Advertisement

Adolescent Research Review

, Volume 3, Issue 2, pp 173–191 | Cite as

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

  • Line Indrevoll Stänicke
  • Hanne Haavind
  • Siri Erika Gullestad
Qualitative Review

Abstract

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.

Keywords

Adolescence Meta-synthesis Self-harm Subjective experience Qualitative research 

Introduction

Self-harm is increasing across several countries, and especially among young girls (Morgan et al. 2017). We know that self-harm is related to different mental disorders and increased suicide risk (Hawton et al. 2012; Nock 2014). The question of what makes young people—most often women—inflict damage on their own bodies is perplexing. The increase of self-harm during adolescence raises the question if such behavior may be related to developmental challenges during adolescence, such as separation, autonomy and identity formation. Existing research has tended to ignore ordinary developmental tasks in their analysis of adolescent’s self-harm. One reason may be that reviews on self-harm have mostly focused on studies with adult participants (Edmondson et al. 2016; Klonsky 2007; Soyemoto 1998). Another reason may be that questionnaires used in epidemiological studies are mostly developed from knowledge about adult patients (Borschmann et al. 2011). Further, current theories on the function of self-harm are primarily based on the author’s descriptions of adult clients’ experience of self-harm, not on the self-harmers’ own descriptions (e.g. Favazza 2011/1987). Knowledge from qualitative studies are often excluded from reviews (Klonsky 2007). There is a need for studies enabling us to hear the adolescents’ own voice. Qualitative studies on adolescents who harm themselves aim at capturing the young persons’ own statements and descriptions of their experience, thus contributing to a deeper understanding of their inner world and the purpose of self-harm. A meta-synthesis of existing qualitative studies of young people’s experience of self-harm is a critical step to synthesize knowledge on self-harm from adolescents own perspective.

Self-Harm—Definition, Prevalence, Methods, and Risk Factors

Definitions of self-harm generally stipulate that the self-injury must be intentional, but differ on whether suicidal intent is included. In the UK, the concept of “deliberate self-harm” (DSH) refers to “intentional self-poisoning or self-injury, irrespective of type of motive or extent of suicidal intent” (Hawton et al. 2012, p. 2373). However, in the US, the concept of “non-suicidal self-injury” (NSSI) refers to “the deliberate destruction of one’s own bodily tissue in the absence of suicidal intent and for reasons not socially sanctioned” (Benley et al. 2014, p. 638). Although the central psychological qualities and method of self-harm may vary, there seems to be agreement in the research literature that self-harming behavior usually starts during adolescence, around 12–13 years of age (Swannell et al. 2014; Whitlock and Selekman 2014). Thus, adolescence may represent a critical period for understanding the development of self-harming behaviors.

Depending on the definition used, estimates of the prevalence of self-harm range from 13 to 17% in nonclinical adolescent samples (Swannell et al. 2014; Evans and Hurrell 2016), and 40–60% among adolescent psychiatric inpatients (Klonsky et al. 2014). Self-harm is more common among girls than among boys from 12 to 15 years of age. Furthermore, self-harm is becoming increasingly widespread among clients in clinical settings as well as among young people in general (Morgan et al. 2017; Whitlock and Selekman 2014). In epidemiological surveys, the frequency of self-harm varies across participants, be it once in a lifetime, once in the last year, or on a more regular basis. Most likely, the frequency with which a person engages in self-harm influences their experience and their psychological interpretation of what is at stake in the personal as well as in the cultural sense.

Self-harm includes a wide range of different behaviors; include cutting, burning, scratching, banging, hitting, and self-positioning. Cutting is the most common method for self-harm by both genders, while young men are more likely to use hitting and burning more than girls and women (Klonsky et al. 2014). Self-poisoning is more common among psychiatric inpatients compared to outpatients (Hawton et al. 2012; Swannell et al. 2014). Favazza (2011/1987) categorized cutting, burning, scratching, banging and hitting as “superficial/moderate self-mutilation”, which may be obsessive, episodic or repetitive behavior. He distinguished superficial self-mutilation from “major” (e.g., cutting one’s leg) or “stereotypic” forms (e.g., pulling out one’s hair). Self-harm may also be related to cultural, creative, religious or sexual acts, which are often excluded from health studies (Favazza 2011/1987).

The considerable number of epidemiological studies, drawing on surveys and quantitative analyses in studies of self-harm, has yielded valuable information about important risk factors for self-harm at the group level (for overview see: Hawton et al. 2012; Nock 2014). Risk factors for self-harm include female gender, low socio-economic status, sexual orientation, adverse childhood experience, abuse, family history of suicide, bullying, mental disorder, impulsivity, poor problem solving and low self-esteem, many of which are not very specific (Nock 2014). Although self-harming is not a separate diagnosis in either the ICD-10 (World Health Organization 2004) or the DSM-V (American Psychiatric Association 2013), it is often related to mental illness as well as increased risk of death. Specifically, self-harm is associated with mental disorders such as depressive disorder, anxiety disorders, drug addiction, eating disorders, post-traumatic stress disorder, autism, bipolar disorder, psychosis, borderline personality disorder (BPD) (Hawton et al. 2012). Klonsky and colleagues (2003) found that NSSI occurs and is associated with psychiatric morbidity even in non-clinical populations.

From laboratory studies, we know that people who self-harm display elevated physiological arousal in response to stressors, discontinue or escape stressful tasks sooner, and report greater efforts to suppress aversive thoughts and feelings during their day (Nock 2009). Research on physiological and neurobiological factors, such as pain endurance (Hooley and St. Germain 2014; Kirtley et al. 2016) and impulse-control (Hamza et al. 2015), and on genetic influence (Althoff et al. 2012; Maciejewski et al. 2014), is of importance to gain further knowledge of the phenomenon of self-harm at a group level.

Function of Self-Harm

Since the initial articles on self-harm (Emerson 1913; Menninger 1938), authors have proposed different functions self-harm may serve for the individual. However, in these articles, the reports on functions were based on the authors’ descriptions of mostly adult clients’ experience of self-harm, not on the self-harmers’ own account (e.g., Motz 2010; Straker 2006), and relatively few focused on adolescent clients (e.g., Brady 2014; Gvion and Fachler 2015). Soyemoto (1998) reviewed theoretical and empirical studies, and proposed “a functional model”. She argued that self-harm can serve different functions—to be reinforced by or to avoid punishment in the person’s environment (the environmental model), to protect the person from suicide (the anti-suicidal model), to satisfy sexual motives (the sexual model), to regulate overwhelming affects (the affect-regulation model), to serve as a defense mechanism against a dissociate state (the dissociation model), and/or to help the person to establish borders against others (“the boundaries model”). Klonsky (2007) systematically reviewed the empirical research on the functions of DSH among adults and adolescents, and found converging evidence for self-harm as “an affect-regulation function”—a way of alleviating overwhelming negative emotions associated with subsequent relief and calmness. The study also indicated strong support for a self-punishment function, and the findings were consistent across different ages and samples.

Nock and Prinstein (2004, 2005) introduced an empirically based “four-function model”. In their study of a clinical sample of young adults, they found support for NSSI being reinforced automatically (i.e., intrapersonally or by oneself) in positive ways (e.g., by making you feel good or generating energy) as well as in negative ways (e.g., by escaping from negative affect). They also found support for NSSI being reinforced socially (i.e., interpersonally or by others) either in positive (e.g., by gaining attention or access to resources) or negative ways (e.g. to avoid punishment by others). In line with these findings, Bentley and colleagues (2014) argue that NSSI regulates emotional and cognitive experiences and is a way to communicate with or influence others.

Most systematic reviews of self-harm focus mainly on adult participants or include only a few studies with adolescent participants (Klonsky 2007; Swannell et al. 2014). This is also the case in Edmondson and colleagues (2016) review of first-hand accounts on the reasons for self-harm other than an intention to die. The most endorsed reason for self-harm was to handle distress and exert interpersonal influence (for example to get attention or punish someone), but of importance was also positive and adaptive functions like self-validation and a personal sense of mastery. Theoretical functional models are not explicitly based on adolescents’ own understanding of their behavior. However, one exception is Jacobson and Gould’s (2007) review of self-harm among adolescents in mixed clinical and non-clinical samples. They found that the main reason for NSSI was to regulate negative emotion (negative reinforcement: to end a state of depression, tension, anxiety and/or fear and to reduce anger). A smaller minority of participants endorsed engaging in NSSI to prompt feelings when none exist (automatic positive reinforcement), to elicit attention (social positive reinforcement), or to remove social responsibilities (social negative reinforcement). Still, Jacobson and Gould (2007) and Edmondson and colleagues (2016) primarily included data from self-report questionnaires with pre-determined answer categories for frequency, methods, and reasons for self-harm, and only a few studies included open-ended questions (see also Klonsky 2007). Many of the questionnaires are thorough, but mostly customized as self-report questionnaires for adults and based on findings from adult clinical samples (Swannell et al. 2014). There are some exceptions, for example, Nock and Prinstein (2004, 2005) adjusted their questionnaire after a focus group discussion with adolescents both with and without self-harm experience.

Although quantitative studies have yielded important knowledge about self-harm, qualitative studies offer a unique opportunity to gain insight into the subjective experience of young people who self-harm. For obvious reasons, first-hand accounts from adolescents describing their experience of self-harm are missing in many of the epidemiological studies. In a phenomenological analysis of open interviews with adolescents (18 years or older) from a normal population who harmed themselves, Brown and Kimball (2013) presented three main themes; (1) self-harming is misunderstood, (2) self-harming has an important role in adolescent culture and (3) advice for professionals. The adolescents were concerned with themes such as differentiating between self-harm and suicidal behavior, self-harming as an addiction, interventions meant to help are not helpful, self-harming reflects mental and physical pain or trauma, and self-harming is about control or a need for punishment. In particular, the results of qualitative research on adolescents’ subjective experiences associated with intentional self-harm offer the potential to increase our understanding of how self-harm can become an important part of some adolescents’—often girls—movement from adolescence towards adulthood. Whatever the open or hidden purposes, there could be more than just one psychological issue at stake, and they are not necessarily the same for all persons engaging in similar self-harming practices. In review articles, qualitative studies are often excluded due to their relatively small number of cases in each study (Klonsky 2007). Although the number of qualitative studies on self-harm is growing, their clinical application and their contribution to knowledge about development will be limited unless the rich understanding collected from these interpretative studies can be synthesized (Levitt et al. 2016; Walsh and Downe 2004). A meta-synthesis of existing studies of young people’s experience of self-harm is a critical step in this direction.

Findings from qualitative studies serve as an essential complement to empirical quantitative studies, which typically focus on general, context-independent knowledge to capture different aspects of the phenomenon of self-harm. In the clinic and in the community, clinicians meet adolescents with different kinds of illness who self-harm for many different reasons and with varying frequency and severity. Findings from qualitative studies may contribute to a deeper understanding of the self-harmer’s inner world and experience. Such understanding may increase clinicians’ ability to empathize with their patients who self-harm, possibly contributing to more productive treatment processes. Qualitative studies can also serve to inform epidemiological and neurophysiological studies, and the ecological quality of existing questionnaires.

Current Study

This study provides a meta-synthesis of qualitative studies of self-harm among young people by exploring first person experiences of self-harm across relevant studies. The research aim was to investigate the purpose of self-harm, as understood by the young person herself. Furthermore, we proposed that self-harm in adolescence might be understood from a developmental perspective, i.e. as related to challenges faced in becoming a young woman or man. Adolescence is characterized by cognitive, biological, psychological and social changes (Siegel 2015). Developmental issues like separation, affect regulation, problem solving, autonomy, identity formation and relational fidelity are of great importance (Erikson 1980; Siegel 2015). In this meta-synthesis, we payed attention to how self-harm is linked to personal experiences and cultural issues in the studies of adolescents. Our research questions were: (1) What is the purpose of self-harm, as understood by the young person? Further, (2) Can adolescents’ experience of self-harm be related to the developmental challenges of becoming a young woman or man?

Method

We applied Noblit and Hare’s (1988, 1998) meta-ethnography method for meta-synthesis, and followed the seven steps they described; (1) Getting started, (2) Deciding what is relevant to the initial interest, (3) Reading the studies, (4) Determining how the studies are related, (5) Translating the studies into one another, (6) Synthesizing translations, and (7) Expressing the synthesis. We included qualitative studies focusing on adolescents’ experience of self-harm from the field of mental health and other disciplines, with different methodologies, and with clinical and non-clinical populations to highlight nuances in reasons for self-harm (Noblit and Hare 1988; Timulac 2009). Although the data from the different studies may not be transferable to different contexts, we assumed that the concepts and findings were relevant in a synthesized form. A meta-synthesis can serve to “reveal what is hidden in individual studies and to discover a whole among a set of parts” (Campbell et al. 2003, p. 680). We have found no meta-synthesis of self-harm among adolescents that focus on first-person experiences and open-question interviews. As this was a secondary synthesis of data, ethical approvals were not required.

Literature Search

The main author (LIS) undertook a conventional literature search, guided by words that could connect to self-harm, qualitative research, intention and adolescence (see Appendix for details). The following databases were searched: MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Pep-Web, ProQuest Dissertations & Theses, ProQuest Sociological Abstracts, Scopus, IBSS and Cochrane Library. We searched both MeSH words and free text in the relevant bases. The electronic search strategy identified 2300 references. We removed 952 duplicates, and 1348 unique records remained.

Inclusion and Exclusion Criteria

The first author (LIS) screened the records against the broad inclusion criteria ages 12–18 years, topic on self-harm, and qualitative methodology based on title and abstracts (see Table 1 for inclusion and exclusion criteria). This step excluded 1208 articles, and identified 140 articles for independent appraisal of the abstract by all reviewers (LIS, HH & SEG). We excluded studies with participants who primarily described suicidal intention. However, we included some studies with participants who had attempted suicide if they also described other motives for self-harm. Studies where self-harm was presented as the sequelae of a particular serious illness, such as psychosis, eating disorder, personality disorder, or mental retardation, were not found to be relevant to the meta-synthesis. The same principle for exclusion was applied when studies only covered indirect methods of self-harm, such as starving, smoking or using drugs. We included articles written in English, published and peer-reviewed in an academic journal or as a PhD thesis.

Table 1

Inclusion and exclusion criteria

Inclusion criteria

Exclusion criteria

Study population

Participants from 12 to18 years of age

Girls, boys and mixed gender

Participants younger than 12 and older than 18 years of age

Topic of interest

First-person descriptions of the experience of self-harm

Studies from the field of mental health and other disciplines, with different methodologies, nonclinical and clinical populations

Self-harm as part of a particular illness, such as psychosis, eating disorder, personality disorder, or mental retardation

Indirect ways of self-harm, such as starving, smoking or using drugs

Qualitative methodology

Explicit qualitative method for data analysis, and data collected with open interviews, semi-structured interviews or written text

Primarily used quantitative methods, questionnaires or presenting theoretical models

Direct citations

Includes reports of adolescents’ direct citations

No direct citations

Suicide attempt and motives for self-harm

Studies with participants who had attempted suicide if they also described other motives for self-harming behavior

Studies with participants who primarily described suicidal intention

Articles or Ph.D. thesis

Articles written in English, published and peer-reviewed in an academic journal or as a Ph.D. thesis

Study reported in another included article

The three authors appraised the appropriateness of the methodology using criteria adapted from Campbell and colleagues (2003). In particular, we looked for interview methods named as “open”, “semi-structured” or “in-depth”, and paid attention to results presented with direct citations and first-person accounts of self-harm from adolescents with relevant experiences. We excluded some seminal reviews, which primarily brought together the results from quantitative analyses, or knowledge from adults, as well as some books that mainly presented theoretical models (e.g., Adler and Adler 1998; Edmondson et al. 1916; Favazza 2011/1987; Gardner 2001; Hawton et al. 2012; Jacobson and Gould 2007; Klonsky 2007; Nock 2014). We checked reference lists of pertinent articles to complement the electronic search (“gray literature”). We included 41 articles for full-text review by all reviewers (LIS, HH & SEG), and ended with 20 articles after this phase (see Fig. 1 for a flow diagram). The first author (LIS) extracted characteristics of the included studies (author, year, title, context, participant characteristics, research methodology, and data analysis) dating from 1981 to 2016 (see Table 2).

Fig. 1

Flow diagram—steps and outcome

Table 2

Characteristics of studies included in the meta-synthesis

Authors (year)

Title

Country

Characteristics of participants

Sample size/gender

Age

Research design and analysis

Data collection

Concept of self-harm

Abrams and Gordon (2003)

Self-Harm Narratives of Urban and Suburban Young Women

US

Non-clinical, urban and suburban

6 girls

15–17

Thematic analysis of narratives

Semi-structured qualitative interviews

Self-harm

Adams et al. (2005)

Investigating the ‘self’ in deliberate self-harm

UK

Online discussion forums for self-harmers

13 (11 girls, 2 boys)

16–25

Interpretive Phenomenological Analysis

Two online focus groups and four email interviews

Deliberate

self-harm

Ayerst (2005)

The autobiographical construction of self-harm: A discourse-analytic study of adolescent narratives

Canada

Internet (25 narratives)

Mostly girls

1 boy?

12–25

Discourse analysis/Social-constructionist orientation

Narratives by adolescents about self-harm

Self-harm

Bedenko (2001)

A qualitative analysis of the function and intent of self-mutilative behaviour in an adolescent female

US

Clinical, therapy

1 girl

15

Qualitative study/

Grounded hermeneutic theory/A single subject case-study

Progression and analysis of psychotherapeutic treatment

Self -mutilative

behavior

Crouch and Wright (2004)

Deliberate Self-Harm at an Adolescent Unit: A Qualitative Investigation

UK

Adolescent Unit

Residential treatment setting for adolescents with mental health problems

6

(4 girls, 2 boys)

12–16

Qualitative study/interpretative phenomenological analysis

Semi-structured interviews and process notes from observations at the unit community meeting

Deliberate

Self-Harm

Gulbas et al. (2015)

An exploratory study of non-suicidal self-injury and suicidal behaviors in adolescent Latinas

US

Self-harmers with or without suicide from clinic population and non-self-harmers from non-clinic population

NSSI

(18 girls)

NSSI and attempted suicide (8 girls)

Suicide (29 girls)

11–19 years, average 15 years

Exploratory mixed-method analytic design/thematic analysis

In-depth qualitative interviews

No suicidal

self-injury

Holley (2016)

The lived experience of adolescents who engage in non-suicidal self-injury

US

Outpatient

Clinical

Purposive sample

6 (5 girls, 1 boy)

14–17

Phenomenological research

Semi-structured interviews/open ended interviews

No suicidal self-injury

Lesniak (2010)

The lived experience of adolescent females who self-injure by cutting

US

Students

6 girls

15–18

Qualitative study/phenomenological method/The Giorgi method and Humanistic Nursing Theory

Semi-structured Interviews

Self-injure

Lewis and Mehrabkhan (2016)

Every scar tells a story: Insight into people’s self-injury scar experiences

US, Europe, Australia and New Zealand

Internet

53 online testimony/posts on a popular NSSI message board

52 members

 

Thematic analysis

Posts online on experiences with scars from NSSI

Non-suicidal self-injury (NSSI)

Machoian, L. (2001)

The possibility of love: A psychological study of adolescent girls’ suicidal acts and self-mutilation

US

Private psychiatric hospital on an unlocked, voluntary adolescent residential unit

3 girls

12–17

Case study analysis/The

voice-centred relational method for data analysis, the “Listener’s Guide”

In-depth semi-structured clinical interviews

Self-mutilation

Magagna, J. In Briggs, S., Lemma, A., & Crouch, W. (2008)

Attacks on life; suicidality and self-harm in young people

US

Clinical case

1 girl

15

Case-study

 

Self-harm

Marshall, H. & Yazdani, A. (1999)

Locating Culture in Accounting for Self-Harm amongst Asian Young Women

UK

History of self-harm

7 girls

16–28

Qualitative research/discursive analysis

In-depth semi-structured interviews

Self-harm

McAndrew, S. & Warne, T. (2014)

Hearing the voices of young people who self-harm Implications for service providers

UK

Non-clinical sample

7 girls

13–17

Qualitative research/Interpretive phenomenological analysis/narratives

Face to face interviews

Self-harm

McDermott, E., Roen, K., & Piela, A. (2015)

Explaining Self-Harm: Youth Cybertalk and Marginalized Sexualities and Genders

Internet

Online forums for marginalized sexualities and genders (lesbian, gay, bisexual, and trans (LGBT) people)

49 excerpts, from 290 members

16–25

Qualitative virtual methods/

Thematic analysis

Posts online on emotional distress and self-harm

Self-harm

Moyer, M. & Nelson, K. W. (2007)

Investigating and understanding self-mutilation: The student voice

US

Students

6 (4 girls, 2 boys)

12–17

Qualitative research/Phenomeno-logical research

In-depth phenomenological interviewing, semi-structured interviews

Self-mutilation

Nice, T. (2012)

Troubled minds and scarred bodies: a grounded theory study of adolescent self-harm

UK

Presenting to hospital after an episode of self-harm

12

(9 girls, 3 boys)

13–16

Grounded theory study/Thematic analysis using a narrative and construct category based approach

Semi-structured interviews conducted after episodes of self-harm

Self-harm

Parfitt, A. (2005)

On aggression turned against the self

UK

NHS outpatient clinic, Psychoanalytic psychotherapy

1 girl

17

Case-study

Case-analysis

Deliberate self-harm

Privé, A. A. (2007)

An existential-phenomenological investigation of self -cutting among adolescent girls

US

High school, large urban school district

6 girls

15–18

An existential-phenomenological investigation and/Thematic analysis

Semi-structured interviews, open ended research questions

Self-cutting

Rissanen, M.-L., Kylmä, J., & Laukkanen, E. (2008)

Descriptions of self-mutilation among Finnish adolescents: a qualitative descriptive inquiry

Finland

Non-clinical adolescents

70 (69 girls, 1 boy)

12–21

A qualitative descriptive design/Content analysis

Asked to write descriptions of their self-mutilation

Self-mutilation

Yip., K.-S., Ngan, M-Y., & Lam, I. (2004)

Adolescent self-cutters in Hong Kong

Hong Kong

Secondary school

3 (2 girls, 1 boy)

14–18

Qualitative study/Thematic analysis

In-depth interviews about cause, process, and pattern

Self-cutters

The total number of participants was approximately 550 adolescents between 11 and 28 years of age. We included three studies with participants over 18 years with direct citations from those below 18 years represented in every theme (Adams et al.; Marshall and Yasdani 1999; Rissanen et al. 2008). In four studies, the participants’ age was not available, but the sample was based on Internet blogs for adolescents (Adams et al. 2005; Ayerst 2005; Lewis and Mehrabkhani 2017; McDermott et al. 2015). Eleven studies comprised samples with only women, and eight studies comprised mixed-gender samples with more than 75% girls. Two studies did not report gender. The majority of the studies were conducted in the US (n = 9) and the UK (n = 5). Seven studies were based on non-clinical samples, five in a hospital setting (acute ward or long-term treatment), four based in an outpatient unit, one based on a mixed clinical and non-clinical sample, and four with unknown samples (e.g., internet samples). Most authors used the concept of self-harm (n = 7) (both from UK and US), and some used self-mutilation (n = 5) (US and Scandinavia), DSH (n = 3) (UK) and NSSI (n = 3) (US). The most common form of self-harm among the participants was cutting. The studies represented different qualitative methodological traditions.

Translation and Synthesis

We read and reread the selected studies to identify first-, second-, and third-order constructs (Britten et al. 2002). One of the reviewers (LIS) listed the authors’ original findings, using their own concepts (first-order constructs), the authors’ interpretations of their findings (second-order constructs in the original studies), and looked for participants’ quotes supporting the concepts in each article (see Table 3 for an example). We developed sub-categories of the data between and within every study, and translated these findings from one study to another, by generating sub-themes (third-order constructs). Some of the sub-themes borrowed the terminology of one of the constituent articles (e.g., the term “feeling alive” from Ayerst’s (2005) article). The sub-themes encompassed most of the original concepts. In the end, we synthesized the sub-categories and sub-themes into meta-themes (third-order constructs).

Table 3

Example of first- and second-order constructs and participant’s quote

Author, year, title

E. E. Holley (2016): The lived experience of adolescents who engage in nonsuicidal self-injury

Participant’s quote

“I hate anger. I can’t do it. When I show it, I try to stop it right away. I hate when people are angry, so like whatever I hate I try not do it” (p. 70)

Themes and concepts

First-order constructs

“Negative emotionality”

Interpretations

Second-order constructs

Low distress tolerance, poor affect regulation skills, and utilized NSSI to obtain temporary emotional relief. Self-injurers are avoidant, as they supress both positive and negative emotionality, and actively avoid initiating, managing, or addressing conflict

Subcategory

A struggle to express feelings such as anger and sadness

Subtheme

A struggle to express affective experiences and tame anger

Meta-theme

Self-harm as a way to represent unaccepted feelings

During the review process, the team met for consensus meetings to decide on inclusion criteria and data extraction, to enhance multiple interpretations of data, and to develop concepts, in order to enhance the trustworthiness of our findings (methodological integrity checks; Levitt et al. 2016). In addition, we made individual discussion notes and engaged in self-reflection to enhance reflexivity of our therapeutic perspectives in the reading of the data (Lewitt et al. 2016).

Results

In the following, we document and illustrate how four meta-themes represent different ways adolescents experience self-harm: to obtain release or relief from a burden or intense feelings, to gain control over and cope with difficult feelings, to represent unaccepted feelings, and to connect with others. We present the sub-themes within each meta-theme, and each sub-theme was composed of a collection of sub-categories (see Table 4). We identified all meta-themes in the results across a majority of the studies (14 to 16 studies), and we found the sub-themes and sub-categories in some studies and not in others. We present the sub-categories with a sample of the original quotes to specify and add meaning to the four meta-themes, and to make the meta-synthesis transferable.

Table 4

Meta-themes, sub-themes, and sub-categories

Meta-themes

Sub-themes

Sub-categories

1. Self-harm as a way to obtain release or relief from a burden or intense feelings

1.1 Release

1.2 Self-hate

1.3 Feeling alive

1.4 Rush of

positive feelings

1.1.1 All the bad things go away

1.1.2 Release of pent up feelings/the pressure/distress related to an experience of necessity or else become mad

1.1.3 To get rid of pain, the stress, a problem

1.2.1 Hate towards self and a wish to disappear

1.2.2 Because they felt ugly and disgusting inside

1.2.3 A negative internal monologue

1.3.1 To get a feeling of being alive and feel something

1.3.2 A need to see the blood to know that they were alive

1.4.1 To get a positive feeling and experience of themselves

1.4.2 A positive feeling of rush and calm down

1.4.3 Like an addiction

2. Self-harm as a way to gain control or cope with difficult feelings

2.1 Get away from desperation and frustration

2.2 Control

2.3 Numbness

2.1.1 To get rid of emotional pain, such as anxiety, depression or feeling sad or anger

2.1.2 To get rid of difficult thoughts and feelings after traumatic experiences or ending a dissociated state

2.1.3 To get rid of pain, which also makes the adolescent feel guilty and shameful

2.2.1 To end feelings of alienation

2.2.2 To end specific feelings like sadness or angry

2.2.3 To take back control when helpless and overwhelmed

2.2.4 A way to change emotional pain to physical pain

2.2.5 A way to cope when nothing else helps

2.3.1 To reach a neutral feeling

2.3.2 Could end alienation

3. Self-harm as a way to represent unaccepted feelings

3.1 A struggle to express affective experiences and tame anger

3.2 Protect others

3.1.1 A struggle to find words and claim efficacy

3.1.2 To clear their mind and to make borders to others

3.1.3 A struggle to express feelings such as anger or sadness

3.1.4 To be aware of their own needs and to get help

3.2.1 A wish to not hurt others

3.2.2 To avoid conflicting or negative feelings in relation to or in situations with others

3.2.3 Don’t want to tell others about self-harm (secrecy)

4. Self-harm as a way to connect with others

4.1 Identification

4.2 A wish to share and be open

4.1.1 An experiment

4.1.2 The group identity, being connected to others with the same problems or identity - an oppositional element

4.1.3 Searching for self-identity

4.2.1 Unresolved anger

4.2.2 To express feelings and pain to others when other possibilities are unavailable or are unheard by others

4.2.3 To ask for help when they experienced a conflict between others about their problems

An experience of intolerable internal pressure with high intensity, which is overwhelming, has to end, and cannot be shown to other people. Self-harm makes it possible to express difficult affects, and still protect others

First Meta-theme: Self-Harm as a Way to Obtain Release or Relief from a Burden or Intense Feelings

Release

Ten of the studies highlighted release as the most important experience while self-harming. This sub-theme covered three sub-categories: (1) self-harm makes all the bad things go away (n = 6): “I don’t always cut to make a point, I cut because I need to…when I cut, when I see the blood, and I feel it rushing, it’s such relief. I can feel it; it’s like everything that is (bad) is just going out” (Machoian 2001, p. 26). (2) The release of pent up feelings/pressure/distress was experienced as a necessity or else the person would go mad (n = 3): “I felt I was going mad. I felt you know, I felt very blocked up inside, I didn’t feel normal, I felt different from everyone else. I felt angry and confused and empty, very empty inside, so I felt I was going mad, very much. I thought I was going mad” (Marshall & Yazdani 1999, p. 421). (3) After the release of feelings, the adolescents experienced that they were relieved of the pain, stress, or problem (n = 1): “It would be a relief for, basically, like, everything that was going on, the stress. It was a kind of a relief for me because each cut that happened was a relief from a problem” (McAndrew and Warne 2014, p. 573).

Self-Hate

In six articles, adolescents reported self-harm due to self-hate. The sub-theme encompassed three sub-categories: (1) Often, they reported hate towards themselves and a wish to disappear (n = 4): “It (body dissatisfaction) made me really depressed, contemplate suicide, and start self-harming” (McDermott et al. 2015, p. 880). Furthermore, “I want to scream, I want to cut myself so much that I disappear, I fucking hate myself” (Parfitt 2005, p. 161). (2) Two articles described how adolescents directed hate towards themselves because they felt ugly and disgusting inside: “I’ve cut loads recently, there’s so much shit inside me and I hate myself so much, I’m such a bitch slut I have to be punished” (Parfitt 2005, p. 161). (3) A few articles (n = 2) reported self-harm in relation to a negative internal monologue: “I just get everything going through my head, and then just think about it, and then I just cut myself” (Moyer and Nelson 2007, p. 45).

Feeling Alive

In four articles, self-harm was described as a way to feel alive, and this sub-theme consisted of two sub-categories: (1) Three articles reported self-harm as a possibility to feel alive, or just feel something: “…My harmness to myself is an expression of emotional pain, I needed to feel something, to know that I was still alive…” (Ayerst 2005, p. 90). (2) Another sub-category was a need to see the blood to know that they are alive (n = 1): When I saw my blood running out I knew I was alive (Rissanen et al. 2008, p. 156).

Rush of Positive Feelings

In four articles, the positive feelings related to self-harm were important for the adolescents. This sub-theme included three sub-categories; (1) Self-harm was reported as a way to get a positive feeling and experience of themselves (n = 3): “The bliss I felt during it was practically orgasmic. It was the best feeling I had ever felt” (Ayerst 2005, p. 84). (2) Others described a positive feeling of a rush and calmness as an important part of the self-harming experience (n = 1): “It’s like a drug… It’s kinda like a rush that you get in your head and you are like YES” (Privé 2007, p. 78). (3) Some also described the experience more like an addiction (n = 1): “I feel I’m hooked on cutting” (Rissanen et al. 2008, p. 157).

Second Meta-theme: Self-Harm as a Way to Control or to Cope with Difficult Feelings

To Get Away from Desperation and Frustration

In eleven studies, adolescents described the effect of self-harm as an escape from desperation and frustration. Three sub-categories were identified: (1) Adolescents described how they used self-harm to get rid of emotional pain, such as anxiety, depression or feeling sad or angry (n = 6). An adolescent from Privé’s (2007) study said “I was very upset… I was just mad…I was just angry at them… then every time I was mad, I would just sit there…and I wouldn’t scream, I would just cut myself” (p. 75). (2) The cutting was also done to get rid of difficult thoughts and feelings after traumatic experiences or to end a dissociated state (n = 2), as described by a girl in Ayerst’s (2005) study: “The pain washes over, cleaning off the dark and hurtful things that cling to my mind” (p. 88). (3) In some studies (n = 4), self-harm is related to getting rid of pain, which also results in the adolescents feeling guilty and shameful: “I’m starting to feel guilty every time. That’s the only feeling afterward now” (Moyer and Nelson 2007, p. 46). In this way, self-harm can be seen as a method to get rid of difficult feelings, and to find a solution to reduce tension, frustration, or pressure, but may also contribute to additional problems, such as guilt and shame, for some young people.

Control

In nine of the studies, the adolescents highlighted the element of control that self-harm provided in relation to different feelings and in relation to other people, and five sub-categories were included: (1) Control is related to ending feelings of alienation (n = 1): “For once I had a sense of control on my body. I wanted to feel unique and I had to cope with my feelings of alienation” (Ayerst 2005, p. 93). (2) How self-harm can end more specific feelings like sadness or anger was also of importance (n = 5): It was in my hand (the nail file), and I was thinking, “What I’m going to do with this? I’m not going to kill myself because I do not want to die. I want to just stop feeling angry. Inside me was screaming. I was feeling really, really angry” (Gulbas 2015, p. 306). The necessity of taking control was associated with difficulties showing feelings in general: “By self-mutilation, I can avoid crying in the wrong places, stay cool” (Rissanen et al. 2008, p. 156). (3) Self-harm may also be related to a state of helplessness and to feeling overwhelmed and represent a way to take back control (n = 3): “I hate the feeling that other people can make me cry so it’s a relief that they are not controlling me crying this time. I can do it myself” (Gulbas 2015, p. 306). (4) Self-harm was also mentioned as a way to change emotional pain to physical pain, which gave a feeling of being in control (n = 1): “Cleansing, just getting rid of it (the pain). Every feeling you feel is going into your cut. The pain you feel goes into that (cutting)” (Moyer and Nelson 2007, p. 46). (5) Some reported self-harm as their last choice, but a way to cope when nothing else helps (n = 2): “Writing didn’t help anymore, talking didn’t help anymore… so I just got the razor blade” (Privé 2007, p. 80). The experience of regaining control after being overwhelmed is a central aspect for these adolescents.

Numbness

In some of the studies (n = 6), the element of control was the first step in a process to become neutral. Two sub-categories were found: (1) Self-harm was a way to reach a neutral feeling: “It went numb, I couldn’t feel it anymore… I couldn’t feel anything” (Privé 2007, p. 80). For some, numbness was the goal. (2) For others, achieving numbness through self-harm could end feelings of alienation.

Third Meta-theme: Self-Harm as a Way to Represent Unaccepted Feelings

A Struggle to Express Affective Experiences and Tame Anger

In eight of the studies, adolescents indicated self-harm as part of a struggle to express their own feelings and difficulties. This sub-theme comprised four sub-categories: (1) More specifically, they experienced a struggle to find words, assert their voice, and claim efficacy (n = 4) in difficult situations and in interpersonal conflicts: “I feel extremely frustrated when my friend and teacher blame me. I feel crazy. I don’t know how to scold back. I feel frustrated. I need to do self-cutting to release my sense of emptiness” (Yip et al. 2004, p. 44). (2) Self-harm may also be a way to clear one’s mind and to establish boundaries with others (n = 1): “… clear my mind and get everything else out. It just blocks the whole world so it’s just me” (Moyer and Nelson 2007, p. 46). (3) Some mentioned a struggle to express feelings (n = 3), such as anger, as a reason for self-harm: “I hate anger. I can’t do it. When I show it, I try to stop it right away. I hate when people are angry, so like whatever I hate I try not to do” (Holley 2016, p. 70). Others struggled to express happiness; “True happiness or joy… it’s really hard to express for me. I feel it sometimes I don’t know why I can’t show it” (Holley 2016, p. 71). (4) Some described self-harm as a way to be aware of their own needs and especially to get help from others (n = 2): “I think it’s a form of manipulation, of manipulating other people, and I hate that. And I hate to think that I do that, but I know I do… in some ways, I have used it to get the support that I need at that moment of time. And I think that is manipulation. And I hate that” (Machoian 1998, p. 26).

To Protect Others

In five studies, adolescents described how important it was for them to protect others (parents and friends) from their difficult feelings in general or from the fact that they were harming themselves. This subtheme included three sub-categories: (1) Adolescents reported an explicit wish not to hurt others (n = 1): “I don’t take my anger out on other people. Like some people fight to let out their anger. I don’t do that. I hurt myself” (Moyer and Nelson 2007, p. 47). (2) Others avoided the conflicting or negative feelings in relation with others in general (n = 4): “I have enormous amounts of rage within and I’m afraid to express it outwardly, and by injuring myself, it is a way of venting my feelings” (Ayerst 2005, p. 92). (3) They also described how they don’t want to tell others about their self-harm (secrecy) (n = 1): “…’cos I went for years without no-one finding out about my self-harming and I didn’t want anyone to know about it, so that makes me angry, especially when I know some people that do it for attention” (Crouch and Wright 2004, p. 194).

Fourth Meta-theme: Self-Harm as a Way to Connect with Others

Identification

This sub-theme included eight articles and covered three sub-categories related to how adolescents perceived self-harm as part of being in a social group and of identity construction processes: (1) In some studies, adolescents reported starting with self-harm as an experiment (n = 2): “When I started junior secondary school, my puberty was beginning. At that time, I cut myself for the first time. It was just an experiment, nothing more” (Rissanen et al. 2008, p. 156) and “I had nothing else to do” (Rissanen et al. 2008, p. 156). (2) In six studies, the group identity (n = 11) for adolescents who harmed themselves was important, especially to be a real self-harmer, not copying others, but also to see themselves as different and having trouble: “I’m also more f***d up in the head than most people. Looking at my cuts this morning made me feel sick—it reminds me that I’m screwed up, that my head doesn’t work the same as everyone else’s” (Adams et al. 2005, p. 1305). This sub-category also included a positive experience of being connected to others with the same problems or identity as outsiders: “It wasn’t until I managed to persuade my mum to get the internet on our computer that I discovered that I was far from being the only one who liked to harm herself. I have met loads of really fab people online through self-harm websites and chat rooms and stuff” (Ayerst 2005, p. 94). An oppositional element was also described: “Why waste my time just so society can think I’m a happy guy like the rest of them?” (Holley 2016, p. 67). (3) The last sub-category was about self-harm as part of a process of searching for self-identity (n = 2): “Yeah. What I was and what I was meant to be, and where I was happier. Taking part from then, and now reconnecting it to my experiences and myself now. Well, it’s just moving on. And like, I saw that as connected. Like this thing, and like I could have gone down that path or that path, but I took the weird one and it just eventually connected with my real path, the one I was meant to be on” (Bedenko 2001, p. 148). The sub-theme of identity highlighted how adolescents are conscious of self-harm as a cultural sign, and not just as a symptom of mental illness—as an alternative to being an outsider of the dominant culture.

A Wish to Share and Be Open

In twelve studies, adolescents described different ways self-harm was related to expressions of feelings, and three sub-categories were identified: (1) In three studies, self-harm was related to unresolved anger: “I just get pissed, and whenever I get mad, I like… throw things, and I’m like really aggressive… and sometimes when I get mad, I just carve things on myself. Whenever I was mad, it was just like a way to calm down. So, sometimes I still do that. Like one time I was mad at my boyfriend, and I did something wrong. And I was sorry. He was pissed, and he didn’t want to talk to me. So, I carved it in my arm, but you can’t see it anymore” (Abrahms & Gordon 2003, p. 437). (2) Three studies, report self-harm as a way to express emotional pain to others: “It just makes my pain easier to see” (Lesniak 2010, p. 141). The expression of pain in this way was particularly important when other possibilities are unavailable or felt unheard by others: “When they see it, like actually see it (a cut), they’re like, wow, maybe something is wrong. It’s like yes, you (expletive) idiot something is wrong. I’ve only been saying it for the last 17 years… People won’t believe that something is wrong… It’s, it’s an actualization of pain, you know…The most basic is that even if you tell people that something is wrong, a lot of times…they won’t, they won’t know how wrong. But all they’ll do is see a cut along a vein, and they get the message right away” (Machoian 1998, p. 25). (3) In five studies, adolescents described self-harm as a way to ask for help about their problems: “It is true that cutting is a cry for help. I wish someone adult would see my cuts and scars and help me. I have no words to ask for it (help)” (Rissanen et al. 2008, p. 156).

Discussion

This meta-synthesis of qualitative studies of first person accounts of self-harm supplements quantitative studies in important ways. This is particularly so when it comes to the conceptual modeling of the psychological functions of self-harm. Attention is moved from “causes” and “risk factors”—which are not very specific—to purpose and consequences. Theories of the function of self-harm are mostly based on the authors’ rendering of their clients’ understanding of self-harm (Soyemoto 1998), and studies of the participants’ experience are often based on questionnaires with pre-determined categories developed from adult clients (Edmondson et al. 2016). Consequently, we had limited knowledge about the motives of self-injuring behavior, particularly among adolescents.

Since the number of qualitative studies of subjective experience of self-harm is growing, there was a need to synthesize existing findings about young people in the phase of life when such behaviors tend to develop. Finding twenty highly relevant studies appeared to be a strong start. During the analysis, it was possible to compare content and design themes across studies including clinical as well as non-clinical samples.

In the following, we discuss how our findings on the purpose of self-harm from the adolescent’s perspective support and add nuance to our existing knowledge. We argue that self-harm is a way to regulate affect. Furthermore, we underline how the action of self-harm may be a way to contain important emotional and relational content for the adolescent, and may express an intention or wish to connect and communicate with others. We also discuss common elements across the meta-themes and how self-harm may represent an insufficient solution to conflicting psychological needs and developmental challenges in adolescence. We highlight how the studies included in our meta-synthesis seldom relate their findings to developmental issues in adolescence, or the fact that young girls are overrepresented in the studies on self-harm.

The Purpose of Self-Harm from the Adolescents’ Perspective

Common across the four meta-themes is an experience of intolerable internal pressure and intense frustration, which is overwhelming, must be brought to an end, and cannot be shown to other people. Adolescents experience self-harm as a way to obtain release or relief, or to gain control of difficult and overwhelming stress and feelings. The first and second meta-theme in our findings overlap with Klonsky’s (2007; Klonsky et al. 2014) and Jacobson and Gould’s (2007) focus on self-harm as a way to regulate or activate affect, and Edmondson and colleagues’ (2016) report on how self-harm is a way to handle distress and establish a personal sense of mastery. Thus, affect regulation emerges as a major function of self-harm.

The third and fourth meta-theme in our findings nuance our current understanding of adolescents’ experience of self-harm. The third meta-theme shows how self-harm may be an important way to represent unacceptable affective experiences in general. Self-harm may be a way of becoming aware of one’s own needs and difficulties. Further, self-harm may express the struggle to represent that something is difficult when other options are unavailable (Adams et al. 2005; Machoian 2001), or the ability of symbolization is undeveloped (Bouchard and Lecours 2008). The concrete action of self-harm may bring something to attention from the individual’s inner or outer world. The fourth meta-theme highlights how adolescent girls, and some boys, often experience self-harm in a relational context. Self-harm may serve to express internal pain to others in a situation of conflict or to ask for help (Adams et al. 2005; Crouch and Wright 2004). When feeling lonely and isolated, self-harm may convey a wish to connect with others (Lesniak 2010; Machoian 1998) or a way to be part of a sub-group (Moyer & Nelsons 2007; Nice 2012).

Our findings underline the importance of understanding self-harm not only as a disturbance in an individual’s capacity for affect regulation, but also in connection to the adolescent’s problems in finding ways to express themselves, to communicate more freely, and to share experiences in relation to important others. Communicative and interpersonal functions of self-harm are mentioned in Klonsky’s (2007; Klonsky et al. 2014), Nock and Prinstein’s (2004, 2005), and Soyemoto’s (1998) models of self-harm. Edmondson and colleagues (2016) report that self-harm can serve to define the self and exert interpersonal influence. Jacobson and Gould (2007) underline that self-harm can elicit attention and can be a way to get away from social responsibilities. However, more specifically, adolescent girls and boys often struggle to represent their experiences, and they may adjust their expressions of difficult issues and harm themselves to protect and not hurt important others. In this way, self-harm can contain important emotional content and represent a wish to connect, communicate with, and be understood by others. In a clinical setting, this content may be important to explore further in order to help the self-harming adolescent get to know and tolerate their needs and feelings, and express themselves more freely and less destructively.

Self-Harm as an Expression of a Conflict and Developmental Challenges

A remaining question, however, is why some adolescents end up with a strong inclination to damage their own body-tissue in order to handle unbearable and overwhelming feelings and tensions?

In many of the studies, adolescents reported ambivalence about sharing their experiences with others. They were afraid of showing their feelings or frustration, did not want to be judged by others, but also explicitly wished to gain some understanding from others. In our view, self-harm can be a way to solve a conflict between basic psychological needs and developmental tasks, which are important in adolescence (Erikson 1980; Siegel 2015). On the one hand, the young girl or boy needs to represent and express affective experiences, and on the other, they have a relational need for attachment, safety, acceptance, and affiliation. Expressing unbearable pressure or feelings, such as anger and frustration, may be impossible for some adolescents because of their need to protect others from their feelings and their need for support. Self-harm may be an expression of this inner conflict.

Furthermore, self-harm—after the immediate relief—may evoke strong and difficult feelings and reactions in others, and subsequent feelings of shame, loneliness, and hopelessness in the young girl or boy. Thus, self-harm does not release the adolescent from all of their problems. Nevertheless, self-harmers return to self-harming behaviors that, although insufficient, still seem to be the only possible solution available to them now. The adolescent can hide the issue causing distress, and yet the adolescent is still trying to express him or herself and share their experience—which could be the ultimate experiential proof of existence. What is at stake here is the ongoing developmental process of psychological separation towards autonomy, to become an authentic self, to establish a boundary between self and others, and to establish new forms of relational reciprocity with important others. In adults, self-harm may have lost its initial association with these issues. From this perspective, self-harm may be a sign (Brady 2014; Motz 2010) of urgent developmental challenges in the process of self-representation and identity formation (Erikson 1980).

Descriptions of self-harm comprise a wide range of affective experiences. Some adolescents specify difficult feelings, thoughts or interpersonal conflicts, but others describe diffuse stress or arousal. For some, self-harm is associated with specific representations of mental content, but for others, self-harm may be a sign of a more pervasive deficit and disturbance in their ability to differentiate and express affect and needs (Bouchard and Lecours 2008).

Many of the reported citations refer to problems with or different ways to deal with anger. Some of the adolescents do not want to experience anger at all, or do not want to show anger to others (Bedenko 2001; Magagna 2008). Other adolescents express relief that they can turn the anger toward themselves and thereby protect others from their own difficult feelings (Parfitt 2005; Yip et al. 2004). Anger is one of our basic emotions and is critical to protecting our body and self from threats in the environment, or from difficult inner feelings, thoughts or fantasies (Panksepp 2010). From this perspective, the “harming” and the violent aspect of self-harm may be related to the adolescent’s effort to tame or express anger. Further, self-harm may be a way to establish, or re-establish, a boundary between self and others when they feel intruded or threatened. The harming of the body may represent, in a concrete way, the undeveloped or insufficient solution to psychological challenges in adolescence.

Self-Harm in a Developmental and Cultural Context

Although the participants in the included studies were primarily between 12 and 18 years of age, the authors of the studies seldom related their findings to developmental challenges in adolescence. There are some exceptions (Crouch and Wright 2004; Machoian 2001; McDermott et al. 2015; Parfitt 2005; Privé 2007), but often the findings are interpreted as being “age neutral”. In our opinion, it is important to relate our findings to our knowledge of adolescence in general. Impulsivity, sensation seeking, emotional instability, risk behavior—such as self-harm—and testing of limits are usual phenomena in adolescence (Casey et al. 2008). For many adolescents, this behavior declines as they reach adulthood.

Favazza (2011/1987) argues that the main perspective in the research literature on self-harm is a clinical-medical perspective and that self-harm cannot be reduced to a symptom of a mental illness (see also Adler & Adler 2003). In “The coming of age of self-mutilation”, Favazza (1998) asks whether self-mutilation has become more normalized in recent years. Whitlock and Selekman (2014) also ask whether the social motivation for starting to self-harm is increasing. Among the studies included in our meta-synthesis, some authors report social or existential issues as important factors to understanding self-harm, like social belonging and psychosocial exclusion (Abrams & Gordons 2003; Adams et al. 2005; Ayerst 2005), control and vulnerability (Marshall & Yazdani 1999), bullying, and cultural differences (Gulbas 2015; McDermott et al. 2015). Self-harm is underlined as a cultural expression of identity and as an accepted way of coping with difficult feelings.

Participants in the included studies are mostly girls and young women, but only a few authors discuss this gender disparity in their articles (McDermott et al. 2015; Lesniak 2010). The findings are presented in a somewhat “gender neutral” way. Although girls are overrepresented in the studies, it is important to remember that self-harm is not a “normal” behavior among girls in general. Still, adolescent girls (and some boys) may struggle to find “accepted” channels to express frustration and conflicting needs. Self-harm may be related to a narrow and limiting pathway to adulthood in a given cultural context, particularly for girls. Their relational need to be accepted and cared for overrules their need for expressing themselves. In our perspective, self-harm can be a sign of mental illness, but may also be regarded as a destructive “answer” or coping strategy for responding to challenging developmental tasks like separation, autonomy and identity formation in the process to become a young woman.

Limitations of the Current Study

Every included study consists of rich and comprehensive data-material, and our analysis was depending on the findings in every study. Therefore, a meta-synthesis cannot present conclusions, but may serve as a working model. Still, it is valuable to consider the various strengths and weaknesses of the included studies.

In our meta-synthesis, we included studies with different terminology and definitions of self-harm. However, our focus was on the adolescent’s perspective of self-harm, rather than a wish to die. There is also heterogeneity in the conduct and presentation of meta-ethnography, and a lack of consistency in reporting procedures for the meta-synthesis (Evans and Hurrell 2016). We have tried to be explicit concerning our methodological approach, our analytic process, and our presentation of the findings. Despite the limitations, the themes that emerged and their clustering and hierarchy brought more specificity to how a young person experience the act of self-harm and the purposes it serves.

Implications for Further Research

The many related sub-categories highlight the diversity and commonalities among adolescents’ descriptions and experiences of self-harm. However, further studies are needed to address hypotheses about sub-groups, which then would be interesting to explore in more detail.

Differences in frequency, methods and mental illness are important aspects of the individual differences among adolescents who harm themselves (Hawton et al. 2012; Bentley et al. 2014; Whitlock and Selekman 2014), but differences in subjective experience could also be an important aspect to study in this regard. For example, are there differences in adolescents’ capacity to represent, symbolize and reflect upon their affective and inner experiences? Are there important differences in self-esteem and their representation of self? Further, are there developmental differences (i.e., vulnerabilities or deficits) among adolescents when they start to self-harm that influence their experience of self-harm, the development of pathology such as BPD, or the degree to which self-harm affects their life? These questions are difficult to answer, but may be important in further research on differences between clinical and non-clinical adolescents, and between girls and boys.

Conclusion

Since self-harm seems to start in adolescence and has increased among young people in recent years, there are reasons to see self-harm as a phenomenon with core characteristics, a set of sub-categories, and specific subjective aims. In this meta-synthesis, we translated and integrated findings from prior qualitative studies. The four meta-themes that emerged represent different ways adolescents experience self-harm—as a way to obtain release, to control feelings, to represent unaccepted feelings, and to connect with others. The meta-themes “to obtain release” and “to control feelings” overlap with findings in reviews on adolescents (Jacobson and Gould 2007) and adults using self-report methods (Klonsky; Edmondson et al. 2016), and support the theory of self-harm as a function of affect regulation (Klonsky et al. 2014).

However, the meta-themes “to represent unaccepted feelings” and “to connect with others” highlight the importance of understanding how self-harm may contain emotional and relational content. Self-harm in adolescence is closely related to a struggle to express themselves and a wish to communicate and share experiences with important others. Given that self-harming behavior typically emerges during adolescence, it is helpful to link our knowledge of self-harm to the major developmental challenges adolescents face, such as separation, identity formation, autonomy and relational fidelity (Erikson 1980; Siegel 2015). The meta-themes and the common theme—intolerable internal pressure—points to a psychosocial dynamic understanding. We argue that self-harm can be understood as a conflict between basic psychological needs—a possibility to express frustration and still protect important others. It may be challenging to find ways to represent and express feelings, such as sadness, jealousy, anger, and frustration, because of the enduring need to be cared for in their daily life. Our findings can be important in a clinical setting, particularly by informing the therapist about the necessity of helping the adolescent to explore and develop alternative ways to regulate and express feelings. In addition, it may be fruitful for the therapist, like researchers, to relate self-harm to identity formation, and to the adolescent’s developmental need to become an authentic self in relations with others. In this way, self-harm does not need to be the only way to handle overwhelming feelings, trauma, and loneliness.

Notes

Acknowledgements

The authors wish to thank Glenn Karlsen Bjerkenes and Hege Ringnes at the University of Oslo, Norway for their assistance with the literature search, and Caryl Gay, PhD at the University of California, San Francisco for proof reading the manuscript.

Authors’ contributions

LIS conceived of the study, participated in its design and coordination and drafted the manuscript; HH participated in the design and interpretation of the data; SEG participated in the design and interpretation of the data. All authors read, helped to draft, and approved the final manuscript.

Funding

The Norwegian Extra Foundation for Health and Rehabilitation and The Norwegian Council for Mental Health provided funding for this study, FO4115. They had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the article for publication.

Compliance with Ethical Standards

Conflict of Interest

The authors report no conflict of interests.

Research Involving Human and Animal Participants

This article does not contain any studies with human participants or animals performed by any of the authors.

References

References marked with * are included in the meta-synthesis

  1. *Abrams, L. S., & Gordon, A. L. (2003). Self-harm narratives of urban and suburban young women. Affilia-Journal of Women and Social Work, 18(4), 429–444.  https://doi.org/10.1177/0886109903257668.
  2. *Adams, J., Rodham, K., & Gavin, J. (2005). Investigating the ‘self’ in deliberate self-harm. Qualitative Health Research, 15(10), 1293–1309.  https://doi.org/10.1177/1049732305281761.
  3. Adler, P. A., & Adler, P. (2011). The tender cut. Inside the hidden world of self-injury. New York: New York University Press.Google Scholar
  4. Althoff, R. R., Hudziak, J. J., Willemsen, G., Hudziak, V., Bartels, M., & Boomsma, D. I. (2012). Genetic and environmental contributions self-reported thoughts of self-harm and suicide. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics, 159B(1), 120–127.  https://doi.org/10.1002/ajmg.b.32010.CrossRefGoogle Scholar
  5. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association: Washington, DC.CrossRefGoogle Scholar
  6. *Ayerst, S. (2005). The autobiographical construction of self-harm: A discourse-analytic study of adolescent narratives. (Doctoral dissertation). Available from ProQuest Dissertations and Thesis database. (UMI No. MR01787).Google Scholar
  7. *Bedenko, W. E. (2001). A qualitative analysis of the function and intent of self-mutilative behavior in an adolescent female. (Doctoral dissertation). Retrieved from ProQuest Dissertations Publishing. (UMI No. 2001. 3024540).Google Scholar
  8. Bentley, K. H., Nock, M. K., & Barlow, D. H. (2014). The four-function model of nonsuicidal self-injury: Key directions for future research. Clinical Psychological Science, 2(5), 638–656.  https://doi.org/10.1177/2167702613514563.CrossRefGoogle Scholar
  9. Borschmann, R. J., Hogg, R., Phillips, P., & Moran, P. (2011). Measuring self-harm in adults: A systematic review. European Psychiatry.  https://doi.org/10.1016/j.eurpsy.2011.04.005.PubMedGoogle Scholar
  10. Bouchard, M. A., & Lecours, S. (2008). Contemporary Approaches to Mentalization in the Light of Freud´s project. In F. Busch (Ed.), Mentalization: Theoretical Considerations, Research Findings, and Clinical Implications. New York: Taylor and Francis.Google Scholar
  11. Brady, M. T. (2014). Cutting the silence: Initial, impulsive self-cutting in adolescence. Journal of Child Psychotherapy, 40(3), 287–301.  https://doi.org/10.1080/0075417X.2014.965430.CrossRefGoogle Scholar
  12. Britten, N., Campbell, R., Pope, C., Donovan, J., Morgan, M., & Pill, R. (2002). Using meta-ethnography to synthesize qualitative research: A worked example. Journal of Health Services Research & Policy, 7(4), 209–215.  https://doi.org/10.1258/135581902320432732.CrossRefGoogle Scholar
  13. Brown, T. B., & Kimball, T. (2012). Cutting to Live: A phenomenology of Self-Harm. Journal of Marital and Family Therapy, 39, 2,195–208.CrossRefGoogle Scholar
  14. Campbell, R., Pund, P., Pope, C., Britten, N., Pill, R., Morgan, M., & Donovan, J. (2003). Evaluating meta-ethnography: A synthesis of qualitative research on lay experiences of diabetes and diabetes care.. Social Science & Medicine, 56, 671–684.  https://doi.org/10.1016/S0277-9536(02)00064-3.CrossRefGoogle Scholar
  15. Casey, B. J., Jones, R. M., & Hare, T. A. (2008). The adolescent brain. Annals of the New York Academy of Sciences, 1124, 111–126.  https://doi.org/10.1196/annals.1440.010.CrossRefPubMedPubMedCentralGoogle Scholar
  16. *Crouch, W., & Wright, J. (2004). Deliberate self-harm at an adolescent unit: A qualitative investigation. Clinical Child Psychology and Psychiatry, 9(2), 185–204.  https://doi.org/10.1177/1359104504041918.
  17. Edmondson, A. J., Brennan, C. A., & House, A. (2016). Non-suicidal reasons for self-harm: A systematic review of self-reported accounts. Journal of Affective Disorders, 191, 109–117.  https://doi.org/10.1016/j.jad.2015.11.043.CrossRefPubMedGoogle Scholar
  18. Emerson, L. E. (1913). The case of Miss A: A preliminary report of a psychoanalytic study and treatment of a case of self-mutilation. Psychoanalytic Review, 1(1), 41–54.Google Scholar
  19. Erikson, E. H. (1980). Identity and life cycle. New York: WW Norton.Google Scholar
  20. Evans, R., & Hurrell, C. (2016). The role of schools in children and young people’s self-harm and suicide: Systematic review and meta-ethnography of qualitative research. BMC Public Health, 16, 401–416.  https://doi.org/10.1186/s12889-016-3065-2.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Favazza, A. R. (1998). The coming of age of self-mutilation. The Journal of Nervous & Mental Disease, 186(5), 259–268. ISSN: 0022–3018.CrossRefGoogle Scholar
  22. Favazza, A. R. (2011/1987). Bodies under siege. Self-mutilation, nonsuicidal self-injury, and body modification in culture and psychiatry (Third edn.). 2011. Baltimore: The John Hopkins University Press.Google Scholar
  23. Gardner, F. (2001). Self-harm: A psychotherapeutic approach. New York: Taylor & Francis Inc.CrossRefGoogle Scholar
  24. *Gulbas, L. E., Tyler, T. R., & Zayas, L. H. (2015). An exploratory study of nonsuicidal self-injury and suicidal behaviors in adolescent Latinas. American Journal of Orthopsychiatry, 85(4), 302–314.  https://doi.org/10.1037/ort0000073.
  25. Gvion, Y., & Fachler, A. (2015). Traumatic experiences and their relationship to self-destructive behavior in adolescence. Journal of Infant, Child, and Adolescent Psychotherapy, 14(4), 406–422.  https://doi.org/10.1080/15289168.2015.1090863.
  26. Hamza, C. A., Willoughby, T., & Heffer, T. (2015). Impulsivity and nonsuicidal self-injury: A review and meta-analysis. Clinical Psychology Review, 38, 13–24.  https://doi.org/10.1016/j.cpr.2015.02.010.CrossRefPubMedGoogle Scholar
  27. Hawton, K., Saunders, K. E. A., & O’Connor, R. C. (2012). Self-harm and suicide in adolescents. Lancet, 379, 2373–2382.  https://doi.org/10.1016/S0140-6736(12)60322-5.CrossRefPubMedGoogle Scholar
  28. *Holley, E. E. (2016). The lived experience of adolescents who engage in nonsuicidal self-injury (Doctoral dissertation). Retrieved from Open Access Thesis and Dissertations. (Record No. oai:etd.ohiolink.edu:antioch1434043151).Google Scholar
  29. Hooley, J. M., & St. Germain, S. A. (2014). Nonsuicidal self-injury, pain, and self-criticism: Does changing self-worth change pain endurance in people who engage in self-injury? Clinical Psychological Science, 2(3), 297–305.  https://doi.org/10.1177/2167702613509372.CrossRefGoogle Scholar
  30. Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research, 11(2), 129–147.  https://doi.org/10.1080/13811110701247602.CrossRefPubMedGoogle Scholar
  31. Kirtley, O. J., O’Carroll, R. E., & O’Connor, R. C. (2016). Pain and self-harm: A systematic review. Journal of Affective Disorders, 203, 347–363.  https://doi.org/10.1016/j.jad.2016.05.068.CrossRefPubMedGoogle Scholar
  32. Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226–239.  https://doi.org/10.1016/j.cpr.2006.08.002.CrossRefPubMedGoogle Scholar
  33. Klonsky, E. D., Oltmanns, T. F., & Turkheimer, E. (2003). Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. American Journal of Psychiatry, 160, 1501–1508.  https://doi.org/10.1176/appi.ajp.160.8.1501.CrossRefPubMedPubMedCentralGoogle Scholar
  34. Klonsky, E. D., Victor, S. E., & Saffer, B. V. (2014). Nonsuicidal self-injury: What we know, and what we need to know. The Canadian Journal of Psychiatry, 59(11), 565–568.  https://doi.org/10.1177/070674371405901101.CrossRefPubMedGoogle Scholar
  35. *Lesniak, R. G. (2010). The lived experience of adolescent females who self-injure by cutting. Advanced Emergency Nursing Journal, 32(2), 137–147.  https://doi.org/10.1097/TME.0b013e3181da3f2f.
  36. Levitt, H., Pomerville, A., & Surace, F. I. (2016). A qualitative meta-analysis examining clients’ experiences of psychotherapy: A new agenda. Psychological Bulletin, 142(8), 801–830.  https://doi.org/10.1037/bul0000057.CrossRefPubMedGoogle Scholar
  37. *Lewis, S. P., & Mehrabkhani, S. (2017). Every scar tells a story: Insight into people’s self-injury scar experiences. Counselling Psychology Quarterly, 29(3), 296–310.  https://doi.org/10.1080/09515070.2015.1088431.
  38. *Machoian, L. (2001). Cutting voices. Journal of Psychosocial Nursing & Mental Health Services, 39(11), 22–29. ISSN: 02793695.Google Scholar
  39. Maciejewski, D. F., Creemers, H. E., Lynskey, M. T., Madden, P. A., Heath, A. C., Statham, D. J., Martin, N. G., & Verweij, K. J. (2014). Overlapping genetic and environmental influences on nonsuicidal self-injury and suicidal ideation: different outcomes, same etiology? JAMA Psychiatry, 71(6), 699–705.  https://doi.org/10.1001/jamapsychiatry.2014.89.CrossRefPubMedPubMedCentralGoogle Scholar
  40. *Magagna, J. (2008). Attacks on life: suicidality and self-harm in young people. In S. Briggs & S. Lemma, A. & W. Crouch (Eds.), Relating to self-harm and suicide: Psychoanalytic perspectives on practice, theory and prevention (pp. 109–127). New York, NY: Routledge/Taylor & Francis Inc.Google Scholar
  41. *Marshall, H., & Yazdani, A. (1999). Locating culture in accounting for self-harm amongst asian young women. Journal of Community & Applied Social Psychology, 9(6), 413–433.  https://doi.org/10.1002/(SICI)1099-1298(199911/12)9:6<413::AID-CASP543>3.0.CO;2-U.
  42. *McAndrew, S., & Warne, T. (2014). Hearing the voices of young people who self-harm: Implications for service providers. International Journal of Mental Health Nursing, 23(6), 570–579.  https://doi.org/10.1111/inm.12093.
  43. *McDermott, E., Roen, K., & Piela, A. (2015). Explaining self-harm: Youth cybertalk and marginalized sexualities and genders. Youth and Society, 47(6), 873–889.  https://doi.org/10.1177/0044118X13489142.
  44. Menninger, K. (1938). Man against himself. New York: Harcourt, BraceWorld, Inc. (/1966. .Google Scholar
  45. Morgan, C., Webb, R. T., Carr, W. J., Kontopantelis, E., Green, J., Chew-Graham, C. A., Kapur, N., & Ashcroft, D. M. (2017). Incidence, clinical management, and mortality risk following self-harm among children and adolescents: cohort study. BMJ, 359, j4351.  https://doi.org/10.1136/bmj.j4351.CrossRefPubMedPubMedCentralGoogle Scholar
  46. Motz, A. (2010). Self-harm as a sign of hope. Psychoanalytic Psychotherapy, 24(2), 81–92.  https://doi.org/10.1080/02668731003707527.CrossRefGoogle Scholar
  47. *Moyer, M., & Nelson, K. W. (2007). Investigating and understanding self-mutilation: The student voice. Professional School Counseling, 11(1), 42–48. ISSN: 1096–2409.Google Scholar
  48. *Nice, T. (2012). Troubled minds and scarred bodies: A grounded theory study of adolescent self-harm (Unpublished doctoral dissertation). The University of Kent.Google Scholar
  49. Noblit, G. W., & Hare, R. D. (1988). Meta-ethnography. London: SAGE Publications, Inc.CrossRefGoogle Scholar
  50. Nock, M. K. (2014). The Oxford Handbook of Suicide and Self-injury. New York: Oxford University Press.CrossRefGoogle Scholar
  51. Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72(5), 885–890. ISSN: 0022-006X.CrossRefPubMedGoogle Scholar
  52. Nock, M. K., & Prinstein, M. J. (2005). Contextual features and behavioral functions of self-mutilation among adolescents. Journal of Abnormal Psychology, 114(1), 140–146.  https://doi.org/10.1037/0021-843X.114.1.140.CrossRefPubMedGoogle Scholar
  53. Panksepp, J. (2010). Affective neuroscience of the emotional BrainMind: Evolutionary perspectives and implications for understanding depression. Dialogues in Clinical Neuroscience, 12(4), 533–545. ISSN: 1294–8322.PubMedPubMedCentralGoogle Scholar
  54. *Parfitt, A. (2005). On aggression turned against the self. Psychoanalytic Psychotherapy, 19, 160–173.  https://doi.org/10.1080/02668730500115127.
  55. *Privé, A. A. (2007). An existential-phenomenological investigation of self-cutting among adolescent girls (Doctoral Dissertation). Available from ProQuest Dissertations Publishing (UMI No. 3292573).Google Scholar
  56. *Rissanen, M.-L., Kylmä, J., & Laukkanen, E. (2008). Descriptions of self-mutilation among Finnish adolescents: A qualitative descriptive inquiry. Issues in Mental Health Nursing, 29(2), 145–163.  https://doi.org/10.1080/01612840701792597.
  57. Siegel, D. J. (2015). Brainstorm: The power and purpose of the teenage brain. New York: Jeremy P. Tarcher/Penguin.Google Scholar
  58. Soyemoto, K. L. (1998). The functions of self-mutilation. Clinical Psychology Review, 18(5), 531–554.  https://doi.org/10.1016/S0272-7358(97)00105-0.CrossRefGoogle Scholar
  59. Straker, G. (2006). Signing with a scar: Understanding self-harm. Psychoanalytic Dialogues, 16(1), 93–112.  https://doi.org/10.2513/s10481885pd1601_6.Google Scholar
  60. Swannell, S. V., Martin, G. E., Page, A., Hasking, P., & John, St, N. J (2014). Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide and Life-Threatening Behavior, 44(3), 273–303.  https://doi.org/10.1111/sltb.12070.CrossRefPubMedGoogle Scholar
  61. Timulak, L. (2009). Meta-analysis of qualitative studies: A tool for reviewing qualitative research findings in psychotherapy. Psychotherapy Research, 19(4–5), 591–600.  https://doi.org/10.1080/10503300802477989.CrossRefPubMedGoogle Scholar
  62. Walsh, D., & Downe, S. (2004). Meta-synthesis method for qualitative research: A literature review. Journal of Advanced Nursing, 50(2), 204–211.  https://doi.org/10.1111/j.1365-2648.2005.03380.x.CrossRefGoogle Scholar
  63. Whitlock, J. L., & Selekman, M. (2014). Non-suicidal self-injury (NSSI) across the lifespan. In M. Nock (Ed.), Oxford Handbook of Suicide and Self-Injury. Oxford Library of Psychology: Oxford University.Google Scholar
  64. World Health Organization (2004). The ICD – 10 Classification of Mental and Behavioral Disorders. Diagnostic criteria for research. 10th ed.Google Scholar
  65. *Yip, K.-S., Ngan, M.-Y., & Lam, I. (2004). Adolescent self-cutters in Hong Kong. Asia Pacific Journal of Social Work and Development, 14(2), 33–51.  https://doi.org/10.1080/21650993.2004.9755953.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Lovisenberg HospitalNic Waals InstituteOsloNorway
  2. 2.Department of PsychologyUniversity of OsloOsloNorway

Personalised recommendations