Summary / Abstract

Title: “Why don't you do it properly?” Young women who self-injure

Synopsis: Analysis of interviews with four self-injuring young women suggests that the meaning of self-injury isnot the same as the meaning of attempted suicide, and that the two acts are related in the sense that self-injury is an adaptivealternative to suicide. The function of self-injury as a communicative act and the extent to which self-injurers can control theiractions are also discussed. It is suggested that, within the context of self-injury as survival, issues of communication andcontrol do not have the significance that they are frequently supposed to have. Implications for clinical practice arediscussed. self injury, suicide, control, self injurers, self cutting, communication, act, self injuring, adolescence, meaning, self injure, attempted suicide, interviews, context, clinical practice, Solomon, experiences, professionals, Implications, emotional distress, treatment, situations, selfinjury, psychiatry, distinction, physical pain, self harm, deliberate self harm, emergency department, first time,

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journal adolescence 1996 19 111 119 don t properly young women self injure yvette solomon julie farrand analysis interviews four self injuring young women suggests meaning self injury meaning attempted suicide two acts related sense self injury adaptive alternative suicide function self injury communicative act extent self injurers control actions discussed suggested context self injury survival issues communication control significance frequently supposed implications clinical practice discussed 1996 association professionals services adolescents introduction self injury self cutting forms violent self injurious behaviour burning scalding frequently described maladaptive behaviour symptomatic disturbance dysfunction paper shall argue usefully understood adaptive act means survival borne carry despite overwhelming feelings helplessness despair self hatred standpoint liberates self injure medical model trivializes experiences past present fails recognize meaning actions context survival impossible circumstances common experience self injurers seek help health services asked suicidal intentions self injuring reports wanting kill determines large treatment accident emergency department mental health service levels assumptions made self injury presupposes connection suicide damaging failure report suicidal intent leads implicit explicit accusations manipulative behaviour assumption non suicidal self injurer able stop injuring sufficiently motivated self injury rewarded analysis presented based four case studies young women selfinjury suggests recognition good reasons women self injure lead appropriate forms help current descriptions explanations survey recent literature self injury reveals significant gap research selfreprint requests correspondence addressed y solomon department educational research university lancaster bailrigg lancaster la1 4yl u k 0140 1971 96 02011109 18 00 0 1996 association professionals services adolescents 112 y solomon j farrand cutting violent means despite growing evidence problem widespread pembroke 1994 self poisoning hand accurately recorded widely researched see hawton 1986 kerfoot 1980 reder et al 1991 cases deliberate self poisoning tend referred psychiatrists frequently cases obvious admitted self injury scott powell 1993 studies scott powell 1993 deals purely issue adolescent self mutilation accident emergency department level rare lumsden walker 1980 typically reports group 50 school age children referred bristol child psychiatry department boy selfinflicted cuts remaining 49 ingested toxic substances form commonly aspirin majority studies lumsden walker concerns lie area suicidal intention precipitating events general socio economic family circumstances attitudes school family typically study concentrates establishing correlates self poisoning seeking examine meaning acts individuals concerned lumsden walker finds sample disproportionate number parent lone mother families large families families physically handicapped parent parent history psychiatric illness reports greater incidence sibling crime involvement social services child guidance attendance sibling death successful suicide parent reported case self injury relatives friends present third children lumsden walker observes significant proportion young people involved experienced experiencing extreme family difficulties tensions view echoed hawton 1986 van der kolk et al 1991 suggest history neglect separation chaos associated self cutting clearly young people experience family difficulties self injure self injurers experiences self injurers injure circumstances moving identification correlates effective treatment requires understanding meaning context act selfinjury gained extensive interviewing self injurers accounts interviews adolescent self injurers tend concentrate overdose opposed self cutting see mccallum lang 1982 aldridge rossiter 1984 reder et al 1991 latter discussion initial interview 15 year old girl family attempted suicide aspirin overdose lists familiar frame reference clinical intervention particular interest present context reder et al assumption deliberate self harm communication crisis feels control act self harm young adolescents rarely secret intend interpersonal effect p 136 emphasis true young people overdose see hawton et al 1982 hawton 1986 clearly case self cut lack accurate statistics self cutting tendency cases reach accident emergency departments bandaged sent home little likelihood referral mental health services means grounds making claim self cutting simply know meaning action presenting oneself hospital treatment necessarily mean self injury longer secret matter family friends clinical interviews self cutters limited present symptoms problems 113 young women self injure persistently self injuring information regard life circumstances motives equally limited recognized categorizing self cutting self poisoning attempted suicide four interviews self injuring women women interviewed study contacted first author 1994 project funded department health two contacted southampton gay young people support group two reached word mouth manchester case 1 helen self injuring age 11 time parents split time interview 21 distinguishes instance suicidal behaviour age 19 cut arm badly contrast unequivocal intention die time attempt response relationship difficulties parents girlfriend selfinjury form coping transforms emotional distress manageable physical pain i m hard time head t take i lash things cos different pain takes pain away re feeling helen articulates choice suicide self injury clearly says self injurer causes problems terms people reactions preferable suicide causes problems people i ll feel bad i d lot serious i d commit suicide altogether case 2 contrast sue 17 attempted suicide thought self injury dealing anger describes detail feeling calm comes cutting seeing blood important time i m trying take anger i m doing people lets anger doing wrist seeing blood makes feel calmer sue describes cutting addiction easiest response available difficult situations i suppose easiest thing i m feeling depressed angry taking cos i m sort person shout go beating people easiest thing get razor cut take cos i m nearest person i am sue describes 13 cut first time direct result unhappiness school family found self injury difficult cope understand reacted anger father dislike lesbianism effect fuelling distress coping case 3 central place anger feature carol account self cutting distinction self injury suicide made carol blurred carol 21 interview described long history 114 y solomon j farrand suicide attempts self cutting going back age 15 cutting result anger extent anger alternatively delay acting reflected amount injury done anger goes ve cut ve done identifies source anger father sexual abuse sister resultant life care ages 10 18 carol sees problems terms mother daughter relationship need unconditional love beginning i feel angry put arms i wouldn t i d know i d feel safe angry i cut cos first place carol tried forms coping finds anger mounts level end cutting inevitable order disperse carol describes suicidal mood cutting uncontrollable severe feels finish anyway knows cares deep cutting times stops pain excess blood theme suicide loss control evident first experience paracetamol overdose suicidal intent knock subsequently decided kill started overdose got hold kitchen knife carol describes episode control i picked big carving knife i discovered i gonna actually kill point like helen carol describes suicidal behaviour control self injury involves control theme clear point carol actively chose begin self injuring coping discussion fellow patient self harmed psychiatric hospital i asked gave solution getting i started cutting glass case 4 like carol liz identifies injuring behaviour learned degree case mother sees significant mother attempt suicide dosen t know fact suicide selfinjury event age 8 liz witnessed mother injuring 15 i learnt behaved crisis coped things first time i boyfriend left i upset i didn t go home cry i went cut arm liz makes sharp distinction suicide self injury teenage years overdoses says different meaning i tend think pills suicide attempt i thought taking pills dangerous said liz describes confused meaning doing partly people reactions case carol overdosing means escape intolerable situations ending life i didn t die people ask tried kill treat like ll think tried kill perceives cutting dangerous overdosing liz found confusion doing applied somebody said doing i said i trying kill people treat i think treat liz self injury far attempted suicide parallel helen self 115 young women self injure injury deal emotional stress cutting preferable alternative depressed sense meaning self injury survival appears liz story i didn t i didn t know i d i imagine i hadn t done i felt depressed i felt worse death mother break relationship liz injured see wholly negative i felt kind dead flat emotion i d feeling i thought re ve got get ve got pick injuring like i d reached rock bottom try improve things bumbling like i d hit reality say self injury entirely control i think felt like i ve i think i ve done better judgement emotional rush self injury brings period depression liz injuring allows kind allow sympathy parallel carol need love liz recognizes need looked caring wounds substitute somebody caring keep clean nice things like make sure rest cook nice dinner re treating like invalid re kind contrast feelings liz says felt deserved good things like i felt know definite self loathing i ve done things i e self injured i feel i don t like discussion acknowledged four cases reported conclusions necessarily tentative similarity accounts cohesiveness picture present suggest important aspects self injury merit close attention fully understood self injurers live work sympathetically treated clinical practice major issues relationship self injury suicide b self injurers trying communicate c extent self injurers control analysis issues leads suggestions self injurers choose particular action self injury vs suicide central accounts self injury idea self injury suicidal behaviour approaching women made clear distinction two three four made suicide attempts sue contemplated suicide carol persistently attempted suicide self injured makes distinction despite fact begun self injury turned attempted suicide acts blur meaning emerge link two acts sense self injury alternative suicide preferable idea clearly articulated helen hinted liz carol forming wider interpretation self injury survival damaged 116 y solomon j farrand damaging relationships severe emotional distress four cases fact onlookers frequently blur boundaries suicide self injury observed liz notes power situation re define self injury self injurer clearly blurring likely encourage misassumptions self injury counteracted self injurers state distress vulnerable interpretations actions obvious issue needs addressed context selfinjurer trying trying communicate self injurers trying communicate clear four case studies self injury means directly communicating needs wants young women value contexts psychiatric inpatient prison environments frequently assumed self injury fills precisely role note instance reder et al 1991 comment deliberate self harm communication crisis feels control intend interpersonal effect reder et al view close attention paid problems precipitated state crisis communication legitimate assume communication self injury assumption unusual sympathetic treatment walsh rosen 1988 observe treatment typically tends behaviourist based premise self injury reinforced attention staff self injury reported done knowledge situations crisis point reached self injury prevent crisis occurring frequently relationships gone crisis point total loss destruction point view self injury direct communicative effect oneself order feel real express self hatred case liz reach point rock bottom pick alternatively desire expel feelings anger pain strong case carol self injury communication pain distress unresponsive absent audience contrast single cry help act attempted suicide precipitated desire escape effect change immediate redeemable situation crisis reder et al describe chronic self injury appears response irredeemable situations cases described talk directly self injury form communication possible exception liz talk choosing self injury alternative suicide giving completely response impossible situation considering role choice communication raises issue central reactions self injury general treatment professionals particular extent self injurers control actions extent self injurers control implicit behaviourist treatments idea self injurers exercise choice injuring behaviour ultimately ability control doing degree notion self injury communication carries implication decide unconsciously communicate dangerous ground 117 young women self injure wants avoid accusations manipulative behaviour certainly four accounts express self injury terms staying control carol particular contrasts control suicidal mood control self injuring helen implies suicidal constitute loss control sue describing injuring easiest coping difficult situations suggests injure channelling anger controlling liz describes injuring coping response times keeping touch reality avoiding deep depression danger assuming control aspect self injury entails automatically ability wanted stop self injuring distinction made self injury staying control giving vent unbearably strong emotions control self injury terms genuine choice doing assumption alternative self injury acting normally contrary helen particular points alternative self injury total loss control possibly suicide forced choice limited options self injury concern paper uncover origins causes self injury sense establishing common correlates common experiences argument possible useful aim analyse meaning act self injury starting point attempt distinguish suicide self injury behaviours look fact different acts case histories detailed support distinction suggest self injury perceived alternative suicide depression coping intense emotional distress pain staying control necessarily communicative act seeking explain understand self injury need arguably go sufficient say instance experiences described women likely lead major problems adolescence adulthood obvious question selfinjury alcoholism eating disorder depression women men self injure 1 begin answer question need look closely significance act self injury two aspects self injury important context experience physical damage pain act cutting letting blood seen self injury transforms emotional pain manageable physical pain damage reason physical damage manageable origins obvious unproblematic origins emotional distress unclear difficult face tension relieving factor selfinjury relevant terms release emotion necessarily involve crying self injurers report unable cry possibly dangerous activity get emotionally control 2 self injury 1 address meaning self injury prison environments incidence self injury men rises important parallels drawn powerlessness men prisons women general insofar self injury internalizing anger incidence men prison alternative internalize feelings unsurprising 2 thanks wendy williams observations 118 y solomon j farrand substitute crying safe focus means triggering difficult feelings liz bringing feelings angry hurt makes cry release lot tension fact self injurers report feel pain problematic analysis carol reports lack feeling doing damage visual evidence brings relief tension anger helen hand says actual physical pain banging head make feel real funny head i ll get like i m i lash purpose get rid pain head brings head back reality women self injure cut apart impact physical damage caused cutting act cutting letting blood significance acts convey sue carol comment impact seeing blood link bleeding release tension anger number possible interpretations suggest link crying bleeding instance indisputable statement control body mind sue says i wanted i body stop doing liz comments issue control life describes trying fit mould i didn t fit i trying things everybody i think contrasts respectable good housewife image side unconventional side selfinjuring side internalization control anger distress clearly issues particular relevance women reasons unable express think feel wounds scars evidence internal battle form external reminder mental pain making permanent real ignored trivialized hidden helen says i feel i d like able say know i m i m day cry front i hold time put smile make re happy wears implications clinical practice power act self injury means dealing difficult emotions experiences makes clinical management difficult findings suggest helping self injurer stop clinician ultimate goals primary goal counter productive techniques based premise self injury reinforced attention sanctions withdrawal treatment certainly cause greater distress allow self injurer come terms unthinkable pace four cases discussed paper self injury means dealing extremely difficult experiences analysis suggests need help face experiences express emotions associated able stop self injuring references aldridge d rossiter j 1984 strategic assessment deliberate self harm journal family therapy 6 113 129 119 young women self injure hawton k 1986 suicide attempted suicide children adolescents beverly hills sage hawton k cole d o grady j osborn m 1982 motivational aspects deliberate selfpoisoning adolescents british journal psychiatry 141 286 291 kerfoot m 1980 family context adolescent suicidal behaviour journal adolescence 3 335 346 lumsden walker w 1980 intentional self injury school age children study fifty cases journal adolescence 3 217 228 mccallum p lang m 1982 blackmail law australian journal family therapy 3 173 195 pembroke l 1994 self harm perspectives personal experiences london survivors speak reder p lucey c fredman g 1991 challenge deliberate self harm young adolescents journal adolescence 14 135 148 scott w powell j c 1993 brief report adolescent self mutilation rural area journal adolescence 16 101 110 van der kolk b perry c herman j 1991 childhood origins self destructive behaviour american journal psychiatry 148 1665 1671 walsh b rosen p m 1988 self mutilation theory research treatment new york guildford, com_apnet_jado_jado_1996_0011, KnowledgeStor, Knowledge-Stor,