Adolescents’ Perceptions About Non-Suicidal Self-Injury, Suicidal Ideation and Suicide Attempts

Abstract

Introduction: Non-suicidal self-injury, suicidal thoughts and behaviors present
high prevalence rates in adolescence.
Aims: This study aimed to describe adolescents’ perceptions about these
phenomena, and to analyze and compare the differences of these perceptions
among adolescents with and without a history of non-suicidal selfinjury,
suicidal ideation, and suicide attempts.
Methods: The convenience sample consisted of 452 adolescents in ages between
12 and 18 (M(SD) = 15.59(1.50), 48% male and 52% female. For
data collection, the Free Association Test was used in a survey, and data was
analyzed through content analysis.
Results: Results showed that 10.8% of the participants presented a history
of non-suicidal self-injury, 19.9% suicidal ideation, and 2.7% suicide
attempts. Perceptions were grouped into eight dimensions: Consumption
of Psychoactive Substances; Death/Suicide; Interpersonal Factors;
Intrapersonal Factors; Moral Judgments; Negative Emotions; Psychological
Functions; and Self-Injurious Methods. Further analysis revealed that
adolescents with and without a history of non-suicidal self-injury, suicidal
ideation, and suicide attempts presented differences in their perceptions of
these phenomena.
Conclusions: These findings contribute to the understanding regarding the
perceptions of adolescents about these phenomena and might have implications
regarding their prevention and intervention.

Full text

Adolescents’ Perceptions About Non-Suicidal
Self-Injury, Suicidal Ideation and Suicide
Attempts
Eva DUARTE 1 , Sofia SILVA 2, Maria GOUVEIA-PEREIRA 1
Introduction: Non-suicidal self-injury, suicidal thoughts and behaviors pre-
sent high prevalence rates in adolescence.
Aims: is study aimed to describe adolescents’ perceptions about these
phenomena, and to analyze and compare the dierences of these percep-
tions among adolescents with and without a history of non-suicidal self-
injury, suicidal ideation, and suicide attempts.
Methods: e convenience sample consisted of 452 adolescents in ages be-
tween 12 and 18 (M(SD) = 15.59(1.50), 48% male and 52% female. For
data collection, the Free Association Test was used in a survey, and data was
analyzed through content analysis.
Results: Results showed that 10.8% of the participants presented a his-
tory of non-suicidal self-injury, 19.9% suicidal ideation, and 2.7% suicide
attempts. Perceptions were grouped into eight dimensions: Consump-
tion of Psychoactive Substances; Death/Suicide; Interpersonal Factors;
Intrapersonal Factors; Moral Judgments; Negative Emotions; Psychologi-
cal Functions; and Self-Injurious Methods. Further analysis revealed that
adolescents with and without a history of non-suicidal self-injury, suicidal
ideation, and suicide attempts presented dierences in their perceptions of
these phenomena.
Conclusions: ese ndings contribute to the understanding regarding the
perceptions of adolescents about these phenomena and might have impli-
cations regarding their prevention and intervention.
Keywords:
adolescence, non-suicidal self-injury, suicidal ideation, suicide
attempts, free word association
OPEN
1 APPsyCI – Applied Psychology Research Center
Capabilities & Inclusion, Ispa – Instituto Univer-
sitário, Lisbon, Portugal
2 ISPA – Instituto Universitário, Lisbon, Portugal
 Correspondence
Eva Duarte
Rua Jardim do Tabaco 34, 1149-041
Lisboa, Portugal
Email: eduarte@ispa.pt
History
Received: 13 November 2021
Accepted: 25 September 2022
Published: 24 March 2023
Citation
Duarte, E., Silva, S., & Gouveia-Pereira, M.
(2023). Adolescents’ Perceptions About
Non-Suicidal Self-Injury, Suicidal Ideation
and Suicide Attempts.
European Journal of Mental Health, 18, e0004, 1–11.
https://doi.org/10.5708/EJMH.18.2023.0004
RESEARCH ARTICLE
ISSN 1788-7119 (online)
© 2023 The Authors. Published by Semmelweis University, Institute of Mental Health, Budapest. ejmh.eu
European Journal of Mental Health
https://doi.org/10.5708/EJMH.18.2023.0004
Introduction
Over the past few decades, there has been an increase in the prevalence of suicidal thoughts and behaviors (STBs)
among adolescents, including suicidal ideation (SI; Azevedo & Matos, 2014; Werlang et al., 2005) and suicide
attempts (SAs; Bilsen, 2018; Evans et al., 2017). Likewise, research suggests that the prevalence of non-suicidal
self-injury (NSSI) has also been growing in adolescents (Muehlenkamp et al., 2012; Zetterqvist et al., 2021). Al-
though dierentiated phenomena, NSSI and STBs usually co-occur, and evidence points to a shared continuum
of self-harm (Knorr et al., 2019; Rogers et al., 2018; Webb, 2002).
In Portugal, NSSI prevalence in adolescence ranges from 20.3% to 34.5% (Carvalho et al., 2017; Gaspar et
al., 2019; Gonçalves et al., 2012; Nobre-Lima et al., 2018), SI prevalence oscillates between 10.7% and 22%
(Azevedo & Matos, 2014; Carvalho et al., 2017; Pereira & Cardoso, 2015), and about 7% of adolescents report

E. DUARTE ET AL. Non-Suicidal Self-Injury, Suicidal Ideation and Suicide Attempts
Eur. J. Ment. Health 2023, 18, e0004, 1–11. 2
having attempted suicide (Oliveira et al., 2001; Sampaio et al., 2000). ese rates are identical to those found in
international studies that focused on adolescents: 7.5-46.5% NSSI (Cipriano et al., 2017), 8.1- 16.9% SI (Biswas
et al., 2020; Georgiades et al., 2019; Sampasa-Kanyinga et al., 2017; Uddin et al., 2019), and 3- 17% SAs
(Geor
giades et al., 2019; Sampasa-Kanyinga et al. 2017; Uddin et al., 2019).
NSSI serves a variety of psychological functions, namely intrapersonal (e.g., to escape from aversive states, or
generate positive feelings) or interpersonal (e.g., to access help, or to escape from negative social situations) func-
tions (Klonsky, 2007; Nock & Prinstein, 2004). Studies that focused on the perceptions about these functions
concluded that individuals without a history of NSSI tend to emphasize interpersonal functions more than those
with a history of these behaviors, while their views regarding intrapersonal functions remain similar (Batejan et
al., 2015; Duarte, et al., 2019c).
Exploring and characterizing the societal perceptions of NSSI and STBs might contribute to the understand-
ing of these issues (O’Connor & Nock, 2014; Sampaio et al., 2000; Vieira & Coutinho, 2008). It is also impor-
tant to comprehend whether these perceptions change according to the lived experiences of young people with
NSSI and STBs (Grimmond et al, 2019). For instance, previous studies have shown that adolescents with and
without a history of deliberate self-harm reveal dierent representations regarding the functions of these behaviors
(Bresin et al., 2013; Duarte et al., 2019b; Duarte et al., 2019c), which indicates that experience inuences how
this phenomenon is represented. Other studies have found that a more permissive and accepting attitude towards
suicide may itself be a risk factor for STBs (Arnautovska & Grad, 2010; Hollinger, 2016; Joe et al., 2007), which
underlines the importance of assessing these perceptions.
e adolescent’s interpersonal sphere can play an important role in this context, namely regarding the indi-
vidual’s initiative to reveal STBs and NSSI to others, to search for specialized help, and to search for support dur-
ing follow-up and treatment (Baetens et al., 2015). More specically, peers can be considered both a risk factor
and a protective factor for NSSI and STBs. On the one hand, if peers are aware of the reasons for an adolescent
to become involved in STBs, they can denitely promote identifying these behaviors and reducing the associated
stigma (Bresin et al., 2013). On the other hand, peers can be a risk factor themselves due to the social contagion
eect that may exacerbate or encourage these behaviors within peer groups (Hasking et al., 2015). Furthermore,
peers can be relevant agents for developing strategies to prevent STBs (Fortune et al., 2008; Hasking et al., 2015;
Schlichthorst et al., 2020; Wasserman et al., 2015). Taking these factors into account, the understanding of the
perceptions about NSSI, SI and SA can simultaneously contribute to comprehending the personal experience of
these phenomena and to the clarication of how interpersonal relations can be a crucial factor for prevention and
intervention.
erefore, considering the prevalence of NSSI and STBs in adolescence and due to the scarcity of Portuguese
studies that focused on adolescents’ perceptions about these phenomena, the current study comprises two main
goals: 1) to explore and describe the perceptions of adolescents about NSSI, SI and SA by means of free word as-
sociation; 2) to compare the perceptions of adolescents with and without a history of NSSI, SI and SA. Since this
still remains an under-researched topic, the present study follows a qualitative design to allow a deeper analysis
of these perceptions.
Methods
Participants
Participants consisted of a convenience sample involving 452 adolescents who studied in public schools located in
Portugal’s central area. From this total, 48% (217) were male and 52% (235) were female, and their ages ranged
between 12 and 18 years old (M(SD) = 15.59(1.5)). Participants attended school years between the 7th and 12th
grades, with the majority (74.1%) attending secondary school (10th to 12th grades). As shown in Table 1, the
lifetime prevalence of NSSI was 10.8% (n = 49), the prevalence of SI was 19.9% (n = 90) and the prevalence
of SAs was 2.7% (n = 12). However, these phenomena coexist in some participants: 18 adolescents reported a
history of NSSI and SI; one adolescent NSSI and SAs; three participants reported a history of SI and SAs; and
seven adolescents revealed a history of NSSI, SI and SAs. Female participants revealed a higher prevalence of these
phenomena (Table 1).

E. DUARTE ET AL. Non-Suicidal Self-Injury, Suicidal Ideation and Suicide Attempts
Eur. J. Ment. Health 2023, 18, e0004, 1–11. 3
Measures
Considering the goal of the present study, the Free Word Association Test was selected as the method of data
collection, since it allows the broad study of perceptions and has been previously used in studies with similar
objectives (e.g., Araújo et al., 2010). is instrument consisted of three main questions for each of the study vari-
ables (NSSI, SI and SAs). ese questions started with a brief introduction in which the variables were presented:
“Some adolescents exhibit behaviors in which they intentionally hurt themselves” (NSSI); “Some adolescents
have ideas and thoughts about suicide” (SI) and “ere are some adolescents who have already made suicide at-
tempts, that is, who tried to commit suicide” (SAs). After each of these introductions, the respondent was asked
to write down at least ve words that came to mind when they thought of the mentioned phenomena. ere
was an additional question regarding each of the variables (e.g., “Have you ever tried to commit suicide? At what
age?”), which allowed us to assess the previous history of NSSI, SI and SAs. Sociodemographic questions were also
applied to collect basic information about the participants’ age, sex, and school year.
Since these are sensitive topics, at the end of the questionnaire, several helplines and community contacts were
provided. e schools’ administration was also given the contacts from the research team in order to allow further
communication if any issue arose.
Procedures
Several convenience contacts were made with schools, presenting the research goals and procedures. After the
request for cooperation was authorized by the schools’ administration, classes were chosen, and the schools’ direc-
tor selected specic dates for data collection. After that, consent forms were given to the legal guardians of the
students. In a later phase, the adolescents who had this authorization lled out the questionnaire.
e participants were informed about the voluntary nature of the study, as well as regarding the anonymity and
condentiality throughout the process of data collection and analysis.
Ethical Procedures
e current study integrated a wider research project that aimed to characterize NSSI and STBs in Portuguese
adolescents. is project was approved by the General Education Directorate of the Ministry of Education and
Science from Portugal during March 2017 concerning the participation of adolescents.
Data Analysis
e participants’ sociodemographic data was analyzed using SPSS v25 software. e data collected through the
Free Word Association Test were studied using content analysis (Bardin, 2008). is analysis implies the specica-
tion of categories that constitute classes grouping elements with common characteristics (Bardin, 2008), allowing
to reduce the complexity of the study’s themes (Vala, 1999). us, each answer elicited through the Free Asso-
ciation Test was considered a coding unit that was further sorted into categories. Two researchers conducted the
analysis independently, grouping the coding units into categories framed by the existing literature. In a posterior
phase, the resultant sets of analyses were compared and discussed, identifying dierences and possible issues in
the coding process.
Table 1. Participants’ gender and history of NSSI, SI and SAs
Female Male Frequency %
NSSI With NSSI 42 7 49 10.8%
Without NSSI 193 210 403 89.2%
SI With SI 56 34 90 19.9%
Without SI 179 183 362 80.1%
SAs With SAss 10 2 12 2.7%
Without SAs 225 215 440 97.3%

E. DUARTE ET AL. Non-Suicidal Self-Injury, Suicidal Ideation and Suicide Attempts
Eur. J. Ment. Health 2023, 18, e0004, 1–11. 4
Results
Considering the total of responses given by the adolescents, 4237 coding units emerged (mean of nine units
per participant). e coding units were organized into 66 categories, which were then grouped into eight main
dimensions. As shown in Table 2, these dimensions comprise: Consumption of Psychoactive Substances (42
coding units and three categories); Death/Suicide (247 coding units and two categories), which refers to issues
of consummated suicide and death; Interpersonal Factors (601 coding units and 13 categories), that refers to
interpersonal and social variables (e.g. Bullying and Social Isolation); Intrapersonal Factors (775 coding units
and ve categories), that includes intrapersonal factors such as Depression and Low Self-esteem; Moral Judg-
ments (513 coding units and 11 categories), that includes moral judgments and stereotyped perceptions (e.g.
Cowardice and Stupidity); Negative Emotions (1792 coding units and 16 categories); Psychological Functions
(92 coding units and three categories) that consist of three types of psychological functions usually associated
with DSH; and Self-Injurious Methods (175 coding units and 13 categories).
Overall, the Negative Emotions dimension was the most referenced by the four groups of participants (1790
coding units), followed by the dimensions related to intrapersonal (776 coding units) and interpersonal factors
(599 coding units). Focusing on the coding units of each adolescent group, some dierences emerged. ese dif-
ferences can be seen mostly between groups of participants with and without a history of NSSI, SI and SA. For
instance, only the adolescents who did not report a history of these phenomena mentioned the consumption of
psychoactive substances. Similarly, in the dimension concerning self-injurious methods, no coding units were
mentioned by adolescents with a history of NSSI and SA. In the Moral Judgments dimension, adolescents with-
out a history of NSSI, SI and SA presented more coding units, particularly regarding NSSI. ese dierences will
be further discussed in detail.
Discussion
To comprehensively discuss results, we will rst describe the contents that emerged from our analysis and compare
them with information from previous research. Secondly, we will focus on the results from each participant group
(i.e., adolescents with and without a history of NSSI, SI and SA) and their comparison. Finally, we will reect
on our results as a whole and on their possible impact on the prevention and intervention of NSSI, SI and SA.
From a global perspective, Negative Emotions was the dimension most mentioned by all groups of partici-
pants. In addition, it also revealed a considerable diversity of contents with more than 16 categories, which indi-
cates that emotionality amounts to a great importance in how NSSI, SI and SAs are perceived. It is known that
emotions have an inuence on the prediction of STBs, namely on the propensity of young people to get involved
in these behaviors (Kranzler et al., 2016). Sadness, pain, suering, and despair were the most mentioned negative
emotions, which may also be linked to the idea that STBs are associated with diculties in the emotional eld
(Xu, 2020; Wol et al., 2019). Negative emotionality is also often linked to NSSI, and one of the most reported
motivations for engaging in these behaviors is to regulate negative emotions (Klonsky, 2007; Taylor et al., 2019).
us, NSSI is commonly performed as an emotion regulation strategy, as it decreases the experience of negative
aect (Andover & Morris, 2014). Furthermore, a recent study revealed that individuals with a history of NSSI
showed greater diculties in negative emotion reactivity and regulation than the comparison group without a
history of NSSI (Mettler et al., 2021).
e two following dimensions with more coding units were Interpersonal and Intrapersonal Factors associated
with NSSI, SI and SAs. Regarding interpersonal factors, previous studies found that STBs are associated with
social isolation (Calati et al., 2019; Oexle & Ruesch, 2018), bullying and peer rejection (Holt et al., 2015), family
issues (Fortune et al., 2008), lack of social support (Stewart et al., 2017) and other interpersonal issues (Bazraf-
shan et al., 2016; Hawton et al., 2012). Likewise, most intrapersonal factors mentioned by the participants have
been previously associated with NSSI, SI and SA, namely depression (Chu et al., 2016; Hegerl, 2016; Wang et al.,
2017), low self-esteem (Soto-Sanz et al., 2019), and other psychopathologies (Nock et al., 2013).
Regarding the less mentioned dimensions, the consumption of psychoactive substances has been associated
with NSSI and SA (Fortune et al., 2008; Stewart et al., 2017), and it can also be a self-injurious method (Duarte
et al., 2019a; Gouveia-Pereira, & Gomes, 2019; Hawton et al., 2003). e psychological functions that were ref-
erenced by the participants are in accordance with those described by the literature (e.g., Klonsky, 2007), as well
as the several self-injurious methods that can be utilized (Duarte et al., 2019a; Gouveia-Pereira, & Gomes, 2019;
Klonsky, 2007; Klonsky et al., 2015).

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Eur. J. Ment. Health 2023, 18, e0004, 1–11. 5
Table 2. Content analysis (NSSI, SI and SAs) – Percentage (%) and frequency (N) of coding units per group of participants
in each dimension
NSSI SI SAs
Dimensions Categories With
NSSI
Without
NSSI
With
SI
Without
SI
With
SAs
Without
SAs
Consumption of
Psychoactive
Substances
Alcohol – 0.2 (3) – 0.2 (2) – 0.4 (5)
Drugs – 1.1 (14) – 0.2 (3) – 1.1 (14)
Smoking – 0.1 (1) – – – –
Total – 1.4 (18) – 0.4 (5) – 1.5 (19)
Death/Suicide Death – – 6 (19) 6.7 (81) – 6.1 (77)
Suicide 6 (9) 4.3 (54) – 0.7 (7) – –
Total 6 (9) 4.3 (54) 6 (19) 7.4 (88) – 6.1 (77)
Interpersonal
Factors
Arguments 1.3 (2) – – – – –
Bullying 5.3 (8) – 2.5 (8) 2.5 (30) – 2.8 (35)
Discrimination – 0.8 (10) – 0.5 (6) – 0.5 (6)
Family Issues 1.3 (2) 0.7 (9) 0.6 (2) 1.2 (15) 4 (1) –
Friends – 0.5 (6) 1 (3) – 4 (1) 0.6 (7)
Lack of Social Support – – 1.6 (5) – – –
Loss of Someone
Significant – – – 1 (12) – 1.2 (15)
Love Issues 1.3 (2) 0.6 (8) 0.6 (2) 0.4 (5) – 0.4 (7)
Rejection 0.7 (1) 0.4 (5) – – – –
Social Isolation 8.6 (13) 6.5 (82) 11.5 (36) 6.1 (74) 12 (3) 6.9 (88)
Social Issues – – – 0.2 (2) – –
Social Pressure – 0.6 (7) – 0.7 (9) – 0.7 (9)
Violence – 1.8 (23) – 1.5 (19) – 1.8 (23)
Total 18.5 (28) 11.9(150) 17.8 (56) 14.1 (172) 20 (5) 14.9 (190)
Intrapersonal
Factors
Depression 11.2 (17) 7.5 (95) 9.9 (31) 6.5 (78) 8 (2) 6.3 (80)
Insecurity – 1.5 (19) 2 (6) 1.2 (15) – 1.1 (14)
Low Self-esteem – 2.8 (35) 5.8 (18) 3.3 (40) 16 (4) 4.2 (53)
Psychological Issues – 0.9 (11) 6 (19) 8.9 (107) – 9 (114)
Psychopathy – 0.6 (7) – 0.4 (5) – 0.4 (5)
Total 11.2 (17) 13.3 (167) 23.7 (74) 20.3 (245) 24 (6) 21 (266)
Moral
Judgments
Childishness – 1.2 (15) – 0.4 (5) – –
Cowardice – – 1 (3) 0.3 (4) – 1 (13)
Exaggeration – – – – – 0.7 (9)
Madness – 3.6 (46) – – – –
Masochism – 1.7 (22) – – – –
Pity – 0.9 (11) – 0.3 (4) – 0.7 (9)
Ridiculousness – – 0.3 (1) – – –
Selfishness – – 0.9 (3) 0.7 (9) – 0.5 (6)
Stupidity – 11.7 (148) 2.2 (7) 5.3 (64) – 3.6 (46)
Unnecessary – – 1 (3) 0.9 (11) – 1.2 (15)
Weakness – 1.5 (19) – 1.7 (21) – 1.5 (19)
Total – 20.6 (261) 5.4 (17) 9.6 (118) – 9.2 117)
(continued on the next page)

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Eur. J. Ment. Health 2023, 18, e0004, 1–11. 6
Table 2. continued
NSSI SI SAs
Dimensions Categories With
NSSI
Without
NSSI
With
SI
Without
SI
With
SAs
Without
SAs
Negative
Emotions
Anger 2.6 (4) 2.7 (34) 1.6 (5) 2.5 (30) – 1.8 (23)
Angst 2 (3) 1.7 (22) 0.3 (1) 2 (25) – –
Blame – 0.6 (7) – – – –
Contempt 1.3 (2) – – – – 0.5 (6)
Despair 7.9 (12) 5 (63) 8.3 (26) 6.4 (77) 4 (1) 7.6 (97)
Disappointment – – – 1.7 (21) – 0.9 (12)
Disgust – – – 0.7 (9) – –
Fear 3.3 (5) 2.1 (26) – 2.2 (27) 4 (1) 3 (38)
Frustration 1.3 (2) 0.9 (11) 0.6 (2) 1 (11) – 1.4 (18)
Impulsivity 0.7 (1) 0.2 (3) 0.6 (2) – – –
Pain 11.8 (18) 7.7 (98) 8 (25) 5.2 (63) 12 (3) 6.1 (78)
Rebellion 1.3 (2) 2 (25) 0.6 (2) 1.3 (16) – 1.3 (17)
Sadness 15.8 (24) 12.6 (159) 7.3 (23) 10.9 (132) 12 (3) 11.7 (149)
Shame 0.7 (1) 0.6 (7) – – – –
Sorrow 2.6 (4) 2.3 (29) 1.3 (4) 2 (24) 12 (3) 2.4 (31)
Suffering 4.6 (7) 6.2 (78) 4.5 (14) 4.8 (58) 12 (3) 5.1 (65)
Total 55.9 (85) 44.6 (562) 33.1 (104) 40.7 (493) 56 (14) 41.8 (534)
Psychological
Functions
Affect Regulation 4.6 (7) 0.5 (6) 2 (6) – – –
Escape Mechanism 4 (6) – 3.1 (10) 2 (24) – –
Interpersonal Influence – 2.5 (33) – – – –
Total 8.6 (13) 3 (39) 5.1 (16) 2 (24) – –
Self–Injurious
Methods
Drowning – – – – – 0.2 (3)
Hanging – – 1 (3) 1 (12) – –
Jumping from High
Places – – 1 (3) 1.2 (15) – 0.5 (6)
Knife – 0.6 (8) – 1 (12) – 1 (13)
Lye – – 4.7 (15) – – –
Medication – 0.1 (1) 0.3 (1) 0.4 (5) – 0.9 (12)
Overdose – – 1 (3) – – 0.7 (9)
Pencil Sharpener – 0.1 (1) – – – –
Rope – – – 0.2 (3) – 0.5 (6)
Run Over – – – – – 0.3 (4)
Scissors – 0.2 (2) – – – –
Self-Mutilation – – 0.6 (2) 1.1 (13) – 0.7 (9)
Weapon – – 0.3 (1) 0.6 (7) – 0.5 (6)
Total – 1 (12) 8.9 (28) 5.5 (67) – 4.8 (68)
Total Coding Units 152 1263 314 1212 25 1271

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Eur. J. Ment. Health 2023, 18, e0004, 1–11. 7
Focusing on the comparison of the contents mentioned by the six adolescent groups , some dierences emerged
from our analysis. Globally, these dierences were considerably accentuated in the dimensions Consumption of
Psychoactive Substances, Moral Judgements and Self-Injurious Methods, where the three groups without a history
of NSSI, SI and SAs presented less or no coding units. On the other hand, the dierences in the remaining dimen-
sions/categories were residual. Regarding the dimension Consumption of Psychoactive Substances, this nding may
be explained by the fact that adolescents without a history of STBs generally attribute contents and causes of external
nature to individuals with STBs, such as the consumption of drugs and alcohol (Stewart et al., 2017). Likewise, in
our results, adolescents without a history of NSSI, SI and SA tended to associate negative judgments and stereotypes
with these phenomena, using terms such as “Stupidity”, “Cowardice” and “Ridiculous”. ese results are somewhat
in accordance with previous research indicating that stereotypical discourses and stigma are common in the context
of STBs (Duarte et al., 2019c; Gouveia-Pereira, & Sampaio, 2019; Fortune et al., 2008; Hollinger, 2016). Regarding
the dimension of Self-Injurious Methods, our results suggest that the perceptions of adolescents without a history of
NSSI, SI and SA give greater emphasis to the physical or behavioral engagement in self-aggressive methods.
Besides these disparities, most dimensions/categories were mentioned by all the adolescent groups, implying
that their perceptions were integrated in a system of shared meanings and that they were independent of the per-
sonal experience of STBs. ese conclusions allow us to hypothesize that adolescents without a history of these
behaviors are aware of these phenomena and try to understand the possible reasons that lead adolescents to engage
in NSSI, SI and SA. Likewise, it might imply that adolescents share information amongst themselves, discuss dif-
ferent subjects, considering each other’s opinions and experiences, which can justify the absence of dierences in
most of the categories. Other possible justication for this lack of dierences is due to the growing media visibility
regarding mental health, NSSI and STBs and to the fact that it may inuence views, attitudes and beliefs about
these issues. Lastly, we think it is essential to highlight the similarity of the perceptions concerning the three vari-
ables, which might be a sign that adolescents view NSSI, SI and SA as part of the suicidal continuum (Knorr et
al., 2019; Rogers et al., 2018) and not as entirely separate phenomena.
Strengths and Limitations
Although this study’s results contribute to the understanding of the perceptions of NSSI, SI and SAs, it is im-
portant to underline some limitations. Firstly, the free word association test has some negative points, such as the
fact that free associations are determined by fragments of ideas and concepts that, instead of continuing thought
and elaborate new associations, may create blocks that do not allow individuals to relate new associations to the
previous concept (Merten, 1992). Secondly, although the qualitative approach allows a deeper content analysis,
it also limits the results’ generalization. irdly, the previous history of NSSI, SI and SAs was assessed through
simple questions, which might bear some inuence on the prevalence rates. Since this study used a convenience
sample, further limitations relate to the homogeneity of the sample, sample size, sampling method, and data col-
lection setting (classroom).
Conclusion, Implications, and Future Directions
Considering the scarcity of studies focusing on the perceptions of NSSI, SI and SA and their increasing prevalence
in adolescence, this study aimed to describe adolescents’ perceptions about these phenomena, and to compare the
dierences of these perceptions among adolescents with and without a history of NSSI, SI and SAs. Our ndings
revealed that all the participants groups associated negative emotions with these variables and that adolescents
with and without a history of NSSI, SI and SAs presented dierences in their perceptions of these phenomena.
Besides contributing to the global understanding about these perceptions, our results might also have clinical
implications, since they indicate? that peers can play a potential supportive role in signaling NSSI and STBs and
for posterior intervention. Also, these results help to clarify and identify stereotypes and stigma that should be
addressed in prevention programs, adapting them to adolescents and their realities.
We consider it important to continue this line of research. Future studies could focus on understanding the
possible changes of perceptions over the development of adolescents, as well as should they change their percep-
tions according to the exposure to NSSI, SI and SA (i.e., friends’ knowledge; contact with online contents about
these phenomena). Also, we consider it equally important to understand whether STB perceptions dier in ar-
ticulation with other variables, such as religion or cultural background.

E. DUARTE ET AL. Non-Suicidal Self-Injury, Suicidal Ideation and Suicide Attempts
Eur. J. Ment. Health 2023, 18, e0004, 1–11. 8
Acknowledgements:
e authors would like to thank all the research participants.
Funding
e authors received neither nancial nor non-nancial support for the research (including data acquisition) and/
or authorship and/or publication of this article.
Author contributions
Eva Duarte: conceptualization, design, methodology, investigation, data management, formal analysis, interpreta-
tion, writing original draft, writing review and editing.
Soa Silva: conceptualization, methodology, project administration, data management, formal analysis, interpre-
tation, writing original draft.
Maria Gouveia-Pereira: conceptualization, design, methodology, project administration, interpretation, supervi-
sion, writing review and editing.
All authors gave their nal approval of the version to be published and agreed to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately
investigated and resolved.
Conicts of Interest
e authors declare no conicts of interest to disclose.
Ethical Statement
e research was approved by the General Education Directorate of the Ministry of Education and Science from
Portugal during March 2017.
is manuscript is the authors’ original work.
All participants engaged in the research voluntarily and anonymously, and provided their written informed con-
sent to participate in this study.
Data are stored in coded materials and databases without personal data, and the authors have policies in place to
manage and keep data secure.
Data Availability Statement
e data presented in this study are available upon request. All information regarding datasets was kept safe in an
encrypted le in our computers to preserve the anonymity of all participants. Still, we can make it available upon
request, by sending the authors an email with a valid request.
ORCID
Eva DUARTE https://orcid.org/0000-0001-6617-3252
Soa SILVA https://orcid.org/0000-0001-7166-8575
Maria GOUVEIA-PEREIRA https://orcid.org/0000-0001-7814-466X
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