted in mortality. The adjusted ED visit rate for suicidal ideation/or and self-harm did not differ significantly by urban-rural location. For the subset of visits for self-harm, the adjusted visit rate was significantly higher in small metropolitan (aIRR 1.39, 95% CI 1.01, 1.90), micropolitan (aIRR 1.46, 95% CI 1.10, 1.93), and noncore areas (aIRR 1.39, 95% CI 1.03, 1.87) compared with large metropolitan areas. When stratified by injury mechanism, ED visit rates were higher among youth living in rural than in urban areas for self-inflicted firearm injuries (aIRR = 3.03, 95% CI 1.32, 6.74).
Conclusions
Compared with youth living in urban areas, youth living in rural areas had higher ED visit rates for self-harm, including self-inflicted firearm injuries. Preventive approaches for self-harm based in community and ED settings might help address these differences.
Thematic analysis methods, including the reflexive approach we have developed, are widely used in counselling and psychotherapy research, as are other approaches that seek to develop ‘patterns’ (themes, categories) across cases. Without a thorough grounding in the conceptual foundations of a wide variety of across‐case analytic approaches, and qualitative research more broadly—something rarely offered in counselling training—it can be difficult to understand how these differ, where they overlap, and which might be appropriate for a particular research project. Our aim in this paper is to support researchers in counselling and psychotherapy to select an appropriate across‐case approach for their research, and to justify their choice, by discussing conceptual and procedural differences and similarities between reflexive thematic analysis (TA) and four other across‐case approaches. Three of these are also widely used in counselling and psychotherapy research—qualitative content analysis, interpretative phenomenological analysis and grounded theory. The fourth—discourse analysis—is less widely used but importantly exemplifies the critical qualitative research tradition. We contextualise our comparative approach by highlighting the diversity within TA. TA is best thought of as a spectrum of methods—from types that prioritise coding accuracy and reliability to reflexive approaches like ours that emphasise the inescapable subjectivity of data interpretation. Although reflexive TA provides the point of comparison for our discussion of other across‐case approaches, our aim is not to promote reflexive TA as ‘best’. Rather, we encourage the knowing selection and use of analytic methods and methodologies in counselling and psychotherapy research.
Objective
There have been multiple criticisms against commonly used theories of coping limiting their usefulness in research and practice.
Method
This paper describes and evaluates a new functional conceptualisation of reactions to reduce distress or unpleasant emotions, the Health Theory of Coping.
Results
The theory recognises that all coping reactions are adaptive and may initially reduce distress and categorises these strategies as either healthy or unhealthy, depending on their likelihood of adverse consequences. Categories are conceptually clear, mutually exclusive, comprehensive, functionally homogenous, functionally distinct, generative and flexible, overcoming limitations of previous theories. The theory captures a hierarchy of strategies across the continua of internality, intensity, and adversity. Healthy coping categories are self‐soothing, relaxing or distracting activities, social support, and professional support. Unhealthy categories are negative self‐talk, harmful activities, social withdrawal, and suicidality. All coping strategies fit within one of these categories.
Conclusions
The categorisation of coping strategies as either healthy or unhealthy is empirically supported. The Health Theory of Coping has clinical utility in stigma reduction, suicide prevention, and treatment of physical and psychiatric illnesses.
Self-harm remains a major health issue, particularly for adolescents. This qualitative study explored the reflections of adults who had self-harmed during adolescence. Foci included reasons for commencing and ceasing self-harm, as well as the perceived meaning of the self-harm and advice they would provide to adolescents currently engaging in self-harm. Participants included 185 adults aged 18 to 61 years, who had self-harmed at least once in adolescence. Participants responded to four qualitative questions that were part of a larger survey. Participants’ responses were analyzed using either directed or conventional content analysis. Participants reported ambivalence about their self-harm with coexisting feelings of shame along with a recognition of the functions served by the behavior. The most frequently reported reasons for cessation included changes in personal relationships, frustration with shame, and receiving professional treatment. Most participants encouraged adolescents currently self-harming to seek help and to develop alternative coping mechanisms, although harm minimization also emerged as a theme. These findings are compared to international findings on reasons for initiation and cessation of self-harm as well as the advice for others. These insights may guide clinicians’ understanding of motivations for adolescent self-harm and effective management of this behavior.
Non-suicidal self-injury (NSSI) is a prevalent behaviour among youth and young adults, yet little is known about their NSSI disclosure experiences. Disclosure of NSSI may have important implications for accessing treatment and eliciting support from family and friends; it may also highlight where efforts are needed to combat potential barriers (e.g. shame). This study sought to better understand the factors that facilitate and discourage NSSI disclosure in a sample of undergraduate students as well as gather a richer understanding of young adults’ experiences disclosing NSSI. To do this, a thematic analysis of interview transcripts with 17 students (16 women and 1 man) was conducted. Themes related to barriers to disclosure (shame, concern about others) and disclosure recipients’ responses (silence/avoidance, understanding) were explored. Results underscored the central role of shame in NSSI disclosures, both as an experience impacting the difficulty and likelihood of disclosure and as a potential consequence of receiving avoidant responses to disclosure. Among the clinical implications discussed is the import of initiatives to reduce NSSI stigma and foster supportive and understanding responses to NSSI disclosures.
The Ottawa Self-Injury Inventory (OSI) is a comprehensive self-report measure of non-suicidal self-injury (NSSI). In an effort to build on past research and further validate the OSI, this study presents a confirmatory factor analysis of the OSI's subscales measuring the functions and addictive features of NSSI using a university sample. Participants were 316 university students aged 17–25 years (84.8% female) who had engaged in NSSI at least once in their lifetime. Consistent with past research, results confirmed the four-factor structure of the Functions items (Internal Emotion Regulation, Social Influence, External Emotion Regulation, Sensation Seeking), as well as the single-factor structure of Addictive Features items. Correlations calculated between the obtained factors and indicators of NSSI severity revealed that higher endorsement of NSSI's Internal Emotion Regulation functions, External Emotion Regulation functions, and Addictive Features were associated with more frequent lifetime NSSI, recent (past 6 months) NSSI, and greater distress regarding NSSI urges; greater endorsement of NSSI's Sensation Seeking functions was also linked with more frequent lifetime NSSI. Results provide further support for the OSI's psychometric properties in a university sample, and offer additional evidence for links between specific NSSI functions and addictive features and more severe manifestations of the behavior.
AimTo produce a framework for the development of a qualitative semi-structured interview guide. Background
Rigorous data collection procedures fundamentally influence the results of studies. The semi-structured interview is a common data collection method, but methodological research on the development of a semi-structured interview guide is sparse. DesignSystematic methodological review. Data sourcesWe searched PubMed, CINAHL, Scopus and Web of Science for methodological papers on semi-structured interview guides from October 2004-September 2014. Having examined 2,703 titles and abstracts and 21 full texts, we finally selected 10 papers. Review methodsWe analysed the data using the qualitative content analysis method. ResultsOur analysis resulted in new synthesized knowledge on the development of a semi-structured interview guide, including five phases: (1) identifying the prerequisites for using semi-structured interviews; (2) retrieving and using previous knowledge; (3) formulating the preliminary semi-structured interview guide; (4) pilot testing the guide; and (5) presenting the complete semi-structured interview guide. Conclusion
Rigorous development of a qualitative semi-structured interview guide contributes to the objectivity and trustworthiness of studies and makes the results more plausible. Researchers should consider using this five-step process to develop a semi-structured interview guide and justify the decisions made during it.
Aboriginal Australians are entering university in greater numbers than in past decades, yet many struggle to complete their degrees. This paper reports on the qualitative component of a research project aimed at enhancing understandings about this issue by investigating student perspectives about those structures that facilitate or impede their retention. Interview and survey data were gathered from 57 participants at one university and analysed for emerging themes. The findings demonstrate a diverse Indigenous student population in terms of age; comprised personal, professional and university networks; institutional services and resources; and the students’ personal qualities and study practices. Factors perceived to obstruct retention included: a lack of support from some teaching staff, schools and faculties; financial insecurity; and often interrelated issues surrounding university workload, jobs, health, as well as family and community responsibilities. These findings are discussed in the light of relevant literature and recommendations.
Mental health counselors are facing increased demand to treat both adolescents and adults who present with repetitive non-suicidal self-injurious behaviors, yet there are few empirically supported treatments or general treatment guidelines available. I will review the research on problem-solving and dialectical behavior therapy, two cognitive-behavioral treatments that have the most empirical support for reducing self-injurious behavior. I conclude by providing specific treatment recommendations drawn from the literature that can be of use to mental health counselors working with individuals who self-injure.
Nonsuicidal self-injury is receiving increasing attention in empirical and clinical realms. Indeed, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders designated nonsuicidal self-injury as a condition that requires further study, which signals possible future official adoption. Despite growing interest in this perplexing phenomenon, much remains unknown about why nonsuicidal self-injury occurs, including fundamental features of its etiology and underlying mechanisms. In addition, no evidence-based interventions that directly target this maladaptive behavior currently exist. The recently developed, empirically supported four-function model posits that nonsuicidal self-injury is maintained by four distinct reinforcement processes. In this review, we used the four-function model to guide the understanding of important unanswered questions and suggest much-needed studies for future research in the field of self-injury.
This study examines the potentially mediated relationship between volunteering and well-being. Using survey data from a random sample (N = 2,990) of the population of the state of Victoria, Australia, three hypotheses were tested: Volunteers will report higher well-being than nonvolunteers; volunteers will report higher self-esteem, self-efficacy, and social connectedness than nonvolunteers; self-esteem, self-efficacy, and social connectedness will mediate the relationship between volunteer status and well-being. Results supported the hypotheses and showed that self-esteem, self-efficacy, and social connectedness were all significant mediators of the volunteering–well-being relationship. Increased social connectedness associated with volunteering was found to be the strongest first step in these pathways. This points to the importance of social connection for well-being, but future research using longitudinal designs is required to further test these relationships and provide the capacity for evidence of causality.
Background
Self-harm is a key risk factor for suicide and it is important to have contemporary information on the extent of risk.
Methods
Mortality follow-up to 2012 of 40,346 self-harm patients identified in the three centres of the Multicentre Study of Self-harm in England between 2000 and 2010.
Results
Nineteen per cent of deaths during the study period (N=2704) were by suicide, which occurred in 1.6% of patients (2.6% of males and 0.9% of females), during which time the risk was 49 times greater than the general population risk. Overall, 0.5% of individuals died by suicide in the first year, including 0.82% of males and 0.27% of females. While the absolute risk of suicide was greater in males, the risk relative to that in the general population was higher in females. Risk of suicide increased with age. While self-poisoning had been the most frequent method of self-harm, hanging was the most common method of subsequent suicide, particularly in males. The number of suicides was probably a considerable underestimate as there were also a large number of deaths recorded as accidents, the majority of which were poisonings, these often involving psychotropic drugs.
Limitations
The study was focussed entirely on hospital-presenting self-harm.
Conclusions
The findings underline the importance of prevention initiatives focused on the self-harm population, especially during the initial months following an episode of self-harm. Estimates using suicide and open verdicts may underestimate the true risk of suicide following self-harm; inclusion of accidental poisonings may be warranted in future risk estimates.
Objective:
Nonsuicidal self-injury (NSSI) and suicidality among undergraduates represent important public health issues. This analysis identified risk factors that distinguished 3 groups, those who reported no history of self-harm; self-injury, but no suicide attempts (NSSI only); and self-injury and a suicide attempt (NSSI + SA) in the past year.
Methods:
Data came from 16,044 undergraduates who completed the Fall 2010 National College Health Assessment.
Results:
Over 3% of students reported NSSI, and one third of these individuals also attempted suicide. Factors that distinguished the NSSI only and NSSI + SA groups from the no self-harm group included current depressive symptoms, nonheterosexual orientation, an eating disorder/extreme weight control behavior, and diagnosis of an internalizing disorder. Factors that distinguished the NSSI + SA group from the NSSI only group were current depressive symptoms and diagnosis of an internalizing disorder.
Conclusions:
Students experiencing mental health problems demonstrate increased risk for NSSI and/or suicidal behavior.
Aim:
To explore the methodological and ethical issues of conducting qualitative telephone interviews about personal or professional trauma with critical care nurses.
Background:
The most common method for conducting interviews is face-to-face. However, there is evidence to support telephone interviewing on a variety of sensitive topics including post-traumatic stress disorder (PTSD). Qualitative telephone interviews can limit emotional distress because of the comfort experienced through virtual communication. Critical care nurses are at increased risk of developing PTSD due to the cumulative exposure to work-related stress in the intensive care unit. We explored the methodological and ethical issues of conducting qualitative telephone interviews, drawing on our experiences communicating with a group of critical care nurses.
Data sources:
Qualitative research interviews with 27 critical care nurses. Fourteen of the nurses met the diagnostic criteria for PTSD; 13 did not and had scores consistent with high levels of resilience.
Review methods:
This is a methodology paper on the authors' experiences of interviewing critical care nurses on sensitive topics via the telephone.
Discussion:
The authors found that establishing rapport and connections with the participants and the therapeutic use of non-verbal communication were essential, and fostered trust and compassion. The ethical issues of this mode of communication include protecting the privacy and confidentiality associated with the disclosure of sensitive information, and minimising the risk of psychological harm to the researcher and participants.
Conclusion:
Qualitative telephone interviews are a valuable method of collecting information on sensitive topics.
Implications for research/practice:
This paper explores a method of interviewing in the workplace. It will help inform interventions to promote healthy adaptation following trauma exposure in the intensive care unit.
Information on how individuals cease deliberate self-harm behaviors, and what they experience as helpful and hindering to this process, was sought in order to optimize and inform treatment. University students (N = 54) with a past history of self-harm were queried about their experience with DSH cessation. Qualitative analysis revealed 6 themes of reasons for DSH cessation, 5 themes of strategies used to cease DSH behaviors, and 4 themes of barriers to cessation. Treatment can be informed by the motivations, strategies, and barriers that individuals experience during the cessation process. The positive strategies that individuals naturally use to cease DSH should be capitalized on in treatment, and the negative strategies should be minimized.
This article examines the effectiveness of a mentoring programme supporting the transition of first year psychology students. The programme, in which third year students worked with small groups of first year students within tutorials, was developed to enhance five aspects associated with student success (capability, connectedness, resourcefulness, purpose, and culture), encourage deep and strategic learning approaches, and build psychological literacy. The programme was implemented across the first year of the undergraduate programme at a metropolitan Australian university, and 241 first year students (166 females and 65 males) provided data for the evaluation study. Significant positive change was noted on three of the five aspects of student success, with an increase in deep and strategic learning approaches and a decrease in surface learning. Significant change was reported for six of the nine psychological literacies. Compared with previous cohorts, grades also showed a shift upwards, with a higher proportion of final grades in the range between 60% and 80%. Together, these findings suggest that proactive interventions in the first semester of first year can enhance important aspects of learning and increase success for undergraduate psychology students. Recommendations for amendments to the mentoring programme, particularly surrounding its use with mature age students, are discussed.
The publication of the third edition of Qualitative Research and Evaluation Methods offers the author an opportunity to reflect back over two decades of developments in qualitative inquiry. Major developments include: the end of the qualitative-quantitative debate; the flowering of diverse and competing approaches within qualitative inquiry; the increased importance of mixed methods; the elaboration of purposeful sampling approaches; increasing recognition of the creativity at the center of qualitative analysis; the emergence of ever more sophisticated software to facilitate qualitative analysis; and new ethical challenges in the face of the potential impacts of qualitative inquiry on both those studied and those engaged in the inquiry.
THERE has been increasing interest in the use of qualitative methodologies in many health-related areas. Several studies, undertaken by the New South Wales Medical Education Unit on Alcohol and Other Drugs, to examine doctors' attitudes and experiences towards treating patients with drug and alcohol problems, are presented to illustrate the comp lementary nature of qualitative and quantitative methods of investigation. The inherent strengths of each approach are highlighted, as is the potential for their application in a wide range of health-related areas.