Time has a way of sneaking up on us, and in the blink of an eye (okay, maybe several blinks) we have approached the end of the school year. The following is a scientific reflection I wrote for my brain and behaviour course, PSYC 304. It is with bittersweet emotions that I part with PSYC 304, it has been a wonderful experience, not only of learning, but also reflection and growth through the curriculum and the development of SHARE. Sorry if it’s a little dull reading through all the papers and studies!
In class, we briefly discussed self-injury in the context of Borderline Personality Disorder (BPD), and noted the fact that self-harm is not indicative of BPD, and can occur in the general population. Most of the literature on self-harm refers to non-suicidal self-injury (NSSI), which Klonsky & Olino (2008) define as the intentional destruction of one’s own body tissue without suicidal intent and is not socially sanctioned. In SHARE, we define self-harm as any intentional act of violence towards oneself, which include binge drinking, reckless driving, having unsafe sex, purging etc. besides self-injury. Self-harm is not uncommon among adolescents and young adults, and is often used as a coping mechanism for stressful circumstances. With self-harm on the rise, we must take a step back and look at why this is the case. Are youth more vulnerable to negative coping styles or is our current society becoming increasingly demanding or less supportive? These are questions that we should consider when implementing prevention and intervention methods. In the UK, 1 in 5 adolescents report thoughts of self harm and 1 in 10 report at least one act of self-harm over a six month period (Stallard et al., 2013). By the age of 12 to 13, many cases of self harm have already established, and these can persist over times. In another study by Klonsky in 2011, he found the lifetime prevalence of self-injury in US adults to be 5.9%, including 2.9% that had injured five or more times. The average age of onset was 16 years, with alleviating negative emotions to be the most common function of self-injury. There is very limited data on self-injury in Canada, but in the National College Health Assessment II (2013), a survey of US and Canadian universities, 6.6% of undergraduates across Canada reported to have self-injured within the last 12 months. It is evident from the research above that self-harm is on the rise globally and is a serious health concern that must not be addressed lightly.
So we know self-harm is an issue, what steps can we take to tackle it? First off, it’s important to look at the risk factors to developing self-harming behaviours. Contrary to popular misconception, self-harm is not simply a problem of the female sex, in fact, Taliaferros & Meuhlenkamp (2015) did not find a significant difference of self-harm prevalence by sex. They did, however, find that current depressive symptoms, non-heterosexual orientation, disordered eating and having an internalizing mental health disorder increases risk of self-harm, with minority sexual status being at highest risk. In their undergraduate sample, they also observed that freshman and non-white identified individuals were more likely to report self-harm. Substance abuse or addiction was also found to have large effects on self-harm, consistent with findings from Stallard and colleagues.
Next, we look at what drives us to engage in self-harming behaviours. Klonsky and Olino (2008) identified two broad classes of functions: intrapersonal and interpersonal. For intrapersonal functions, it serves as affect regulation, anti-dissociation/feeling generation (stop numbness), anti-suicide (to replace or avoid suicide), marking distress (symbolized emotional pain physically) and self-punishment. Interpersonally, self-harm functions to demonstrate autonomy (ability to rely on self), set interpersonal boundaries, communicate (seeking help from others), retaliate (get back at someone), and indicate toughness (tolerance of pain). In study on the relationship of NSSI functions, frequency and methods, Saraff & Pepper, (2014) concluded that intrapersonal functions correlate with a higher frequency and variability of self-injury methods, and that affect regulation may contribute to a more severe course of self-injury, fuelling repetition of the behaviour. Interpersonal functions on the other hand appeared to be important for those with few acts of NSSI.
One paper that caught my attention while I sifted through the piles of research, was one that explored if self-injury is an addiction by comparing craving in substance use. During my times with self-harm, I definitely felt that it was addictive and at times severely impacted my life because there were days where the need to harm consumed me. In order to borderline function, to socialize, to do school and work, I had to take care of my urge to cut or otherwise self-injure first. Without it, I would feel so overwhelmed the urge and thoughts to self-harm that I felt paralyzed and unable to think clearly. What Victor et al. looked at in this paper was whether or not NSSI should be viewed with an addictions framework, rather than an emotion regulation framework. They compared the nature of craving in NSSI and substance use, noting similarities and differences in the behaviours. Craving for substances were significantly stronger for substances than for NSSI, and that NSSI cravings were almost exclusive to the context of negative emotions, whereas substance cravings were across a wide variety of contexts. It is consistent with earlier work which note substance addiction is maintained by both positive and negative reinforcement, whereas NSSI is primarily perpetuated through negative reinforcement. This study takes into account of previous literature and concludes that self-injury is not an addiction, but it can be “craved”, in the context of emotion regulation.
Even though self-harm is, as some would say, a growing “epidemic”, there are very few prevention, intervention and treatment programs or strategies targeted towards self-harm specifically. Thus motivating the whole reason behind creating SHARE: to build a safety net for self-harm, to encourage and teach self-care. A study from 1993 by Klingman and Hochdorf researched the impact of primary prevention programs of self-harm among adolescents. They found that the program had an overall positive impact on attitudes, emotions, knowledge and awareness of distress coping skills, supporting the need and feasibility of a cognitive-behavioural, school-based prevention program. What bothers me with this is that the positive effects of primary prevention programs for self-harm was identified back in 1993, yet 22 years later it still has not been implemented throughout school curriculum in a similar fashion as sex education and substance use education programs. More recently, researchers (2015) stress the importance of increasing awareness about NSSI and suicide risk to health care providers and campus personnel, ensure adequate assessments, interventions and supports exist. They also indicate that prevention efforts might focus on young first-years, minority groups and students experiencing significant emotional distress and/or mental health disorders. As part of our mission at SHARE, we strive to approach the issue of self-harm at all levels of prevention, ensuring that education, care and support are provided adequately to all people. With the formation of our support group, targeting those who use self-harm currently or in the past, we hope to provide a safe space for people to heal, connect and be empowered. In the modern era with technological advances, e-health has been gaining popularity, and this could also be an alternative option to consider. Owens et al. (2012) explored the effectiveness of online communication amongst young people and health professionals and see if that could break down barriers and promote collaborative learning both ways. They observed that young people were active on the online forums, supporting one another during crises, while despite registering, health professionals took a backseat role and did not participate much. The professionals reported concerns relating to role clarity, private-professional boundaries, duty of care etc. Despite their absence, the youth build a vibrant community, and further work is necessary to understand and overcome the insecurities of the professionals. Moving down from tertiary prevention, we approach those who are maybe at risk of developing self-harming behaviours, and/or wanting to develop productive coping, and would provide workshops much like the one we hosted for the 2015 Mental Health Symposium with more specificity on skill acquisition and practice, and referrals to other resources that could further benefit them. As we arrive at primary prevention, the big picture of everything, SHARE aspires to reach everyone, from the ground up, by connecting with community partners, establishing presence, raising awareness, supporting self-care in all individuals, and (fingers-crossed) implementing self-care promotion and self-care prevention programs in elementary and secondary schools.
And with that, overflowing with weird emotion words, we say goodbye to our first chapter… This is only the beginning of our very big ideas, and we continue to take strides forward.
American College Health Association. (2013). National College Health Assessment II: Canadian reference group executive summary spring 2013. Hanover, ML: American College Health Association
Klingman, A. & Hochdorf, Z. (1993). Coping with distress and self harm: the impact of primary prevention program among adolescents. Journal of Adolescence, 16, 121-140
Klonsky, E.D. (2011). Non-suicidal self-injury in United States adults: prevalence, sociodemographics, topography and functions. Psychological Medicine, 41, 1981-1986.
Klonsky, E.D. & Olino, T.M. (2008). Identifying clinically distince subgroups of self-injurers among young adults: a latent analysis. Journal of Consulting and Clinical Psychology, 76(1), 22-27.
Owens, C., Sharkey, S., Smithson, J., Hewis, E., Emmens, T., Ford, T., and Jones, R. (2012). Building an online community to promote communication and collaborative learning between health professionals and young people who self-harm: an exploratory study. Health Expectations, 18, 81-94.
Saraff, P.D. & Pepper, C.M. (2013) Risk factors associated with self-injurious behavior among a national sample of undergraduate college students. Psychiatry Research, 219, 298-304.
Stallard, S., Spears, M., Montgomery, A.A., Phillips, R., & Sayal, K. (2013). Self-harm in young adolescents (12-16 years): onset and short term continuation in a community sample. BMC Psychiatry, 13, 328-341.
Taliaferro, L.A., & Muehlenkamp, J.J. (2015). Risk factors associated with self-injurious behavior among a national sample of undergraduate college students. Journal of American College Health, 63 (1), 40-48.
Victor, S.E. et al. (2012) Is non-suicidal self-injury an “addiction”? A comparison of craving in substance use and non-suicidal self-injury. Psychiatry Research, 197, 73-77.