Discussion
This study presents unique descriptions of how adolescents living in urban England view self-harm. Adolescents depicted self-harm as a complex behaviour involving a range of methods, functions and taboos. Those who self-harmed described it as a private, inwardly focused expression of distress, often with a reluctance to disclose and seek help. This was reinforced by the comments about self-harm as attention seeking from participants who had not self-harmed. Such views may contribute to fears about responses from others, particularly where social support may be variable or lacking. Self-harm being discovered by others was often viewed as a negative experience. Although most participants were unclear about what would constitute "help", some reflected on the benefits of help they had received following disclosure of self-harm. The ethnic diversity within this sample illustrated that self-harm was concern across a range of ethnic groups. Mixed reflections and experiences described in this study elucidate feelings and intentions which may accompany non-suicidal-self-injury or other self-injurious behaviours.
There were inherent challenges in exploring retrospective accounts of self-harm. The difficulty participants had constructing a coherent narrative about self-harm experiences and intentions may relate to a general difficulty expressing their feelings, poor memory of the events or feeling uncomfortable talking about it. Alternatively the sense of dissociation during self-harm described by some participants may explain patchy recollections and a perceived lack of pain. It is feasible that given the intense emotional states reported when describing self-harm, intentions may not always be apparent to the individual after the event, and may go unreported in retrospect.
This qualitative research presents insights on a sensitive topic from a hard to reach community sample, which complements the findings from survey-based research particularly regarding the social context for self-harm and help-seeking. The inclusion of adolescents both with and without personal experience of self-harm provides information on the attitudes adolescents who self-harm may encounter in their peers. Previous research highlights the association between self-harm and the absence of confidantes, supported in this study through discussion of the isolated nature of some self-harm. That is, perceived isolation may increase the difficulty seeking help.
Analysis suggests that help-seeking may be a more dynamic process than "staged" models of help-seeking indicate. Reasons to seek help (or not) may change over time, alongside changing perceptions of the problem, the context and throughout the process of seeking help. Difficulty in seeking help may arise due to the distressing nature of self-harm, potentially including suicidal ideation, or if the adolescent believed that their disclosure would lead to negative consequences. This is of great concern, akin to the help-negation effect, where higher suicidal ideation has been associated with reduced intentions of seeking-help in young people.
The raw nature of the accounts presented in this study may resemble communication in the presentation of self-harm to clinicians or other sources of help, and illustrates the variation in the circumstances and interpretations of self-harm by adolescents. Comments from adolescents who had not self-harmed provide evidence that help-seeking may also be challenging for those being asked for help. This complements research on help provision for young people who self-harm being difficult for teachers and healthcare professionals. Findings illustrate the complexity required for providing support that is both sensitive and acceptable to adolescents who hurt themselves. Engaging adolescents with services may prove difficult, particularly if self-harm was not viewed as problematic or worth discussing. Personal accounts emphasised the need to address issues leading to self-harm, and not solely respond to the physical injuries. Practitioners may need to consider social, family and cultural influences on an adolescent's life when endeavouring to provide help for self-harm.
This study highlights potential areas of training and development to promote accessible and acceptable care for young people. For example, one-stop-shop facilities provide multiple services in one place to increase the acceptability of service use, if the nature of help being sought could remain concealed. Online service access for young people may overcome barriers relating to privacy and being physically unable to visit a service. Culturally appropriate services may reduce barriers to help-seeking in ethnically diverse communities, particularly as it is known that culture influences causal explanations of health and health behaviours. Barriers may also be reduced if service providers were trained to feel more confident in being able to respond appropriately, or even to open discussions, taking initiative to help young people who may not be comfortable taking that step alone.
Findings about lack of understanding about self-harm, and difficulty responding to self-harm in others raises the need to promote awareness about emotional health, coping strategies and sensitivity in responding to distress in oneself and others at a community level.
Public health interventions in schools to train teachers and welfare staff may facilitate discussion of such issues more routinely, increasing awareness of available support, facilitating help-seeking by making talking about distress less taboo, increasing confidence and knowledge in staff working with young people who self-harm and aiming to ensure help-seeking would not increase stigma for young people. Treatment of anxiety and depression in adolescents who self-harm may alleviate future distress, potentially reducing the risk of later self-harm and suicide. There is also scope to promote easily accessible support in schools and the community, given the constraints adolescents may perceive about help-seeking.
Strengths and Limitations
This qualitative exploration with a young, hard-to-reach sample provides insight into the social and cultural context of adolescent self-harm. Interviews with 30 young people is a strength of the study, facilitating in-depth probing of a wide range of views and experiences of self-harm, and detailing the variability in attitudes accompanying this complex behaviour. However, there are limitations in the insights obtainable from a study using a single interview with adolescents. Given the sensitivity of the issue, follow-up interviews may have enabled adolescents who were more reticent in speaking about self-harm or who had difficulty constructing a coherent story from their recollections to add further perspectives. Future research could explore issues arising in this study in more depth, such as social influences on adolescent self-harm, comparison of experiences in urban, rural and international settings, experiences throughout the process of accessing help, and the potential for psychosocial factors to play a protective role. Further investigation into adolescent self-harm could explore the nature of cultural influences and experiences reported by adolescents from different ethnic groups. There is scope for exploration and interventions for both giving and receiving help; how to make help more acceptable and accessible to adolescents who self-harm and to identify preventive interventions which might help adolescents find more adaptive ways to cope with distress. Although epidemiological research shows a natural decline in self-harm as adolescents reach early adulthood, the subjective distress articulated by young people who self-harm demonstrates the need to provide support accessible to adolescents at a community level.