Adolescent Self-Injury Behavior Are the Intolerable Feelings, the Deliberate Self-Harm, and the Short Term Relief (Lesniak, 2006)

THE LIVED EXPERIENCE OF ADOLESCENT FEMALES

WHO SELF-INJURE BY CUTTING

Rhonda Goodman Lesniak

A Dissertation Submitted to the Faculty of

The Christine E. Lynn College of Nursing

in Partial Fulfillment of the Requirements for the Degree of

Doctor of Philosophy

Florida Atlantic University

Boca Raton, Florida

December 2008

ACKNOWLEDGMENTS

Thank you, Patsy Goodman and the late W. R. Goodman, my parents, whose many sacrifices and hard work made possible the opportunities in my life.

Thank you, Dr. James Lesniak, my husband of almost 33 years, for your love, support, and encouragement.

Thank you to my children, Dr. Melissa, Lt. Dan, Matt, and Tess for giving me joy and inspiration.

Thank you, Dr. Charlotte Barry, my dissertation chair, my mentor, my encourager, my teacher, my guide, and my dear friend.

Thank you, Dr. Shirley Gordon and Dr. Mary Cameron, my committee members, for your thoughtful insight, expertise, and guidance.

Thank you to Dr. Boykin, Dr. Dunphy, Dr. Baer, Dr. Thomas, Dr. McCaffery, Dr.

Folden, Dr. Jett, Dr. Liehr, Dr. Locsin, Dr. Parker, Dr. Purnell, Dr. Smith, Dr. Chase, and

Dr. Glendola Nash, the remarkable educators who guided my journey.

Thank you to my students and research participants for trusting me with your

stories. Keep dreaming, keep hoping, and love yourselves.

Thank you, Josephine Paterson and Loretta Zderad, for a nursing theory that

translates so beautifully into nursing research and nursing practice.

I thank my God whose unwavering presence and love has sustained me all of my

life, especially when it was least deserved. My cup overflows. Philippians 4:13.

ABSTRACT

Author: Rhonda Goodman Lesniak

Title: The Lived Experience

Institution: Florida Atlantic University

Dissertation Advisor: Dr. Charlotte Barry

Degree: Doctor of Philosophy

Year: 2008

Self-injury behavior is identified as the non-suicidal, deliberate infliction of a

wound to oneself in an attempt to seek expression. Self-injury is becoming more

prevalent in the adolescent population; however, many nursing professionals are unaware

of this phenomenon and the implications it holds for nursing. Approximately 12 to 17

percent of adolescents deliberately injure themselves although accurate statistics are

difficult to obtain due to the secret and private nature of the behavior. Nurses, especially

those who care for adolescents, could benefit from an understanding of the implications

of self-injury, the characteristics of adolescents who self-injure, the expressivity of the

behavior, and the repetitive patterns of the emotions experienced by adolescents who

self-injure.

Six adolescent females were interviewed for this study. Their stories were shared

in rich, descriptive narratives. Common themes emerged from the words of the

participants and these themes described the essence of self-injury by cutting for

adolescent females. The themes which emerged were living with childhood trauma,

feeling abandoned, being an outsider, loathing self, silently screaming, releasing the

pressure, feeling alive, being ashamed, and being hopeful for self and others. The general

structure that emerged from a synthesis of the themes was that the experience of self-

injury by cutting for adolescent females is one where they are struggling for well-being

and hoping for more being by using their skin as a canvas upon which internal pain is expressed as tangible and real.

Pat and Bill Goodman

I am so blessed to be your daughter.

I love you.

TABLE OF CONTENTS

LIST OF TABLES ...... x

CHAPTER

1 INTRODUCTION ...... 1 Definition of Terms...... 3 Theoretical Perspective ...... 5 Researcher’s Perspective ...... 6 Purpose of Study ...... 9 Chapter Summary ...... 10

2 REVIEW OF LITERATURE ...... 11 Types of Self-Injury Behavior ...... 11 Description of Self-Injury Behavior ...... 12 Common Characteristics of Those Who Self-Injure ...... 13 Historical and Cultural Significance of Self-Injury Behavior ...... 15 Reflections in Poetry ...... 17 Review of Descriptive Literature ...... 19 Quantitative Research ...... 22 Qualitative Research ...... 28 Chapter Summary ...... 33

3 METHODOLOGY ...... 35 Method ...... 35 Theoretical Guidance ...... 38 Ethical Considerations ...... 42 Participants ...... 43 Recruitment Procedures ...... 43 Data Collection ...... 46 Limitations ...... 47 Data Analysis ...... 48 Methodological Rigor ...... 50 Chapter Summary ...... 50

4 RESULTS...... 53 Annie ...... 53 Belle ...... 58 vii

Caroline ...... 64 Danielle ...... 70 Emma ...... 76 Mary ...... 82 Data Analysis ...... 87 Themes ...... 88 Living With Childhood Trauma ...... 90 Feeling Abandoned ...... 91 Being an Outsider ...... 92 Loathing Self ...... 93 Silently Screaming ...... 93 Releasing the Pressure ...... 94 Feeling Alive ...... 94 Being Ashamed ...... 95 Being Hopeful for Self and Others ...... 96 General Structure ...... 102 Evaluation Criteria ...... 104 Chapter Summary ...... 105

5 SUMMARY, IMPLICATIONS, AND RECOMMENDATIONS ...... 107 Summary of Theory, Method, and Findings ...... 107 Implications for Nursing Practice ...... 110 Living With Childhood Trauma ...... 110 Feeling Abandoned ...... 111 Being an Outsider ...... 113 Loathing Self ...... 113 Silently Screaming ...... 114 Releasing the Pressure ...... 115 Feeling Alive ...... 117 Being Ashamed ...... 118 Being Hopeful for Self and Others ...... 118 Education ...... 119 Policy Development ...... 121 Recommendations for Future Nursing Research ...... 122 Summary ...... 126

APPENDIXES

A Depiction of Various Influences Leading to Self-Injury and the Feelings Following Self-Injury ...... 128

B Institutional Review Board Approval ...... 130

C Parent Consent Form...... 132

viii

D Student (Minor) Assent ...... 134 E Adult Consent Form ...... 136

F Institutional Review Board Amendments ...... 138

G Parent Consent Form...... 143

H Student (Minor) Consent Form ...... 145

I Call for Participants ...... 147

REFERENCES ...... 149

LIST OF TABLES

TABLE

1 Themes, Quotes, and Excerpts of the Data ...... 97

CHAPTER 1

Introduction

She can see the gape of crimson grow larger as it spills over the edges and

runs down her hand. She can see the scarlet drops grow larger as they gather

at her fingertips and then detach and fall through space. But no sound can be

heard from the deep red wound or the flame droplets that fall to a puddle on the

floor. To an onlooker this would seem to be an eerily quiet moment, a moment

engulfed in deathly silence as the crimson puddle grows, making no sound or

warning. But to the girl lying in the puddle, in the middle of the silent war she can

hear the discordant noises, the clamor of the voices raging and roaring as they

grate through her mind, piercing reminders of what she’d rather forget.

But when the last ruby drop falls into the deafening silence, ALL is silenced.

(Anonymous, 2001c; Lesniak, 2008)

Abby (fictitious name) wrote these lines in a poem she submitted to her high school creative writing teacher. She had been cutting her upper arms and thighs with a pocketknife for two years, since she was 15, and had hundreds of healed scars along with several fresh cuts. In an effort to conceal her self inflicted wounds, Abby consistently wore long, black, baggy pants and long sleeved black jackets or blouses. She dyed her hair jet black, which matched the polish on her fingernails and contrasted severely with her pale, white skin. Abby denied that her self-injury was a failed suicidal effort; instead,

she stated that cutting herself actually prevented her from attempting suicide, as the act of cutting provided a temporary relief from her emotional pain, anger, anxiety, and feelings of self-worthlessness. She revealed that she cut herself when she felt dead and numb inside and when she saw her own blood she was relieved to realize that, yes, she was still alive. Abby stated, “it kind of gave me a sense that I was taking care of my problems, but

I really knew in the back of my mind nothing was really getting done” (Lesniak, 2007b, p. 4). She further explained the temporary nature of the relief: “I settled for the quick fix

… the problem would come up again and eventually it would get to the point where I cut myself again” (Lesniak, p. 4; Lesniak, 2008). The high school creative writing teacher took Abby’s poem to the school nurse; thus began this researcher’s journey into the world of adolescents who self-injure.

Although psychologists documented self-injury as early as 1913 (Shaw, 2002), it remains a current behavior practiced in secret by many adolescents who turn to cutting their own bodies to seek relief from pain (Styer, 2006). Self-injury behavior is becoming more prevalent in the adolescent population (Cleaver, 2007; Conterio & Lader, 1998;

Whitlock, Eckenrode, & Silverman, 2006); however, many nursing professionals are unaware of this phenomenon and the implications it holds for nursing. Approximately 12-

17 percent of adolescents deliberately injure themselves (Favazza, 1996; Ross & Heath,

2002; Strong, 1998; Whitlock et al.), although accurate statistics are difficult to obtain due to the secret and private nature of the behavior.

Nurses, especially those who care for adolescents, may not have a working understanding of the implications of self-injury, the characteristics of adolescents who self-injure, the expressivity of the behavior, and the repetitive patterns of the emotions

experienced by adolescents who self-injure. Nurses could benefit from an awareness of the call for nursing embedded in the self-injury experience to create caring nursing responses (Paterson & Zderad, 1976/1988). Reflecting upon the nursing situation and guided by a theoretical framework of caring, the nurse is called to be authentically present for adolescents who self-injure to give voice to their experience. In Chapter 1, the varying definitions of self-injury will be explored, the theoretical perspective will be introduced, the researcher’s perspective will be explained, and the purpose of this study will be described.

Definition of Terms

Researchers have described self-injury behavior (SIB) as a culturally defined phenomenon whereby different cultures have various definitions of the behavior

(Favazza, 1996; Kehrberg, 1997; Lesniak, 2008). Cerdorian (2005) defined self-injury as a complex group of behaviors involving deliberate destruction or alteration of body tissue without conscious suicidal intent. Shaw (2002) described the behavior as a deliberate non-life threatening, self effected bodily harm or disfigurement of a socially unacceptable nature. Levander (2005) offered a definition of self-injury as “the act of attempting to alter a perceived intolerable mood state by inflicting physical harm serious enough to cause tissue damage to the body” (p. 3). LifeSigns Self Injury Guidance and Network

Support (2005, p. 5) defined self-injury as “a coping mechanism…. An individual harms his/her physical self to deal with emotional pain, or to break feelings of numbness by arousing sensation” (Lesniak, 2008). Estefan, McAllister, and Rowe (2004) described the behavior as an indication that the person feels trapped and unable to find a voice, only able to find self-expression in the self-injury, thereby making the voice heard. Favazza

utilized the term self-mutilation, describing it thusly, “the deliberate destruction or

alteration of one’s body tissue without conscious suicidal intent” (p. xviii).

The most important distinction is to differentiate between self-injury behavior without suicidal intent and suicide attempts (Murray, Warm, & Fox, 2005; Starr, 2004).

Researchers agreed that there is a very important distinction between acts of self-injury

without suicidal attempt and those acts which are suicidal, or fatal in nature (Cleaver,

2007). Some described self-injury as a way to prevent suicide as it relieves emotional

pain and distress (Cerdorian, 2005; Starr). Kehrberg (1997) differentiated self-injury

behavior as a method for self-healing in order to avoid suicide while Kubal (2005) called self-injury a type of “partial suicide” (p. 14) which prevents total suicide by “sacrificing one part of the body to save the whole” (p. 14).

Although McDonald (2006) referred to this phenomenon as self-mutilation, most researchers utilized the terms self-injury (American Self-Harm Information

Clearinghouse, 2005; Hoyle, 2003; Levander, 2005; Murray et al., 2005; Shaw, 2002;

Van Sell et al., 2005), self-harm (Ayton, Rasool & Cottrell, 2003; Harris, 2000; Whitlock et al., 2006), or self-wounding (Sharkey, 2003). In fact, Levander (2005) stated the term self-mutilation is particularly annoying to those who self-injure, while Alderman (1997) asserted that the term implies permanent damage or alteration to one’s body. Hoyle described the term self-mutilation as a “negative and offensive label” (2003, p. 14).

Sutton (2005) agreed, stating that the term self-mutilation is not only offensive and detested by those who self-injure, but it is a term which has lost favor with serious researchers due to the grotesque images it may produce (Lesniak, 2008).

Synthesizing the above descriptions, for the purposes of this study, the concept of self-injury behavior is identified as the non-suicidal, deliberate infliction of a wound to oneself in an attempt to seek expression (Lesniak, 2006).

Theoretical Perspective

“Nursing is an experience lived between human beings” (Paterson & Zderad,

1976/1988, p. 3). For this study, the nursing theory which guided the researcher into the

world of adolescent females who self-injure by cutting is the Humanistic Nursing Theory

as described by Paterson and Zderad. The Humanistic Nursing Theory is characterized as

the coming together of the nurse and the patient in an intersubjective existential

encounter called the nursing situation. Paterson and Zderad stated, “nursing is a

responsible searching, transactional relationship whose meaningfulness demands

conceptualization founded on a nurse’s existential awareness of self and of the other” (p.

3). While each person retains their uniqueness, the constant flow of reciprocal give and take enables them to form a trusting and open relationship. This is of utmost importance when the patients are adolescents who may be challenged in forming attachments to others or who may be reticent to entrust their feelings to an adult.

Paterson and Zderad (1976/1988) described the approach and the presence of the nurse with the patient as authentic, intentional, and deliberate. Paterson and Zderad explained this presence beautifully, “to offer genuine presence to others, a belief must exist within a person that such presence is of value and makes a difference in a situation”

(p. 6). Therefore, the nurse must value self in order to be present in a genuine manner.

Authenticity must begin with oneself, a “self-in-touchness” (Peterson & Zderad, p. 4), which raises our senses to a higher self-awareness, or actualization, of our abilities and

potential. Only then may we be authentic with another. The nurse is called to be a

“knowing place”, or a noetic locus; this enables the nurse to be acutely aware of self and

other, leading to a higher ability to be in the moment during the existential encounter known as the nursing situation (O’Connor, 1993; Paterson & Zderad, p. 5). Accordingly, the nurse researcher, through reflection, approaches the encounter with a developed self- awareness.

There is a call and response which flows reciprocally between both the nurse and the patient, as each sends a call to the other, and each fully responds to the call they receive from the other. Paterson and Zderad (1976/1988) believed that the reciprocal call is purposeful as both nurse and patient have expectations as a result of the call. “The nurse expects to be needed” (Paterson & Zderad, p. 29). When the nurse sends a call to a patient, in this case, an adolescent, the nurse expects the adolescent to respond; simultaneously, the adolescent’s response is also a call to the nurse for help. The

Humanistic Nursing Theory will be unfolded further in Chapter Three.

Researcher’s Perspective

In this researcher’s practice of school nursing in a large suburban high school, there were many encounters with adolescents who intentionally injured themselves, primarily by cutting. The most efficacious method of communicating with these students was by listening with intentionality and caring and by providing a safe place in the school health room in which students could verbalize feelings without fear of judgment. The reciprocity of the call of nursing, as posited by Paterson and Zderad (1976/1988), was exemplified in the coming together of the nurse and adolescent. The adolescent called out to the nurse, either verbally or nonverbally, by coming to the clinic in search of

understanding. The nurse called out to students by providing this safe and nurturing place wherein students could find acceptance even in light of the self-injury behavior.

Therefore, the theoretical framework of the Humanistic Nursing Theory of Paterson and

Zderad proved to be a gentle guide in the gathering of the personal stories of adolescents who self-injure.

The synthesized definition as given earlier is illustrated in the model (Appendix

A) of self-injury behavior. This model evolved from the interviews of three young women who self-injured by cutting. The expression comes through an act of deliberate self-harm by cutting, burning, scratching, or scraping the skin (Levenkron, 1998). The participants then experience relief or pleasant feelings; however, the shame of the act of harming one’s own body evolves into emotions which are unacceptable to those who are self-injuring and the pattern is repeated with a subsequent act of self-injury (Lesniak,

2008; Levenkron). The act of harming self and the guilt which ensues continues the pattern and the self-harm recurs as persons who self-injure experience shame and isolation (Estefan et al. 2004; Whitlock et al. 2006). The core attributes of this adolescent self-injury behavior are the intolerable feelings, the deliberate self-harm, and the short term relief (Lesniak, 2006). Through the authentic presence of the nurse with the patient, and as the patient and nurse develop a relationship of trust and respect, the call for nursing may be heard at any time during the pattern; in addition, the response from the nurse enters at any point in the pattern of the phenomenon.

Although Paley (1996) questioned the identification of defining attributes due to the ambiguity of their origin, these attributes of adolescent self-injury behavior were derived from adolescents’ stories obtained during a pilot study of three young women

who cut themselves during their adolescence (Lesniak, 2007a). Their stories are as follows:

Rebecca was a 23- year-old artist who began cutting herself with a safety pin when she was 16. She injured herself in hidden places, such as underneath bracelets, to prevent others from seeing her scars. Rebecca described her self-injury both as a preoccupation which drew her attention away from her problems and as a conduit for

claiming control over her life. She emphasized the repetitive nature of self-injury as one

faces the same problems over and over again and insisted she was not trying to kill

herself. When asked how a nurse might reach out to an adolescent who is self-injuring,

Rebecca stated the best thing a nurse could do is to just listen to the adolescent and allow

open expression of feelings and concerns (Lesniak, 2007a).

Abby, a 21-year-old fashion design student, began cutting herself with a pocket

knife when she was 15 years old. Childhood trauma involving many diagnostics and

surgeries for a congenital cardiac condition led to a feeling of lack of control over her

life; therefore, Abby felt that self-injury reclaimed her control of her body. Like Rebecca,

Abby stated that a nurse’s ability to listen to the adolescent, allowing verbalization of

feelings, would be the most efficacious way to provide appropriate care (Lesniak, 2007a).

Laurie was a 20-year-old college student who began cutting at age 15. She

remembered feelings of anger, frustration, and tension prior to cutting, and calmness and

relief after cutting. Although she had a petite frame and was thin, she stated she felt she

was fat and ugly and did not fit in with the popular crowd at school. Laurie stated she

always had a poor self-image and feelings of worthlessness, and was never able to please

those she loved (Lesniak, 2006). Although she kept her self-injury a secret from her

parents and did not confide in them for a long while, she did, however, have supportive

parents who helped her to find counseling and were always there for her when she needed

them.

All three young women relayed a need to claim control over their lives. In addition, they described cutting as a distraction from their problems; however, since the initial problems were not addressed, the cutting experience happened again. This study embraced a wider audience for further exploration of the phenomenon of cutting.

Purpose of Study

The purpose of this study was to explore the experience of adolescent females who self-injure by cutting. The stories gathered from the participants included the feelings experienced prior to, during, and after self-injury. By increasing awareness of this phenomenon, this researcher hoped to provide resources and assistance to school nurses, nurses who work in emergency departments, pediatric nurses, and nurse practitioners who may encounter self-injury behavior in their nursing situations. The nurse might benefit from an ability to recognize the indicators of self-injury behavior in adolescents, to know how to approach adolescents to elicit evidence of the behavior, and to be able to access resources which will guide adolescents to grow in more-being and well-being. Adolescents are reluctant to report their self-injury behavior or to seek help; therefore, nurses may identify not only the participants of the behavior, but also efficacious methods to prevent it (Whitlock et al. 2006). This study was necessary for nurses to develop an understanding of the self-injury experience as seen through the perspective of the adolescent who self-injures.

Chapter Summary

In Chapter 1, the topic of adolescent self-injury behavior was introduced and defined. The theoretical perspective was briefly introduced and will be developed further in Chapter 3. The researcher’s perspective, both as a practicing school nurse, and as a nurse researcher, was explained. A model depicting the emotions felt by adolescents just prior to and just after self-injury reflects the stories of the three young women who participated in this researcher’s pilot studies. Finally, the purpose and significance of this study were outlined for the reader.

CHAPTER 2

Review of Literature

Chapter 2 provides a review of the classic and current literature on the topic of adolescent self-injury behavior. The first section will be a description of self-injury behavior, including the various methods of self-injury, the locations of self-injury, the commonalities of those who self-injure, and the historical and cultural significance of self-injury. This will be followed by a discussion from samples of the classic literature, examples from contemporary poetry which describe the feelings of the person who self- injures, and a section concerning the patterns of self-injury. Lastly, a review of several quantitative and qualitative studies will be presented. The largest part of the current literature is found in the disciplines of psychiatry and psychology with few from the nursing discipline. This study contributes to the body of knowledge in the discipline of nursing. Nurses are often at the point of first contact with adolescents who self-injure; therefore, they should be able to avail themselves of the most current contributions to the literature on this topic. The literature review supports the need for further qualitative nursing research in the area of self-injury among adolescents.

Types of Self-Injury Behavior

Favazza (1996) described three types of self-injury behavior: major, stereotypic, and superficial/moderate. The superficial/moderate self-injury is further categorized as compulsive, episodic, or repetitive.

Major self-injury behavior is rare and dramatic and includes such examples as eye

enucleation, limb amputation, and castration. This behavior most often occurs with

psychosis, mania, depression, or intoxication (Favazza, 1996). Stereotypic self-injury

behavior is repetitive and rhythmic and includes behaviors such as head banging, biting

one’s self, pulling teeth, and hitting one’s self. This behavior might be noted in a person

with autism, mental retardation, schizophrenia, psychosis, and Tourette’s syndrome. The origins of stereotypic self-injury may be biological urges instead of an expression of

thought or meaning (Favazza).

The third type of self-injury, superficial/moderate, is the most common of the

self-injury types and the one which is studied in this research. This type includes cutting,

scratching, picking, burning, hair pulling (trichotillomania), bone breaking, and the

prevention of wound healing (Favazza, 1996). The first subtype of superficial/moderate

self-injury is compulsive, usually happens several times daily, and is found in persons

who are perfectionists, have obsessive compulsive disorder, and/or pick at sores. Episodic

self-injury, the second subtype of superficial/moderate, happens irregularly, and the

person self-injures purposefully in order to relieve or express tension, anger, or anxiety.

The person does not feel the need to self-injure; however, this may progress to the third

subtype, the repetitive self-injury. In this subtype, the self-injury behavior becomes part

of the person’s identity and the behavior may become addictive. This is the type of self-

injury behavior which is presented in this study (Favazza).

Description of Self-Injury Behavior

Self-injury behavior involves several methods of inflicting harm on one’s own

body, including cutting, burning, and stabbing (Cleaver, 2007; Murray et al., 2005).

Cutting is the most common method of self-injury (Klonsky, Oltmanns, & Turkheimer,

2003). Other methods used are needle sticking, punching self, interference with wound healing, and scratching (Kehrberg, 1997). The tools most often utilized are razors, knives, lighters, broken glass, matches, sewing needles, and even sandpaper (Murray et al., 2005;

Lesniak, 2008). Cerdorian (2005) asserted that self-injury is often inflicted repeatedly on the same part of the body; girls usually cut their arms and legs, and sometimes thighs and breasts. Contrary to the popular notion that persons who self-injure are merely attempting to get attention, most of the adolescents who self-injure wear clothing that covers their scars and wounds (Cerdorian; Cleaver; Hoyle, 2003; Lesniak, 2008; Shannon, 2005).

Estefan et al. (2004) stated that despite the myth that self-injury is an attention-getting behavior, it is still practiced in private because it continues to be socially unacceptable.

Common Characteristics of Those Who Self-Injure

There are many commonalities among persons who self-injure. Most persons who self-injure begin this behavior during their adolescence, usually beginning around ages 12 to 14 and often ending by age 18 (Cerdorian, 2005; Whitlock et al., 2006). Most are female and white and are educated throughout high school and beyond, and many have a history of physical and/or sexual abuse, or a come from a home with an alcoholic parent

(Alexander, 1999; Cleaver, 2007; Conterio & Lader, 1998; Kubal, 2005; Lesniak, 2008;

Murray et al., 2005; Whitlock et al.). However, Kennedy (2004) stated that the behavior is exhibited across all racial, socio-economic and cultural groups.

Santa Mina et al. (2006) argued that childhood abuse and/or neglect may be a predictor of self-injury behavior. However, while childhood abuse and self-injury may be correlated, causality cannot be determined (Cleaver, 2007; Klonsky et al., 2003; Kubal,

2005; Warm, Murray & Fox, 2003; Whitlock et al., 2006). Levenkron (1998) reported that some persons who self-injure do so in an attempt to make themselves unattractive to those who are sexually abusing them. In these instances, the injury often involves the breasts or genitalia. In this researcher’s school nursing practice, one adolescent female was discovered to be cutting her breasts to deter her abuser.

Eating disorders are common comorbid conditions (Murray et al., 2005) as are marital violence, childhood illness, loss of a parent or loved one at an early age

(Kehrberg, 1997; Kubal, 2005), and familial impulsive self-injury behavior (Lesniak,

2008; Shaw, 2002). Self-injury behavior is often accompanied by a diagnosis of dissociation, mood disorders, substance abuse, and anxiety (Shaw). However, Kehrberg and Walsh and Rosen (1988) asserted that the single strongest predictor of self-injury behavior is body alienation, which is a result of a history of having been a victim of physical and/or sexual abuse (Lesniak, 2008).

Low self worth or low self esteem also are reported to be common among persons who self-injure, as well as difficulty in expressing their thoughts and emotions, and difficulty in relationships (Conterio & Lader, 1998; Kehrberg, 1997; Kubal, 2005;

Levenkron, 1998). They desire to be loved and accepted but do not believe they are deserving of those affirmations, and may even apologize for things for which they are not at fault (Conterio & Lader; Levenkron). Other stressors which may provoke self-injury are feelings of hopelessness, lack of control, untreated depression, impulsive disorders, family or social problems, and conflict over one’s sexual orientation (Cerdorian, 2005).

Researchers (Ayton, et al., 2003) have revealed a commonality with social deprivation, unemployment, school problems, high fat diets, cigarette consumption, depression, and

overcrowded housing. Levander (2005) listed the top predictors as history of childhood abuse, post traumatic stress disorder, impulsivity, invalidation of self, hypersensitivity to rejection, chronic anger, depression, chronic anxiety, avoidance behavior, and feelings of lack of control. Cleaver (2007) added that there is a potential connection between self- injury behavior and the Goth youth subculture. Anger and anxiety are the two most common emotional states prior to self-injury (Levander). Due to the complexity of these predictors, nurses may find it a challenge to identify adolescents who self-injure

(Cerdorian).

Historical and Cultural Significance of Self-Injury Behavior

Self-injury behavior is not a new phenomenon, although it is just beginning to appear in nursing literature and conferences. Shaw (2002) argued that the waxing and waning of the appearance of self-injury in the clinical literature mirrors society’s practice of both ignoring and distorting the self-injury, especially as practiced by girls and women. Shaw asserted that “the historical discourse on self-injury mimics women’s experiences of objectification and violence by silencing and distorting their self-injury”

(p. 1).

The first known written account of self-injury is a Biblical story of a man who cut himself with stones night and day (Mark 5:1-5, Life Application Bible, 1988). Other historical accounts recorded after the fall of Jerusalem in 70 a.d. explain the belief that national guilt could be expiated through the atoning sacrifice of self-inflicted wounds

(Favazza, 1996). During the first century a.d. Christian clergy and laity practiced self- flagellation in order to relieve themselves of the guilt of sin. Early church martyrs, such as the Desert Fathers, promoted penance through self-flagellation with small leather

whips (Favazza; Lesniak, 2008). The religious orders renewed this practice in the thirteenth century; it then spread into Italy and Germany and continued into the next century, especially in response to the bubonic plague, as followers believed penance was called for (Favazza; Lesniak, 2008; Levenkron, 1998). Favazza (p. 40) reports this continued practice today, “particularly during the Lenten season prior to Easter, in areas such as the Philippines, Mexico, and some parts of the United States” (Lesniak, 2008).

Self-injury behavior is found to be acceptable in some cultures. Care must be taken to distinguish self-injury from body decoration, such as tattooing, body piercing, scarification, or the wearing of objects pierced into ear lobes, lower lips, etc. These practices are largely for aesthetic value and different cultures express and interpret beauty in a variety of manners (Favazza, 1996). What is beautiful and sensual to one culture may be repulsive to another culture with its own set of mores and values. The members of the

Abidji tribe on the Ivory Coast, while in a trance, cut into their abdomens with knives to celebrate the New Year festival; this is done in order to assuage guilt and anxiety and bring about healing for the entire tribe. In addition, many shamans practice self-sacrifice to promote healing of self and others (Favazza; Lesniak, 2008; Strong, 1998). Hinduism is another religion which demands sacrifice. In fact, suffering and sacrifice are intended to help one identify with the cycles of creation and destruction and maintain control over these cycles (Favazza). The followers of Shia Islam, in order to imitate their religious heroes and martyrs, practice self-flagellation and self-infliction of wounds (Favazza).

Another Islamic sect, the Sufic brotherhood Hamadsha, conducts healing rituals in which they seek union with God by slashing their heads, eating spiny cactus, and drinking boiling water (Favazza). Suffering is a way of penance for these religions and perhaps

even the path of salvation. Estefan et al. (2004, p. 25) argued that the cultural and religious context of self-injury provides the behavior with “significant social purpose and cultural meaning” (Lesniak, 2008).

Reflections in Poetry

Some adolescents find self-injury to be an efficacious act to bring inner pain to the surface (Strong, 1998). The following lyrics were recorded by Plumb (2006) and reflect emotions experienced by those who self-injure:

I may seem crazy

Or painfully shy

And these scars wouldn't be so hidden

If you would just look me in the eye

I feel alone here and cold here

Though I don't want to die

But the only anesthetic that makes me feel anything kills inside

I do not want to be afraid

I do not want to die inside just to breathe in

I’m tired of feeling so numb

Relief exists I find it when

I am cut. (Lesniak, 2008)

The theme of self-injury is also the topic of a song recorded by Nine Inch Nails and recently re-recorded by Johnny Cash:

I hurt myself today, to see if I still feel

I focus on the pain, the only thing that’s real (Reznor, 1994).

The following poem was written by a young girl in high school and reflects her experience with self-injury, and cutting, in particular:

Drop By Drop

They started to fall

Drop by drop

Drip, drip, drip

Into a puddle on the floor

It grew into a pond

Drip, drip drip

Drop by drop

It grew into a lake

Overtaking the pale, still contortions

The frozen smile

And the knowing eyes

Silenced but all-telling

Of the torture they endured.

Drip, drip, drip

Drop by drop

It grew into a sea foaming scarlet

Hiding the suffering eyes underneath

In the murky depths

To bring peace

Once and for all. (Anonymous, 2001b)

Favazza (1996, p. xix) stated that self-injury provides “temporary relief from a host of

painful symptoms” (Lesniak, 2008); this relief is reflected in the above lyrics. These

symptoms may be depression, anxiety, feelings of isolation, or anger. In addition, the

person who self-injures may be seeking salvation, healing or self-nurturing and may be struggling to “maintain equilibrium” (Favazza, p. xix). Alderman (1997) claimed that self-injury provides a means of expressing physical and emotional pain. Cleaver (2007) stated that females cut as a form of self-punishment or to ascertain if anyone really loved them. In addition, Styer (2006) identified reasons for self-injury as loneliness, need for control, need for distraction, tension release, intolerable feelings, and to punish one’s self.

Review of Descriptive Literature

One of the common risk indicators for self-injury, depression, is many times overlooked, under-diagnosed, and under-treated in the adolescent (Evans, 2002; Lesniak,

2008). Depression is defined as an emotional state involving a depressed mood or loss of interest or pleasure, which affects almost every aspect of a person’s life (Fassier, 2006).

Depressed adolescents are more likely to engage in risky behaviors and experience difficulty in school, which may lead to suicide attempts. This is significant as suicide is the third leading cause of death for adolescents in the United States (Evans; Gelmann &

Selekman, 2006).

Sutton (2005, p. 137) described the motivations for self-injury with “the eight Cs:

Coping and crisis intervention, Calming and comforting, Control, Cleansing,

Confirmation of existence, Creating comfortable numbness, Chastisement, and

Communication” (Lesniak, 2008). To explain this further, self-injury is a survival tactic, or a maladaptive coping mechanism, which may provide comfort to the participant, even

allowing a good night’s sleep (Sutton). Adolescents, in particular, feel they have no

control over their lives and those who self-injure claim that the behavior affords them that

desired control over their emotions (Sutton). The motivation for a cleansing ritual is clear in light of the many religious and cultural examples already explored. Some adolescents have described a relief when experiencing the pain of self-injury, because it is then that they know they are truly alive, while others claim it produces a state of numbness, or dissociation (Lesniak, 2008). Chastisement is merely self-punishment for imagined or real mistakes or shortcomings. The communication aspect is most interesting and is exhibited in poetry, song, creative writing, and visual art. The self-inflicted wound is a conduit for the voice which the adolescent lacks (Lesniak, 2008; Sutton).

Another widely held belief is that the act of self-injury produces the release of endorphins (Alderman, 1997; Favazza, 1996; Lesniak, 2008; Strong, 1998; Styer, 2006;

Sutton, 2005). Endorphins are endogenous morphines produced by the body in response to stressful stimuli. They function to inhibit pain impulse transmission in the brain and may possibly produce feelings of relaxation, well-being, euphoria, and excitement, much like the high experienced by runners. The levels of circulating endorphins may be

increased by stress (McCance & Huether, 2002). Therefore, by self-injuring, adolescents

may actually be self-soothing (Estefan et al., 2004).

Others, especially adolescent females, may be battling with a low estimation of

self-worth. Pipher (1994) asserted that adolescent girls have been negatively influenced by cultural stereotypes which somehow make their worth dependent upon their jean size.

Girls which are too pretty are viewed as objects of sexual gratification and those too plain are ignored and marginalized (Pipher). One adolescent female described this feeling as

“seeing nothing in the mirror” (Strong, 1998, p. 19). As a society, we have done a great disservice to our adolescent girls by placing unrealistic and shallow expectations upon them. Conterio and Lader (1998) stated that adolescent females may be responding with self-injury to the societal pressures to be a sexual object. The media portrays very young girls to be sexual and sophisticated and the audience of preadolescent and adolescent girls measure themselves by these standards.

One of the most intriguing, yet less discussed, motivations for self-injury is the concept of self-nurturing, or self-care. Strong (1998) posited that since self-injury provides a temporary relief from emotional turmoil, it can be used as a means of nurturing and preserving self. The person who self-injures has the opportunity to cleanse and dress the wounds, thus providing an avenue for caring for self and aiding in one’s own healing process. In addition, while witnessing the healing of the physical and external wounds, participants may transfer the illusion of healing to their internal pain

(Lesniak, 2008; Strong). Conterio and Lader (1998) reported that self-injury may give the participant either an opportunity to care for self or be used as a method for self- punishment.

Brumberg (2006) argued that self-injury may be a form of communication, with the body as “a critical message board, a way to convey information about the self” (p.

B8). Eells (2006) agreed that self-injury is a form of communication and the participant feels he/she has neither voice nor skills necessary to communicate. Eells also advocated for teachers and administrators to become more knowledgeable about self-injury and to develop protocols to respond to students who self-injure.

Shaw’s (2002) historical and feminist approach is unique and provides valuable information concerning the appearances and disappearances of self-injury behavior in the clinical literature of the past. Shaw states that self-injury is a “gendered and developmental phenomenon” and it “reflects girls’ and women’s experiences of relational and cultural violations, silencing and objectification” (p. 192). Shaw also reported that women self-injure out of feelings of powerlessness and lack of control over their bodies, lives, and environment. The adolescent years are described as risky ones for girls who may be caught between their internal feelings and the world’s external realities. Girls learn quickly that society values them for their bodies, which may be objectified.

Therefore, Shaw argued that the girls replicate that objectification by cutting their bodies.

Shaw argued that girls are silenced by the failure of health care professionals to listen to them. Shaw concluded with an admonition to health care professionals to “choose to see self-injury as meaningful” (p. 210) and advocated for authentic relationships and engagements with girls and women, as only through authenticity may healing occur. The authenticity of the nurse’s presence is a major cornerstone of this study.

Quantitative Research

In the nursing literature, there is a paucity of research published about self-injury behavior (Kubal, 2005). However, several quantitative and qualitative studies from the psychological, psychiatric, and educational disciplines will be discussed in this section.

Shaw (2002) suggested that there are limitations in available studies of self-injury. Most available researchers use a quantitative paradigm, largely because according to Harris

(2000), agencies which fund research are more concerned with statistics that would indicate an increase in the incidence of self-injury behavior than in understanding the

phenomenon. Harris also pointed out that these quantitative studies record the increase in

self-injury without exploring the root causes of this behavior. However, quantitative researchers, such as Ayton et al. (2003), Murray et al. (2005), and Whitlock et al. (2006) presented statistics which may shed some light on self-injury behavior.

Ayton et al. (2003) used the computer records of patients aged 18 years and under who presented with self-injury in the emergency department. Emergency nurses are positioned to witness the most severe incidents of self-injury. The area served by this emergency room is a homogenous community of over 400,000 people. The researchers used the postal codes to identify their population; in addition, they had access to demographic data from the hospital medical records. Scores were used to explore a relationship between self-injury behavior and social deprivation. The variables used to determine social deprivation included overcrowded housing, no possession of a car, a high proportion of single parent households, many working age persons with chronic illnesses, and unemployment statistics among those of working age (Ayton et al.).A very broad approach was used to include behaviors such as overdosing, cutting, and drug and alcohol poisoning. The researchers revealed 730 adolescents (over half were female) fell

into the above mentioned categories, and the self-injury behavior increased sharply at age

14. There were no completed suicides in this age group. There were highly significant

correlations between social deprivation and self-injury. The major flaw in this report is

that self-injuring adolescents who did not require medical attention did not present in the

emergency department, which may explain the low numbers of adolescents presenting with self-injury (Ayton et al.). In addition, the sample was 99 percent non-minority and

the emergency department population was not correlated with the general population.

Another quantitative study (Murray et al., 2005) involved an internet survey of adolescents who self-injure. The researchers used a search engine (Alta Vista) to identify eight Internet discussion groups, using search terms such as self-harm, discussion, and group. The eight groups selected were the most active groups they found, and the groups all addressed self-injury, either as their primary topic, or as a prominent topic. Postings were then placed on the groups’ websites. After five weeks, they received 128 responses, overwhelmingly female with a mean age of 16.7 years. Most respondents reported age 13 as the age they began self-injuring. The respondents were sent a questionnaire with forced choice responses. Due to the ethical implications involved, much care was taken to ensure the anonymity and confidentiality of the respondents and the researchers obtained appropriate consent from the department ethics committee of their institution.

The disturbing news of this survey was the reported result that over half of the respondents had attempted suicide. In accordance with other surveys, many respondents reported a history of physical and/or sexual abuse, eating disorders, substance abuse, body image issues, and conflict with sexual orientation. Most respondents stated that they had consulted a health professional, counselor, psychiatrist, or psychologist. There are methodological problems with this study. The researchers noted that the sampling approach itself was flawed in that perhaps only those persons in the higher educational and socioeconomic brackets would have access to computers and Internet, thereby eliminating the persons in the lower socioeconomic and lower educational brackets. Also the self-selection process lends itself to error and the information they report cannot be verified. The researchers also asserted that sampling bias could occur with this method because those adolescents who visit the websites may be more prone to self-injury

behavior (Murray et al., 2005). The quantitative studies are restricted particularly in

relation to sample selection. Harris (2000), stated, “the quantitative approach to self- harm, which inevitably aims to provide breadth at the expense of depth, fails to provide an explanation for self-harm” (p. 169).

Whitlock et al. (2006) surveyed a random sample of 8,300 undergraduate and graduate students from two northeastern United States universities. Of the 3,069 students who responded to the internet survey, the responses of 2,875 were analyzed. Of these respondents, 17 percent, most of whom were females, reported having self-injured one or more times, without suicidal intent. Over half of the participants revealed a history of physical, sexual, and/or emotional abuse and the majority also reported the onset of self- injury behavior to be during the middle adolescent years. There were several limitations of this study. The response rate was low (37%) and more females than males responded to the survey. In addition, since the samples were taken from two elite universities

(Cornell and Princeton), the external validity is in question. Also, since the participants included undergraduate and graduate students, the results are not generalizable to a younger adolescent population (Whitlock et al.).

Levander (2005) conducted a study at the Vista Del Mar Child and Family

Services, a residential treatment center for thirty adolescent females ages 12 through 17 years. The Self-Injury Screening Instrument was utilized to determine placement in the treatment program and the adolescent’s motivation to participate in the group. Then a demographic survey was given to the residents to elicit information concerning their self- injury, family history, and whether or not they would respond to group therapy. None of the residents experienced their first self-injury accidentally; the acts were all intentional.

Only 13 percent had seen someone else self-injure prior to their own self-injury. The

majority reported their first self-injury to have happened at age 12 and 66 percent

reported physical, sexual, or emotional abuse as a child. Two thirds stated they felt

emotionally neglected or invalidated by their mothers as children, while 100 percent felt

they were emotionally neglected or invalidated by their fathers. Four fifths reported a

history of alcoholism in their families, 93 percent stated they had difficulty in expressing

their feelings to people, and 73 percent admitted to an eating disorder. Most of the girls

were taking prescribed medication. Levander did not compare these results to the general adolescent population.

Ross and Heath (2002) conducted a survey of 440 urban and suburban high school students in order to discover the prevalence of self-injury among adolescents. The suburban school was composed primarily of 231 upper-middle class Caucasian students while the urban school population of 209 was lower middle class and ethnically diverse.

A screening questionnaire with a four point Likert scale was utilized; there were 24 items on the questionnaire. The researchers indicated that 13 percent of the students reported

self-injury behavior, with no significant differences between the schools (Ross & Heath).

The largest percentage of students who self-injured was Caucasian and had both parents

living in the home. These results are contradictory to the study by Ayton et al. (2003)

which correlated self-injury behavior with social deprivation. These contradictions may

make it even harder for the nurse to identify adolescents at risk for self-injury; however,

it broadens the field of who would be screened.

Kubal (2005) conducted a correlation study with multivariate analyses of variance

to examine the commonalities among groups of woman who self-harmed, and who

exhibited eating disorders and characteristics of perfectionism. There was a correlation between self-injury and eating disorders, as well as a correlation between self-injury and characteristics of perfectionism. Kubal described character traits and feelings of women who self injure: dissociation, emotional deadness, estrangement from the environment, history of early surgeries and/or childhood illnesses, body alienation, parent-child attachment difficulties, and perfectionism. Perfectionism is noted primarily in bright, creative, and talented people who push themselves to meet high demands they have set themselves, many of which are difficult to attain. The inability to meet these demands may result in self-injury due to frustration and self-disappointment (Kubal). This may relate to the higher percentages of persons who self-injure while attending elite

Northeastern United States colleges (Whitlock, 2006).

Kubal (2005) also argued for a connection between those who self-injure and a history of parent-child attachments. There were participants who reported being shamed, humiliated, neglected, and criticized in their childhood home and they experienced a lack of approval from their parents. Since they had such little control over their environment, self-injury gave them a sense of control at least over their bodies.

There are additional predictors to self-injury. Ojeda (2004) studied 60 individuals who engaged in self-injury behaviors. Using the Self-Harm Inventory and the Obsessive-

Compulsive Inventory (revised), Ojeda found a correlation between obsessive- compulsive behavior and self-injury.

The quantitative studies have provided some percentages as to how many adolescents are self-injuring; however, since most adolescents do not self-report their injuries, the accuracy of the percentages is lacking. In addition, the internet studies

depend upon adolescents having access to computers and computer skills. Most of the

studies are not generalizable to an adolescent population or the samples are too

homogenous. The quantitative approach has given us some commonalities found among

those who self-injure, but failed to provide the stories of personal experience. This

researcher has provided the personal stories of adolescents who self-injure, how they

perceive their experiences within the context of their lives, and what the self-injury

means to them.

Qualitative Research

Harris (2000) conducted a qualitative survey by corresponding with a national

organization for women who self-injure. Six women responded to Harris’

correspondence, writing letters with details concerning the genesis of their self-injury

behavior, precipitating factors leading to self-injury, and their feelings before, during, and

after self-injury. The respondents were between 20 and 45 years of age, older than the

respondents in the prior studies discussed. The methods of self-injury and the reports of

childhood abuse were similar to those of the already mentioned studies. One participant

described the resultant feeling of cleansing, as she stated, “I was trying to cut out all the

bad inside me” (Harris, p. 166; Lesniak, 2008). One of the participants relayed negative

experiences and humiliation with seemingly uncaring nurses who did not understand the

experience of self-injury. Since the participants were older women, this study is not generalizable to the adolescent population. Further research is needed to explore self- injury in adolescent females since the adolescent years are the most common times for self-injury to begin (Cerdorian, 2005). Also, there is a need to provide nurses with information to promote better understand of self-injury.

Smith (2002) identified a long standing problem of negative perceptions of those

who self-injure by emergency department nurses. Three persons with histories of self-

injury were interviewed concerning their nursing care in hospitals in England. They each

expressed frustration concerning their care and felt the nurses did not understand their self-injury. Each participant felt that what they most needed was for the nurses to sit

down and listen to them. However, the participants felt that nurses viewed them as

failures and no help was offered to overcome the urge to self-injure. Smith also

interviewed the nurses who admitted to having negative views of patients who self-

injured and felt these persons were merely seeking attention. The nurses also stated that

persons who self-injure are not taken seriously and are marginalized in society. The nurses voiced “a general fear of working with these people and … the fear is born out of not quite knowing what to do with them” (Smith, p. 598). Also, the nurses expressed feeling anxious and uncomfortable with self-injury and wanted to have more information about the topic in order to understand their patients and be able to provide appropriate nursing care.

Insensitive attitudes of nurses towards persons who self-injure were also reported by McAllister, Creedy, Moyle, and Farrugia (2002). Three hundred fifty-two emergency department nurses in Australia completed the Attitudes Towards Deliberate Self-Harm

Questionnaire (ADSHQ) and identified the following factors: the confidence felt by the nurses when assessing and referring the patients, their level of empathy, their capacity to work with the patients in an effective manner, and their ability to utilize legal guidelines in their practice (McAllister et al.).

Reece (2005) interviewed 14 nurses as well as nine women who had experienced self-injury. A nurse named Peter stated, “It seems more important for women to have bodies that are not sort of damaged” (Reece, p. 567). One of the women who self-injured relayed, “I just wanted somebody to reach out to me on a one to one basis and talk to me about the inner torment, the inner pain” (p. 568). The women who self-injured voiced similar feelings, stating that self-injury was a way to express the inexpressible, even a form of language. They described their bodies as tools, as canvases used to convey meaning. The nurses voiced a lack of understanding of the meanings behind self-injury, and as a result, had felt negatively about persons who self-injured. Reece argued that a failure to recognize the meanings of self-injury can “lead to painful encounters between nurses and women who self-injure” (p. 564). This supported the need for further qualitative research into the experience of self-injury.

Abrams and Gordon (2003) explored the meaning of self-injury through the narratives of six young women, three from a suburban high school, and three from an urban high school. While all the participants described feelings of frustration, depression, family problems and traumatic experiences, there were some differences between the suburban and urban experiences. The suburban participants were more likely to report comorbid eating disorders, histories of sexual abuse and substance abuse, and the urban participants had a higher incidence of angry feelings and traumatic experiences during childhood.

In an educational setting, Best (2005) surveyed 32 interdisciplinary participants who were teachers, counselors, school nurses, psychologists, tutors, a school chaplain, social workers, and mental health workers. The participants revealed a low level of

awareness of self-injury in their schools to be a major component of the problem. They

also expressed a wide variety of emotions when confronted with self-injury, including

“alarm, panic, anxiety, shock, being scared, distressed, upset…repulsed, frustrated, sorry,

and mystified” (Best, p. 279). The general consensus was that training on the topic of

self-injury was inadequate; in addition, the participants felt the need for greater support and supervision. This is especially needed in the educational setting, wherein teachers and administrators are considered in loco parentis and are obligated to respond to

students’ problems. This study provides an opportunity for increased awareness and

understanding among both the disciplines of nursing and education.

The inability to cope with intolerable feelings leads to alternate ways to express

those feelings (Levander, 2005). The expression comes through an act of deliberate self-

harm by cutting, burning, scratching, or scraping the skin (Levenkron, 1998).

Adolescents may experience relief or pleasant feelings; however, the shame of the act of

harming one’s own body leads in a repetitive manner back into emotions which are unacceptable to the self-injurer (Levenkron). The core attributes of this adolescent self-

injury behavior are the intolerable feelings, the deliberate self-harm, and the short term relief (Levander). Pattison and Kahn (1983) ordered the pattern as:

1. sudden and recurrent intrusive impulses to harm oneself without the perceived

ability to resist;

2. a sense of existing in an intolerable situation which one can neither cope with

nor control;

3. increasing anxiety, agitation, and anger;

4. constriction of cognitive-perceptual processes resulting in a narrowed

perspective on one’s situation and personal alternatives for action;

5. a sense of psychic relief after the act of self-harm;

6. a depressive mood, although suicidal ideation is not typically present. (p. 867)

The stories of three young women who self-injured throughout their adolescent years illustrated the emerging patterns of this phenomenon (Lesniak, 2006; Lesniak,

2007a; Lesniak 2007b). The women each described the antecedent feelings of frustration, anxiety, anger, and tension. As the emotions escalated, the self-injury act took place, resulting in relief, calmness, and relaxation. Later, the women described feelings of shame. They felt stigmatized and experienced increasing feelings of abandonment as their friends and family did not understand their self-injury behavior. These negative feelings led them back to the desire for temporary relief (Lesniak, 2008). As one participant stated, “I just cut myself and thought about the pain and I cried and then it was over and then I felt better until the next time, you know I came upon the problems again whether they were the same ones or different ones and I did the same thing. It was just something that got me through it” (Lesniak, 2007b; Lesniak, 2008, p. 191).

Sutton (2005, p. 114) described the cycle of self-injury with the six following points: “mental anguish, emotional engulfment, panic stations, action stations, feel better/different, and the grief reaction” (Lesniak, 2008). Unpleasant thoughts, feelings of worthlessness, or memories of stressful events begin to build during the mental anguish point and escalate into feelings of fright and anxiety which consume the adolescent during the emotional engulfment phase. During the panic stations phase, the adolescent feels a loss of control over the events causing these emotions, or feelings of detachment

or numbness may surface. Adolescents who self-injure relieve this intolerable tension and

escape the internal suffering by externalizing the pain through self-injury during the action stations phase. Therefore, they experience relief from the tension, dissociation from the pain, a feeling of regaining control over the antecedent circumstance, and the ability to think more clearly and even sleep. Finally, as realization of the self-injury act sinks in, feelings of shame and guilt emerge. These feelings will remain bottled up until the participants are propelled back into mental anguish, only to repeat the cycle once more (Sutton).

Chapter Summary

In Chapter 2 a description of self-injury behavior was provided, including a discussion of the methods used to self-injure, the usual locations of self-injury, and the shared characteristics of persons who self-injure. In addition, historical and cultural examples of self-injury were offered, along with several quantitative and qualitative research studies. Reflections were given on contemporary poetry, which exposed the feelings experienced by those who self-injure, and finally, risk indicators and patterns of self-injury were explored.

While qualitative research of self-injury exists, little of it is concentrated on the adolescent population and few studies are available in nursing journals. Derouin and

Bravender (2004) reported a general lack of research and available literature concerning self-injury in the nursing discipline. The nursing research that has been conducted on the topic of self-injury has not been guided by a nursing theoretical framework, such as

Paterson and Zderad (1976/1988). Nursing theory is developed with the intent of guiding practice. Therefore, this study not only offers insights into the experience of self-injury, it

does so from a nursing perspective, and specifically, from a humanistic nursing perspective.

When encountering adolescents, nurses may be more successful in establishing authentic relationships and nurses may be perceived as more approachable by adolescents. Nursing is often identified as the profession most trusted by the public. In addition, if adolescents wish to maintain confidentiality, there may be fewer stigmas involved in talking with a nurse, especially a school nurse, than with a school official.

This study offers the reader the perspective of nursing but provides information usable and applicable by a multidisciplinary audience.

CHAPTER 3

Methodology

Chapter 3 offers a description of the method of qualitative research, the basic tenets of phenomenology, and an in depth exploration of the Humanistic Nursing Theory.

There will be a discussion of the ethical considerations, the participants for the study, along with data collection and analysis methods.

Method

Edmund Husserl (1967) has been called the father of modern phenomenology, which began in the late 19th century and is a method of qualitative research that studies the lived human experience as it is lived. Husserl wrote that phenomenology should describe the experience itself as it is perceived by the person experiencing it.

Phenomenology considers the intersubjective relationship between the researcher and the person being researched, meaning that each person is self-aware and recognizes the other’s self-awareness. Phenomenology also provides a means to explore the full domain of the person’s experience, and attempts to understand the perceived lived experience.

Merleau-Ponty (1956) gave this description of phenomenology:

The study of essences, a transcendental philosophy that questions facts about our

world to understand the world more adequately, and a philosophical stance or

position that attempts to describe experience as it is lived without concern for how

it came to be the way it is. Causal explanations and interpretations of scientists

and historians are distinguished in this way by the qualitative researcher’s belief

that people and the world can be understood only through an account that

discloses their contacts with the world. (p. 59)

Ray (1990) stated that the lived experience is the subject of phenomenology and the purpose is “to seek a fuller understanding through description, reflection, and direct

awareness of a phenomenon to reveal the multiplicity of coherent and integral meanings

of the phenomenon” (p. 173). Phenomenological research questions the way we

experience the world in which we live, prior to reflection, prior to conceptualization, and

prior to categorization (Van Manen, 1990). There are no results, conclusions, or causes

sought in phenomenology. The interest lies in the experience itself, and not in what

causes the experience (Rudestam & Newton, 2001).

Oiler Boyd (2001b) defined qualitative research as “involving broadly stated

questions about human experiences and realities, studied through sustained contact with

persons in their natural environments, and producing rich, descriptive data that help us to

understand those persons’ experiences” (p. 68). For this study, this researcher engaged

with adolescents about their experiences with self-injury to understand what this

phenomenon means to its participants.

A major characteristic of this method is bracketing, which is hoped to be

accomplished by abstaining from or holding in abeyance an individual’s prior knowledge

of the phenomena (Oiler Boyd, 2001a). Husserl (1967) described bracketing as

disconnecting from previous theories, “a certain refraining from judgment which is compatible with the unshaken and unshakable because of self-evidencing conviction of truth.” (p. 98-99). The term “phenomenological reduction” has been used to describe the

process of putting aside past knowledge of the phenomenon (Giorgi, 2005, p. 77).

Husserl used the Greek word “εποχη,” or abstention, to explain the concept of bracketing, or putting out of action, any prior judgments (p. 98), thus enabling the researcher to approach the phenomenon as a beginner. Cohen (1987) stated that in order to effectively bracket out their own prejudices, “investigators must first examine themselves to determine their prejudgments and personal commitments” (p. 33). The investigators are thus able to see the phenomena as they are, instead of seeing them as reflected through the preconceptions held by the investigators themselves (Cohen).

A further discussion of bracketing is warranted at this point. Van Manen (1990) wrote “the methodology of phenomenology is such that it posits an approach toward research that aims at being presuppositionless…” (p. 29) and should attempt to avoid leading toward a predetermined collection of ideas or concepts. However, the basis of our

living caring (Boykin & Schoenhofer, 2001) is, in fact, our very humanness. As humans,

it is impractical to expect that the researcher can be merely a blank slate, totally leaving behind all the life experiences which have influenced the formation of character and decision making abilities. In fact, awareness of self and all that makes up self is essential for the existential experience (Paterson & Zderad, 1976/1988). Nursing involves both the

way we are and the way we do, our being and our doing. We are a sum total of our

choices and the paths we walked upon to arrive at any point in our journey; therefore,

these things are not easily nor quickly left behind. Paterson and Zderad described

bracketing as holding in abeyance any “adjectival labels and preconceived

viewpoints…in order to consider the thing itself” (p. 11). While Paterson and Zderad

believed that the researcher should strive to eliminate the a priori, they agreed that since

the researcher is a knowing and unique individual with his/her own perspectives, bias cannot be completely eliminated. Instead, the researcher should, through self-searching and self-awareness, become more aware of bias and perspectives, thereby enabling the researcher to see the phenomenon more clearly. This description allows the nurse to bring all that she/he is into the existential moment, yet enables the nurse to set aside labels which would cause dehumanization of the patient by objectification through labeling.

Drew (2001) asserted that self-awareness is necessary for true phenomenological research and self-awareness involves the fullness of person to be present in the encounter. Oiler

(1982) explained bracketing as a laying aside of what the researcher thinks is known about the subject, as a means of bringing the experience into focus, and as an effort to understand the other’s opinion. Omery (1983) cautioned against bracketing, as it would limit the experience.

Theoretical Guidance

The Humanistic Nursing Theory of Paterson and Zderad (1976/1988) provided the theoretical basis for this study. Kleiman (2009) stated “In today’s health care milieu, there is a resounding call for nurses to reemphasize their humanistic nature, which has been pushed into the background of consciousness by a techno-worship medical model”

(p. 2). Paterson and Zderad described humanistic nursing theory as “an experience lived between human beings,” (p. 3). The nurse approaches the nursing experience as an existential one, with intentionality and authenticity. After the experience, which is called the nursing situation, the nurse reflects upon it, describes it, identifies the calls for nursing and the nursing responses and evaluates the knowledge gained from the experience (Lesniak, 2008). This nursing situation involves a moment in time

experienced by nurse and other in which they come together in a reciprocal encounter,

allowing each full expression of their uniqueness.

The elements of the theory are as follows: “incarnate persons (patient and nurse),

meeting (being and becoming), in a goal directed (nurturing well-being and more-being),

intersubjective transaction (being with and doing with), occurring in time and space

(measured and as lived by patient and nurse) in a world of persons and things” (Paterson

& Zderad, 1976/1988, p. 18). This framework gives the participants the freedom to

explore and be creative in their lived dialogue, and it is a framework which is particularly

efficacious when the patients are adolescents struggling with health challenges. The nurse

is concerned for the adolescents’ uniqueness and potential for growth in being and becoming.

Paterson and Zderad (1976/1988) emphasized authentic presence whereby one must commit to being open and available to other; it is through this presence that genuine

dialogue may occur (Lesniak, 2008). Kleiman (2009) described presence as not a mere

“being there” but rather a “being-there-for and a being-there-with” and directing one’s

complete attention toward another person while becoming part of their experience (p. 6).

The Humanistic Nursing Theory has roots in the writings of Martin Buber and Viktor

Frankl. Buber (1970) described presence as a state in which one waits and endures and

confronts; it is lived in the present. Frankl (1984) offered a description of this as “the

self-transcendence of human existence” (p. 133) in which each person is directed to

someone other than self. It is through this presence that genuine dialogue may occur

(Paterson & Zderad). Machoian (2001, p.2) stated that, according to adolescent females, listening may be equated with caring. Machoian further states,

If girls feel someone is not listening, they may conclude that the person does not

genuinely care. Relationships in which girls feel free to express themselves

honestly have been found to be important in assessments of girls’ overall

psychological health. Not being listened to increases girls’ risk for psychological

distress. (Lesniak, 2008)

A nurse who intentionally approaches adolescents, using a caring perspective, may be able to provide the context of respect which may help adolescents find the voice necessary for the expression of intolerable feelings, thus perhaps preventing self-injury behavior. This relationship may be developed through a nurse’s authentic presence, which tells the patient, “I am here, I am still here, I will be here” (Kleiman, 2009, p. 6).

The relationship between nurse and patient and the shared experience between them is the heart of the Humanistic Nursing Theory. This relationship is described by

Buber (1970) as an I-Thou relationship wherein the “I of the basic word I-Thou appears as a person and becomes conscious of itself as subjectivity… persons appear by entering into relation to other persons.” (p. 112). In other words, each person views the other as subject, not object, creating a subject-subject relationship. The concept of this intersubjectivity was further developed by Paterson and Zderad (1976/1988) in encouraging an I-Thou, or subject-subject relationship between patient and nurse. This prevents objectification of either person, thus enabling each to know other as a unique individual.

One crucial aspect of the Humanistic Nursing Theory is that of the “call and response” (Paterson & Zderad, 1976/1988). This involves an intentional call, verbal or nonverbal, from the patient who has a need and expects and hopes to receive care. The

call is heard by the nurse who then responds to that call with the intention of giving care.

However, Paterson and Zderad stress that the call and response may travel both ways

with each person both calling for and responding to the other.

Kleiman (2006) identified the five phases integral to humanistic nursing. They are

the “preparation of the nurse knower for coming to know, nurse knowing the other

intuitively, nursing knowing the other scientifically, nurse complementarily synthesizing

known other, and succession within the nurse from the many to the paradoxical one”

(Kleiman, p. 130). During the first phase, the nurse approaches the unknown situation

with openness and without expectations of a certain outcome. It may help for the nurse to

read, contemplate, and reflect in order to open the mind to different views of the

adolescent world. The second phase begins the development of the I-Thou relationship as

each person affirms other and the nurse becomes a part of what is being studied. The

scientific knowing of the third phase involves the nurse studying what can be observed in

the shared story, then analyzing and conceptualizing the data. Patterns or themes may be

identified. During the fourth phase, the nurse will interpret, compare, and synthesize what

has been learned through dialogue. The fifth and final phase is a higher level inductive

approach whereby known patterns are assimilated into concepts. The nursing situation is

internalized, and through self-transcendence, the nurse is able to expand her/his own

angular view and add to the growth of nursing knowledge. Both the adolescents and the

nurse will have grown, and will be different than they were prior to their time together

(Kleiman; Paterson & Zderad, 1976/1988).

Writing of the early days of the theory development, Paterson (1978) emphasized that the main focus of the theory was practice, education, and research, and nurses were

encouraged to share the description of their nursing experiences; therefore, they were

able to encourage scholarship, advance practice, and share nursing wisdom. Through her

experiences nursing veteran soldiers, Zderad discovered the meaning of “presence” as the

nurse and patient are “aware of oneself and of the other” and in essence, confirm one

another, through mutual respect and caring (Zderad, 1978, p. 42).

The undergirding theme which is the cohesive quality in this research is caring.

Boykin and Schoenhofer (2001) described how a person is enhanced by being part of a

nurturing relationship with a caring person. The focus is in knowing the other as a unique

person, being aware of the uniqueness of both other and self (Boykin & Schoenhofer;

O’Connor, 1993).

Ethical Considerations

This researcher obtained approval to conduct the research from the Institutional

Review Board (IRB) of Florida Atlantic University (Appendix B). All precautions necessary to protect the participants were taken and confidentiality was guarded and maintained. Parental consent forms were signed by the parents or guardians (Appendix

C) and minor assent forms (Appendix D) were signed by the adolescent participants. For those participants who were 18 years of age and older, adult consent forms were obtained

(Appendix E). An IRB amendment (Appendix J) was also granted to place flyers

(Appendix I) in the Student Health Services of Florida Atlantic University.

One participant had moved out of the state and an IRB amendment (Appendix F) was approved to conduct this interview by telephone. The parent of this participant signed a parental consent form (Appendix G) giving permission for her daughter to be interviewed by telephone. The participant signed a minor assent form (Appendix H)

agreeing to a telephone interview. The participant and her parent faxed the signed forms

to the researcher and subsequently mailed the original forms to the researcher.

The informed consent included a thorough explanation of the purpose of the study

and that the interviews would be tape recorded and notes would be taken. Locations for

the interviews were discussed and decided upon with each participant and parent in

agreement. The researcher assured both participants and parents that their confidentiality

would be safeguarded and respected.

The participants were assured that they could withdraw from the study at any time

with no consequences. If, during the course of the interview, a participant was to become uncomfortable, the interview would have been stopped and the researcher would have

contacted the parent or guardian to pick up the participant. The parent and child would

then be referred to their own primary health care provider. If the parent did not have a mental health care provider, information concerning local resources would have been made available to the parent.

Participants

The participants in this study were adolescent females, 15 to 19 years of age, who were presently self-injuring by cutting or who have in the past participated in self-injury behavior by cutting. Saturation was reached after 5 interviews; however, 1 more interview was conducted for verification.

Recruitment Procedures

The study was advertised through the placement of flyers (Appendix I) in the

offices of health care practitioners. Flyers were printed on white letter sized paper. The

main heading read “Do You Cut Yourself?” The inclusion criteria were outlined on the

flyers. The criteria stated that the researcher was seeking adolescent females who were

intentionally cutting themselves. The contact information for the researcher was included

on the flyers. Adolescent females who were interested in participating were asked to contact the researcher using the phone number contact listed on the flyers. The phone number was that of a designated cell phone which was activated for the purposes of the study only. Flyers were placed in the office of Family Medicine of Boca Raton, and referrals will be accepted from the family nurse practitioner in that office, who has a large practice including adolescents. Self-injury behaviors associated with borderline

personality disorders, dissociative organic disorders, developmental disabilities, or

expressed desires to complete suicide were excluded from this study.

The researcher discussed the purpose of the study with adolescents who called the

contact number. It was explained to them that their parents had to give permission and

sign a consent form. If the caller stated an aversion to the parents having knowledge of

the self-injury, they were not invited to participate in the study. In addition, if the caller

declined to participate or did not wish to notify the parent, they were encouraged to speak

to a trusted adult, such as the school nurse or a teacher. Lists of local resources were

provided as well.

The purpose of the study and the research methods were explained to the

participants and their parents and consent forms were obtained. The parents had the

opportunity to rescind permission for their children’s participation at any time. The

researcher provided the parents with general information concerning adolescent self-

injury. If the adolescent was 18 or over, she signed her own consent form.

If at any point during the interview, the adolescent became agitated or voiced a desire or intent to harm herself, the interview would have been stopped immediately. The researcher would have explained that confidentiality would be maintained unless there was reason to believe the adolescent intended to harm herself or others or there was reason to believe she was being harmed by others. At this point the parent would be notified and referred to the child’s primary care provider. If the child did not have a primary care provider, a list of local resources would be given to the parent. If, in the judgment of the researcher, emergency intervention was required, the researcher would have ascertained that the parent had a plan and intended to follow through. If the adolescent verbalized that abuse was presently happening in the home, the researcher, as federally mandated, would have reported this to the Department of Children and

Families.

These participants were asked if they knew other adolescent females who self- injure and may be interested in participating in this study, thus creating a snowball effect for recruitment of participants. It was desired that between 5 and 10 participants would be selected for the interview process, or until data saturation occurs. The participants were willing to tell their stories in sufficient detail to provide the researcher with adequate data for analysis (Kleiman, 2004b).

In the event the flyer had become a catalyst or a risk to participants beyond those who participated in the study, the researcher would have provided information for the nurse practitioners and parents so they would feel more equipped to speak to these students if approached by them. Three of the 5 participants who agreed to be interviewed were referred by a nurse practitioner, 2 participants came from the researcher’s own

practice, while 1 participant was gained through the snowballing effect. There were

several more girls who wanted to be interviewed; however, they did not want their

parents to know about their self-injury or their parents would not sign the parental

consent form. Therefore, the researcher thanked them for their interest but did not invite them to be participants in the study.

Data Collection

The interviews were conducted at private locations decided upon by the participants and researcher. The researcher explained to the participants that the interviews would be taped with a micro-cassette recorder and a back-up digital recorder.

Field notes were taken by the researcher concerning the location, time of day, dynamics

of the relationship between researcher and adolescent, body language, clothing, and demeanor. The tapes were transcribed; however, the tapes were numerically coded and had no personal identifiers attached to them so confidentiality was respected. The identities of the participants were known only to the lead researcher. After transcription, the field notes, tapes, and transcripts were kept in a locked drawer in the office of the lead

researcher and will be destroyed at the completion of the research.

Oiler (1982) stated the approach to the participant should be holistic with the researcher going to the participants “in their circumstances where they are in the world”

(p. 179), thereby preserving the spontaneous nature of the lived experiences. The time together was scheduled as not to interfere with the students’ classes, during a time after school hours, when a small, healthy snack and beverage were provided. The arrangements were confirmed among the students, parents, and the researcher. This time of coming together was mutually nurturing and comfortable for the students and the

researcher. They anticipated individual growth and a corporate growth to nurture well-

being and more-being. After the adolescent was at ease, the researcher asked the following:

Tell me about your experience of cutting yourself.

Tell me about your first experience of cutting.

What matters most to you at this time?

What are your hopes and dreams for the future?

What do you think nurses, parents, and teachers need to know about self-injury?

Is there anything else you would like to share about your cutting?

The questions were open ended and allowed time for the participants to reflect and answer. There were follow up questions which evolved from the shared experience and the participants’ answers. The interviews lasted approximately one hour each, or until the

participants had exhausted their description of their self-injury experience.

Limitations of the Study

The limitations of the study primarily were reflected in the homogeneity of the

participants, who were all white, middle class girls living in a suburban area and attending good quality schools. A different sample may have been one in which the demographics of the participants reflected more diversity. Another limitation was that the participants who were willing to be interviewed may be perceived as being on their journey to recovery since they were willing to talk, several had received therapy in the past, and their parents allowed their participation. There were several adolescent females who expressed a desire to be interviewed, but they did not want their parents to know or their parents declined to sign the consent form.

Data Analysis

Kleiman (2004a) referred to major design constructs as concrete descriptions of the phenomenon, analysis with reduction, and discovery of contextual meanings. The data for this study was analyzed by the Giorgi approach (Giorgi,1997), which involved a complete description of the phenomena, consideration of the participants’ experiences, identification of themes, and the identification of contextual meanings (Kleiman, 2004a).

Kleiman (2004b) described a theme as “an expression of a lived experience containing a discrete idea or thought as expressed by the participant” (p. 264). After the division of interview transcripts into themes, the themes were studied for discovery of their relevance to nursing and to the phenomenon which was studied. Subsequently, a process of free imaginative variation was utilized to determine which of the themes were essential for identification of the phenomenon (Giorgi). This result created a structure of the studied phenomenon (Kleiman, 2004b). These common themes reflected what was interwoven throughout the interviews and represented the lived experiences of adolescent females who self-injure. Within each of these themes are contained unique qualities which give them parameters and depth.. The general structure of the phenomenon which was developed by analysis of these themes provided insight into the self-injury experiences of adolescent females.

The five steps of Giorgi’s data analysis are:

1. The researcher reads the entire description of the experience to get a sense of

the whole.

2. The researcher reads the description again more slowly, identifying transitions

or themes in the experience.

3. The researcher eliminates redundancies in the themes, clarifying or

elaborating the meaning of the remaining themes by relating them to each other

and the whole.

4. The researcher reflects on the given themes, still identified in the concrete

language of the subject, and transforms that concrete language into the language

or concepts of science.

5. The researcher then integrates and synthesizes the themes into a descriptive

structure of the meaning of that experience. (Giorgi, 1997; Omery, 1983, p. 57-

58)

Prior to beginning data analysis, the researcher intentionally and reflectively centered herself, to focus on the data and to hold any previous thoughts about self-injury in abeyance, in order to avoid preconceived notions about theme development. The five steps of Giorgi’s data analysis were employed by the researcher, beginning with an overall reading of the participants’ descriptions of their experiences with self-injury behavior by cutting. After the general reading, the researcher read the descriptions again, this time intentionally being aware of prominent descriptive statements and transitions in thought. The researcher utilized both inductive and deductive approaches to relate these statements and transitions to one another and to the body of work as a whole. Using the participants’ own comments and words, the researcher reflected on the qualities of the statements and categorized them into themes which represented the statements as a whole and divided them into cohesive groupings. The statements in each category were then synthesized into descriptions of the themes. The general overall structure emerged from an integration and synthesis of the themes.

Methodological Rigor

In order to assure rigor of this study, certain criteria were established. Attention was paid to credibility by focusing on the experiences of the participants as they are

lived. The perceptions of the participants of their own experiences were taken into

account. The findings were faithful to the descriptions given by the participants and the

researcher’s own experiences in the interviews were recorded. Fittingness of the study

was achieved by the findings, as they fit the data from which they emerged. A very clear

and logical decision trail outlined by the researcher ensured the auditability of the study.

Another researcher will easily be able to follow the development of the study and the

findings. The researcher’s interest in the study was described along with the impact the

researcher and participants had on each other. Lastly, confirmability was achieved in the

findings themselves, which emerged from the language of the participants, along with the

researcher’s field notes, and the researcher’s reflections.

Chapter Summary

In this chapter, the qualitative method of research and the undergirding

phenomenological approach were described, as well as the supportive theoretical

framework of Paterson and Zderad’s Humanistic Nursing Theory, which gave substance

to the study. The chapter also provided the method of obtaining approval for the study,

the plan for meeting potential participants, and the method of data collection and data

analysis. This researcher hoped to contribute information and understanding of the

phenomenon of self-injury to the nursing literature, as nurses many times have the initial

contact with adolescents who self-injure, either directly, or through their writings, poetry,

or art work. These nurses may not be equipped with effective and appropriate responses

or resources; this may be traumatic to adolescents who are already walking on fragile

emotional ground (Estefan et al., 2004), and for whom their only available response to

emotional angst is to harm their own bodies. If unprepared to recognize adolescents at

risk for self-injury, the nurses may face serious obstacles and challenges.

The discipline of nursing bases its practice on the scientific development of a

body of knowledge. Barry and Gordon (2006) stated, “Members of a discipline commit

themselves to developing knowledge that is consistent with the values and beliefs of its

members” (p. 25). Hoskins (1998) asserted that nursing research is important because it

provides knowledge in the following areas:

1. Practice – understand clients’ experiences, quality of care and outcomes, cost-

effectiveness of care.

2. Professionalism – scientific base for practice, body of knowledge that is

distinct from other professions.

3. Accountability – base decisions and actions in practice, administration, and

education on scientifically documented knowledge, seek scientific answers to

professional issues, read the scientific literature for new knowledge and apply to

nursing practice, administration, and education.

4. Social relevance of nursing – nursing, more than ever, is required by

consumers and sources of reimbursement to document its role in the delivery of

health services. (p. 1-2)

Nurses are in the most advantageous position to provide understanding of self- injury as they are trusted and reliable to advocate for the needs of adolescents (Derouin &

Bravender, 2004). Nurses are also educators and routinely provide their unique perspective in the education of their patients and families. Therefore, it is crucial that nursing research contributes to the body of knowledge available and accessible to nurses and other disciplines. In addition, this knowledge will benefit teachers and school administrators by providing information to assist them in identifying students who are at risk for self-injury behavior. Adolescents who self-injure need nurse researchers to gather and disseminate understanding of their self-injury experiences.

CHAPTER 4

Results

This chapter provides the results of this study. Rich descriptions of the experiences of six adolescent females who self-injure by cutting are offered. The themes which emerged from their descriptions are explained, along with the qualities of the themes. Statements from the participants’ interviews illustrate how the themes developed from the participants’ own words. The themes are further defined with examples from the participants’ stories and confirmed by supporting literature. The general structure, which was synthesized from the themes, is defined as follows: the experience of self-injury by cutting for adolescent females is struggling for well-being and hoping for more-being by using their skin as a canvas upon which their internal pain is expressed as tangible and real. The evaluation criteria are also explained. Following are the stories as told by the participants.

Annie

Annie, a tall, thin, athletic looking 18-year-old, had long dark blonde hair tied up haphazardly. On the afternoon we met, she was dressed in a t-shirt, shorts, and flip-flops, looking like the perfect all-American girl. She met me at a quiet park and expressed her annoyance that smoking was not allowed there. I introduced myself and thanked Annie for meeting me while she looked around to see if anyone else was near. We found a place in the shade to sit for our interview. I explained the adult consent form to Annie; she read the form, stated she had no questions other than to be assured her confidentiality would

be protected and she signed the form. Annie understood the conversation would be tape recorded and transcribed. She began by stating, “I don’t talk about my feelings. I don’t trust anyone, not anyone, not my mom, not my boyfriend.” I asked Annie if she would feel safe sharing her experience with me and she answered, “Well, judging from what you said on the phone, I don’t think you’re gonna [sic] judge me, and you said that no one would know that you talked to me. So I guess I feel safe with you.” I nodded my head, both in understanding and agreement, then assured her that she would be safe and would not be judged in any way. Annie proceeded to speak easily about her experience with cutting and did not need any encouragement to be open with me. We actually became too hot sitting outside, and went to sit in my car with the air conditioning running.

I asked Annie to tell me about her experience with cutting. Annie began cutting when she was in middle school, around 10 to 12 years of age. She discussed how the

“expression inside yourself” sometimes builds up to the point where “you just want to burst out and like yell and scream. It builds up and builds up and finally when I get to a point where I’m at that peak and someone just sets me off the edge and I want to scream.

I have all this pent up stuff beforehand.” Her description was accompanied by rapid, forceful hand gestures in chopping motions.

Annie stated she usually used a knife to cut herself but has used anything she could pick up, saying, “anything that I could just swing, like a frickin’ [sic] knife and hit myself with.” There were numerous healed scars on her arms and legs, each approximately two inches in length; however, there were no visible fresh wounds. She showed me one very long scar on her upper left thigh. Annie hid the cuts with her

clothing and lied to her mother about how she was injured, usually stating, “The dog scratched me.” I asked her how she felt about the scars and she answered, “It hurts everyone around me and I hate that. Cutting is ridiculous but then again, I do it. I cut where my mom would not be able to see the cuts. My mom cried in front of me and she was like, ‘I can’t believe you do this to yourself.’”

Annie answered my questions in a quick, sharp manner; however, her demeanor softened as she revealed the death of her father when she was 9 and the loneliness she experienced while growing up. Though her mother’s intentions of providing a good life for Annie were admirable, Annie longed for her mother’s presence and attention during her childhood years. She described her desire for her mother’s attention, “My mom was never around. She was stripping and working four jobs ‘just to make me happy.’ I just wanted her around. I wanted her, and not that stuff those jobs could buy me.” I asked her to clarify her mother’s job of stripping and Annie said that her mother stripped in night clubs to make ends meet. Annie said, “She was just working. She’s like ‘I’m going to make a better life for you. Don’t you worry. You’re going to have everything I didn’t have when I was a kid.’ I don’t know if she realized it but her parents were there when she was a kid. And I don’t know if she realizes it but she actually had everything she ever needed: a home. It didn’t have to be perfect. A family time. You get to know your family.

Like she thought my favorite color was pink and it was, when I was like five or four.”

Her voice and face reflected a resentful tone during this part of our conversation. I paused often to provide quiet moments of calm, allowing Annie time to reflect.

In order to make ends meet, the younger brothers and sister of Annie’s mother lived in the same house as Annie and her mother. Annie’s uncles were in their late teens

at the time and her aunt was addicted to drugs. While describing the physical abuse and beatings she endured at the hands of her uncles and aunt, Annie became visibly agitated, rapidly tapping both feet against the ground, tapping her fingertips against her thigh, and looking around nervously. She stated, “My Dad died when I was nine years old. I grew up with uncles who used to beat the shit out of me. So they kept beating my ass every day.” I wanted to calm her down as I could see her averting her eyes quickly and her face tightened. I gave her a cold bottle of water and asked her if she was okay and if she wanted to continue; Annie said yes to both questions. However, I waited a while before continuing the interview, until she relaxed and her breathing slowed.

Annie stated that when she looked in the mirror, she was ashamed at the person she saw. She saw breasts that were too small, and a body that was too fat. She was miserable during the pubescent years, struggling with her bodily changes. I asked her to tell me more about those feelings. She said, “I hated myself. I didn’t like my body. I was going through the whole changes like, I’m getting my hips, I’m getting slender but then

I’m getting thicker, like the whole body fluctuating thing. I wanted a skinny waist and I wanted some great legs. Can that happen to me? No, I’m not that lucky. I wanted to be like the skinny girls.” When I asked if she still felt that way, Annie nodded and said,

“Every day.”

During this vulnerable time of her life, Annie and her mother moved to southeastern United States and she started school in unfamiliar surroundings with new classmates. When I asked how classmates in her new school reacted to her scars, she said,

“People would ask ‘what’s wrong with you? Why are there cuts on you?’ When that happens, I just curl up in a ball and realize that I am all alone.” It was obvious by her

facial features and voice that these memories were painful and she felt resentful. Again, I gave Annie time for silence and calm and we just sat there together, sipping our water and watching iguanas running across the grass outside the car.

When she began speaking again, Annie described how it felt to “have no one hear you”, and while cutting released the pressure of the “pent up stuff”, she stated she would much rather have had someone in whom she could trust. “All the pressure and everything were just released. I calmed down. It’s done, it’s over. I don’t have to be so upset anymore.” She yearned for someone to talk to, but mostly, she just wanted her mother to be around and she wanted to experience “a family time” at home. I asked her about her hopes for the future, and she reflected, “Maybe I am doing something (by doing the interview) to help somebody and maybe, you know, somebody will actually remember me and maybe I’ll touch somebody and maybe it will all be worth it.” As for her future hopes and dreams, Annie would like to finish college and have a job working with animals. She hopes to “find some sort of happiness.” I asked Annie what message she would like to send to nurses and how they should talk to teenage girls who cut themselves. She said, “You’ve got to take your time with them. Talk a little bit. Take it gently. Make them feel that they’re loved, they’re there, and they’re acknowledged.”

When asked if there was anything else she wanted to say about cutting, Annie said she had “pretty much said it all.” I thanked her for her time and for her contribution to my study, especially for entrusting me with her personal and painful history, and asked her to call my research cell phone if she wanted to share anything more. Annie went back to her car and I sat for awhile in mine, making some notes, and trying to place her face in

my memories, remembering her facial expressions and body language, and especially her scars.

Belle

Belle, 16, and her mother had agreed to participate in this study; however, they moved to New York before the interview was obtained. The Institutional Review Board at Florida Atlantic University approved an amendment stating that this interview was allowed to be conducted by telephone. I spoke by telephone with both Belle and her mother and explained the nature of the study, the consent forms, and the confidentiality safeguarding precautions. Both Belle and her mother agreed to the telephone interview and agreed to sign the consent forms. The forms were emailed to Belle and her mother.

The mother signed the parental consent form for a telephone interview with her child, while Belle signed the minor assent form for a telephone interview. The forms were faxed to me prior to the telephone interview and the original forms were subsequently mailed to me.

At the scheduled time, previously agreed upon by Belle, her mother, and me, the interview was initiated by telephone. The interview was tape recorded and Belle agreed to this. I was grateful for the opportunity to speak with Belle; however, the telephone interview precluded the ability to observe body language, facial expressions, and visible emotions. During the course of the conversation, however, the nuance of speech gave indication of some of her emotions. She spoke easily with me and did not take much time to formulate her answers. The telephone interview may have given her the benefit of anonymity because I could not see her face, nor she mine.

Belle began cutting at age 12, using needles to scratch her skin, and eventually

moving on to razors. She stated she cut herself to make the pain visible. It was “not

actually for the pain of doing it but because I could see it (blood). It would just make

everything okay.” I asked Belle to tell me more about the desire to see her own blood.

She stated, “I don’t know, it just makes my pain easier to see.” She described how she

would feel upset, and she could not “handle” the emotions, “I would get incredibly

upset…I felt like I couldn’t handle it and that everything was just kind of hopeless. I felt

like I had to cut…if I didn’t I’d just be miserable so it was more like an addiction rather

than something that I just felt like doing. And if I didn’t do it then, I wouldn’t have any other way to deal with anything and I wouldn’t function. Everything would be really hard to handle so then I would do it and that would just make everything okay.” Of the relief experienced after cutting, Belle stated, “cutting would help with anxiety or if I was upset.

I felt better, lighter. It was more like an addiction. It was a lot better than just pretending you’re okay.” After a few moments of silence, Belle continued, “After it’s over, you can do stuff again and be okay with it until it gets worse again and then you have to cut.”

Belle’s father was an alcoholic and he and her mother fought a great deal during

Belle’s childhood. It frightened Belle and she wanted to protect her mother, but she felt

powerless to control the situation. I asked her to tell me more about this period in her life

and she answered, “My mom and dad were really fighting. My dad’s an alcoholic…they would always fight. My mom would tell him to stop drinking and like he wouldn’t and I

don’t know, he was just really loud and they would always fight. I felt like basically I had

to protect my mom from him but I was just a little kid, and I couldn’t.”

In addition, Belle experienced the death of a beloved grandfather, “my

grandfather died…I couldn’t handle that.” She felt she had no control over the

circumstances in her life. I asked her to tell me more about her feelings during the time of

her grandfather’s death. Belle answered, “I had like one of the worst experiences, ever,

for me, in my life. Like I locked myself in a room at my grandfather’s house…people

were banging on the door and they thought I like tried to kill myself or something. But I

cut really deep and it was bleeding a lot and like, I don’t know. I had been really quiet the

whole week. I wasn’t really talking to anyone and my friends started to be like worried

about me. My grandmother was there alone in her house so we would like spend the

nights there with her because she couldn’t be alone and I guess I just couldn’t handle that

so I started cutting again. My friends kept pointing it out to my mother and she just like

didn’t notice because she was so upset and like grieving. And then, just one night, I was

crying hysterically and then I went into like the bathroom then I came back out and I was

fine and she was really confused by that. She was trying to see my arms and I couldn’t let her see them…cause [sic] they were the worst they had ever been.”

I asked Belle about the very first time she ever cut and what she remembered about that time. She replied, “I didn’t know anyone that cut but I like saw it on TV or something and it was in …there was some like traumatic thing…people were cutting and they were trying to get this girl help for it. I don’t know why, but it appealed to me, I guess. And it wasn’t like deep cuts the first time either. It was just like a bunch. Like a lot.” Since I could not see Belle, I could not get a glimpse of any scars to assess how many scars she had or where she had cut.

Since I was aware that some writers refer to this phenomenon as self-mutilation, I asked Belle how she felt about that term. She said, “I feel like for some reason, I think

it’s like it seems like blown out of proportion when you say it like that. I don’t know

really. It’s weird because I never thought of it like that.”

Belle hid her wounds and kept her cutting a secret from her mother and friends for

as long as she could. She wore sweatshirts and she would cut high on her legs in order to

conceal the evidence of her self-injury. She described her feelings of shame, “no one

knew that I cut because I hid it really well. None of my friends even knew unless I knew

they cut, too, and then I told them. The ones that didn’t cut thought it was horrible. Most

of them didn’t want to talk about it.” When her friends discovered her secret, “they

thought it was horrible, and they thought I was trying to kill myself, and they were really

freaked out. They were really scared.” Belle admitted that her behavior frightened her

friends. She experienced the feeling of shame and stigmatization. I asked her how that

made her feel; she answered, “I was fine with it because I didn’t really want to talk about

it at all and I didn’t really want them to know. It was really awkward for me and I was

like, I’d get really uncomfortable. And like start shaking or something if they wanted to

see it…because my arms are like really bad. And they’d always like ask to see it. And I’d

just have like lines all the way up my arms like…they’d freak out but they would like, I

don’t know. It was weird. I have a lot of scars. I never even tried to count them.”

Belle admitted finally telling her mother, “After a year, my mother found

out…well I told her because I was like I want to go to therapy or something, and I just

went to the doctor and I told her I’d stop. And then I didn’t go and do anything about it,

about the cutting and no one really knew I guess. I went and got help for it though, last

year, I think and I stopped.”

I asked Belle to tell me about the help she received. She said, “When my mom

found out, she called my guidance counselor and then like the social worker (at school) called me down to talk to me about it and, I don’t know. I had to do this contract about like…they called it a cutting contract and if I cut then I would break the contract. So like that didn’t work so I just felt guilty every time that I did it. But I’m now…I got help after that from like a psychiatrist outside the school.” I said, “Tell me about that.” Belle answered, “When I was going there, I felt like it didn’t help at all and then I like started taking medications and I don’t know…like I stopped though in December, from taking medication and going and everything …I just felt like it wasn’t helping but now that I look back, I feel like it did because I’m a lot happier now. And like I know how to deal with things.” Belle revealed she had taken Wellbutrin, Lexipro, and Prozac for depression, anxiety, and obsessive/compulsive tendencies; however, she stopped taking them because she did not feel they helped. She does not go to therapy anymore and has not cut in almost a year.

I asked Belle if she ever thought of killing herself when she was cutting. She answered, “No. I don’t…I never tried. I never really thought about it. It was just to make me feel better.” She continued, “Most of the time I would cut at night so I’d just like go to sleep after or like sometimes I would do it before I was about to do something so I’d just like keep going on with what I was doing and it’s like no one knew I cut.”

Belle said she always expected perfect performances in her school work.

Therefore, if her grades were not perfect, it caused her self-esteem to plummet and her

anxiety to escalate. She stated, “If I didn’t get perfect grades, I wasn’t good enough.

Cutting was a way to help me like if I got a bad test score back or something. I’d get really upset over that.” When I asked Belle how she felt about herself at that time, she replied, “I was taking diet pills because I was worried about my weight. I seemed really weird. I have really low self-esteem and I just always think I’m fat. I used to throw up.”

She has dealt with body image issues surrounding her weight and has taken diet pills in the past. During these times, she feels she must cut because “when you’re looking at it

(the wound) you just feel like what was worrying you isn’t really important.” She usually is able to go to sleep after cutting because she experiences a release from the worries.

Although she expressed a desire to continue to cut to deal with difficult feelings,

Belle reflected that it would be better if she did not cut, stating, “I definitely still want to

cut but I try real hard not to. I really hope I don’t cut again.” She stated she distracts

herself from the urge to cut by replacing it with another activity, such as cleaning the

house, writing, or other activities to take her mind off cutting. When I asked if these

distractions had helped, she said they only helped minimally. Belle has tried to talk with

others; however, that has not always been successful as she felt no one was really

listening, “I feel like no one really cares about anything I say so…like that was a part of

me but I can’t really talk to people about it.”

Belle revealed dreams for her future, to be successful in a job that she enjoys. She

expressed a desire to have a happy life. I asked her what she would like nurses, parents,

and teachers to know about cutting. She advised adults to be good listeners to teenagers

who cut and to be there to answer any calls for help. She wanted adults to understand that

cutting is not equal to suicide and it is not meant to seek attention. She warned that adults

cannot force a teenager to stop cutting; however, they can offer direction for that teen to

get the appropriate help that is needed. She confided, “You need people to talk to about it

when you get upset. People are not doing it (cutting) because they want attention or because they want to kill themselves. They need help in their life; they need direction so they can feel ready to stop. They need to know that you’ll be there. The adults need to let the kids know that they’ll help the kids if they need it.”

I asked Belle if she could think of anything else she wanted to tell me about her experience with cutting. She said she could not think of anything at the moment. I thanked her for speaking on the phone with me, for giving me her time, and for telling me her story. I also asked her to phone me if she wanted to speak again.

Caroline

Caroline is an 18-year-old high school graduate who has been in a community college for a year. She met me in the evening after she had finished working. She was dressed in her scrub uniform which is worn at the veterinary office where she works. The short sleeves of the scrub top revealed numerous healed scars on both forearms. There were more scars than I could count in just a cursory glance; however, I did not want to linger over the scars and make her feel self-conscious or like she was on display. Her scrub pants were long and did not afford a view of any scars. She had long, dark brown hair which fell straight around her shoulders, providing a frame for beautiful brown eyes with long lashes and a very pretty face. Although she spoke easily, she seemed a little nervous at first. I offered her a bottle of water, but she politely declined. Caroline sat with her legs crossed but her arms were open on the arms of the chair, so her posture seemed

open to the conversation. The consent form was explained and she signed it, stating she

had no questions.

Caroline began cutting after a long night of listening to her parents argue. Her

father told her he hated her and that he wished she was not his daughter. He proceeded to

tell her older sister how much he loved her. She remembered, “My parents were fighting…my dad was telling me how much he hated me and how everything was all my fault. He wished he never had me as his daughter and that I was the worst daughter in the world. Everything was always my fault.” Caroline went into the bathroom, took a razor and cut her arm, as she felt hopeless and had no place to turn. She began cutting more frequently and wore long sleeves and jackets to hide her healed scars and fresh wounds.

Caroline said she does not know what else to do when her feelings get to the point of frustration and hopelessness. She felt that men have more socially acceptable outlets for their anger, stating, “Men can punch a wall; they have ways to get their anger out.”

I asked Caroline if she had been abused. She stated, “Maybe a little bit verbally. I remember my mom taking me to a hotel sometimes when my dad and I would fight. She would get nervous about it. And she would take me to a hotel. I never really thought much of it until we talked about it.” However, she denied ever having been physically abused.

Caroline’s weight appeared well proportioned for her height, yet she said she has always felt fat and ugly. I asked Caroline how she felt about herself. She stated, “I hated myself all the time. I was fat and ugly. I couldn’t do anything right. Even when it wasn’t my fault, it was still my fault and I got blamed for everything.” She could not remember

when she did not hate herself. Her father called her names and made her feel fat and ugly,

and it was not long before she believed his words.

Cutting felt good to Caroline. She described her feelings, “I was so angry at

everything, at myself, at my family, and I didn’t know what to do. And I just like felt

hopeless.” She liked the feeling of her jeans rubbing against the fresh cuts on her legs.

She said that it hurt, but it was a good pain, “It felt good (to cut). If I cut myself on my legs, it felt good to feel my legs scrape against my jeans. I was reminded of why I cut in the first place.” Cutting relaxed her and gave her relief from her emotions, helping her to feel calm. “I would still be angry but I would be more relaxed. It was like ending the

whole situation. I could breathe in and out. It calmed me down a lot. My crying would

stop after that. My overall mood was better,” she stated.

I asked Caroline what made her think of cutting herself in the first place. She

stated, “I really don’t know because at that time, I didn’t know anyone that did it. When

you see a man, punch a wall or something like to get their anger out, I don’t know.

Cutting was all I had. I was in the bathroom. I didn’t want to make a lot of noise. You

can’t punch anything. I don’t know, I just saw the razor and thought it was a good idea at

the time. Then I cried a lot after and I was upset at myself for doing it.”

However, cutting also embarrassed her. She did not dress out for physical

education class at school, and became the teacher’s assistant in order to avoid a failing

grade in the class. She remembers feeling ashamed at a family wedding because she wore

a short sleeved dress and knew the scars were visible. She expressed this, saying, “I

always wore long sleeves or jackets. It used to not matter if you wear long sleeves.

Sometimes I’ll hit my arm until I bruise and I tell people I walked into something. Or I’ll

cut myself with a pin a few times because that will just leave a little mark and bleed a little bit or I’ll pull my hair. I never go to the beach so I never wore stuff that they could really tell. I never dressed out in P. E. (physical education).” This feeling of shame prevented Caroline from the enjoyment of many teenage and high school activities.

Caroline spoke of her fear of abandonment and she began to cry as she spoke of her need for friends. She said she has no friends, “I have no friends…I have no friends at all. I have no friends that I hang out with even though I’m really nice sometimes. Like all my girlfriends always back stab me or say that you know, they’ll be friends, and then just hate me for some reason so I never really have any girlfriends which I really want.” I gave Caroline some tissues and a bottle of cold water and asked her if she wanted to stop the interview. Caroline shook her head, waited a few minutes, composed herself and continued speaking. I allowed her this time to cry and averted my eyes during this time in order to give her a little privacy. This seemed to decrease the intensity of the moment.

Caroline confided that her mother is dying of ovarian cancer and the prognosis is very bleak. Caroline admitted feeling terrified of being all alone in the world. Her mother has been teaching her how to pay the bills and take care of the household, in order to prepare Caroline for the time when she (the mother) will be unable to complete these tasks, either due to illness or death. I asked Caroline how she felt about this and she said that she can handle all of the household business but she just can’t imagine being alone without her mother. I allowed the sadness of the moment to rest in a few moments of silence while we just sat there together. I wanted to respect the fact that this young woman would soon be losing the only person she really has in this world.

Caroline described her relationship with her boyfriend, stating, “I’m so afraid that

if I lose him, then I’ll have to meet someone else and then, he’s got to know what’s going

on and how I feel about anything. He’s the only one that knows exactly how I feel about

everything and I don’t want to lose that. My boyfriend knows about the cutting and every

time I do it, it just makes me want to do it again because he gets so mad at me. He starts

to yell at me and makes me feel like crap. But I know if I just do it again, he’s just going to keep yelling and maybe he’ll leave me or something. So I’m really afraid. I don’t want

to be totally alone when my mom’s gone. I just need someone. I can’t talk to my dad

about anything. I really don’t like him. I don’t live with my dad anymore. He can’t really

talk to me. If he talks bad to me, I just leave the house and don’t talk to him.” I felt an

overwhelming sadness at the thought of this young woman being all alone in the world,

especially after her mother passes away. Again, I gave Caroline the opportunity to stop

the interview if she was uncomfortable. She shook her head and stated she wanted to

continue.

Caroline was in a magnet program in high school which allowed students to

explore careers in health care. She stated, “I want to be a nurse. I want to be a nurse

practitioner. I want to live. I don’t want to kill myself.” She is doubtful that she will be

able to realize this dream, however, because she did not pass her basic college math

course. Her mother has expressed a desire for Caroline to finish community college,

saying, “‘Before I die, I want you to do this.’” This has contributed to the self-doubts

Caroline has always experienced. She expressed hope for her future, but that hope has

been threatened already.

When asked if she ever received therapeutic help for her cutting, Caroline said,

“My mom took me in for counseling and she called the police and then they took me to a

nearby hospital. Caroline felt she was the recipient of negative comments from nurses

and doctors while she was hospitalized for psychiatric evaluation after an episode of

cutting. She reported that they repeatedly accused her of trying to kill herself and insisted

that she admit the same. She tried to tell them she did not want to kill herself; however,

she became so weary of their accusations that she finally lied, stating she did try to kill

herself, just so they would leave her alone. She stated, “It was more like I had to convince

everyone that I didn’t want to kill myself , so I’d give in and say, ‘well, you know, I just

wanted to kill myself but now I don’t.’ And that was how I got out, pretty much because I

said that.” She continued, “I would never, ever, ever consider killing myself, ever.” She

said none of the nurses understood the act of cutting or the people who cut. She also said

the nurses made her disrobe completely and checked her entire body for cuts and scars,

making note of each. She said, “I was embarrassed, I was very uncomfortable with that.

And then I can see them marking up everywhere I had a scratch. So I just felt violated. I

just hated that.” She even went to support groups with patients admitted for other reasons

because she felt so lonely staying in her room by herself.

Caroline wanted adults to realize that people who cut are not suicidal and to

believe them if they tell you that. She did state that she had one teacher in high school

that truly cared about her and responded with gentleness and calm when the cutting was

discovered. This teacher took Caroline to a school counselor and the principal and the four of them talked for a long time. The teacher also spoke with Caroline’s mother to make sure that Caroline would receive the therapeutic help she needed. This teacher was

also a nurse. Caroline felt safer at school after that and the counselor issued a pass which allowed Caroline to leave class to see the counselor anytime she felt the need. The teacher is still in contact with Caroline and remains available to be present and to listen.

Caroline expressed her relationship with this teacher, “I just wanted someone who was more sensitive and that I could talk to. Someone who would just be there. She was there for me.” There was a long silence and I asked Caroline if she wanted to say anything else about her experiences with cutting. She said no, we ended the interview, and I thanked her for her willingness to share her private experiences with me.

Danielle

Danielle phoned me and voiced an interest in being interviewed for this study.

She had received my flyer from her nurse practitioner. When I explained that I would interview her and I would ask her to tell me about her experience with cutting, she immediately began to tell me, “Well, my mother used to beat me a lot when I was little…” I stopped her and said that I didn’t want her to tell me until we met and the consent forms were signed, and that I would record the interview. This left me with a challenge as I had to intentionally bracket this information to prevent negative feelings I might have upon meeting her mother.

Danielle and her mother met me in the parking lot of their apartment complex and we walked to the clubhouse where there was a comfortably furnished, private room. I explained the purpose of the study and the process of the interview with tape recording.

The consent forms were explained to both Danielle and her mother and they were both assured that should Danielle wish to stop the interview at any time, that would be acceptable and without any consequences. Danielle signed the minor assent form and her

mother signed the parental consent form. Danielle’s mother was very cordial and stated

that she hoped her daughter’s participation would help in the research. The mother left at that time, after I had volunteered to walk Danielle back to their apartment after the interview.

Danielle, 16, was dressed in long, black pants and a black t-shirt with a picture of a skeleton on the front of her shirt. Her long black hair was streaked with patches of red and she wore a wide leather band around one wrist. Her skin was pale especially against her black eye make-up and black nail polish. Danielle appeared shy and hesitant at first, fumbling with her cell phone, but soon began to talk without reservation. I had two bottles of cold water and I gave one to Danielle. I asked her to tell me about her experience with cutting. She began by discussing her childhood, which was mostly spent without her father present in the home. She saw her father only once a week; in addition, she and her mother moved to a new state at about the same time that her grandfather died.

Danielle had many losses to deal with simultaneously. She stated she felt like her mother had taken her away from her father, saying, “I grew up without a dad. He was there but like he lived far away and he only saw me once a week and that really bothered me, especially when we moved down here because I was really close to him and he was my best friend. When we moved down here, my mom pretty much took me from him. And my grandfather died.” Danielle desperately wanted to move back to her father. She has felt very alone in a new state with no friends and no one to talk to. She stated she pushed away most of her friends, “We moved down here away from everyone I knew. I can’t wait to get out of this place. I find myself different than most people. I look different. I

feel different about things. I’ve lost of lot of friends.” She shrugged her shoulders as she spoke in an attempt to affect an indifferent attitude.

Danielle spoke of the abuse she experienced during her childhood. Her mother was physically abusive since Danielle was four years old, and as Danielle became older,

she fought with her mother frequently. Danielle stated, “My mom was extremely abusive

as I grew up. The first time my mom hit me, I was four. I was clicking a pen and it stuck

and made a clicking noise. She beat the crap out of me, for stupid reasons like because I

loaded the dishwasher wrong. She would punch me in the face. My stepdad held me

down while she hit me. She used to hit my dad, too.” She continued, “I finally hit her

back and I hit her so hard that I’m proud of myself. I got arrested for that, but I think she

deserved it.” I became concerned with this report of abuse and asked Danielle if the abuse

was continuing at the present time. I was prepared to end the interview and take the

necessary precautions to protect her. However, Danielle said, “No, because after I hit her back, she won’t touch me anymore.” The abuse had been reported in the past, however, and the Department of Children and Families has made several visits to the home. I asked about her present relationship with her mother and Danielle replied, “We still fight a lot, but it is not physical. I don’t get along with my mother and I want to live with my dad.”

Self-hatred was a prominent focus in Danielle’s story of her experience with cutting. She felt that she looked different than others and that her perspective was different. Danielle confided, “I hate every cell inside my body. I hate everything about myself.” She continued, “Cutting was an easier way to take out the frustration, especially on myself, because I felt everything was my fault. I look different. I feel different. I’m such a loser. I have no respect for myself. I have never had a good self esteem. I don’t

like the way I look. I’m too fat, too ugly. People judge you and no one really gives you a chance to let them see your inner person.” She spoke further of her low self esteem and lack of self respect and how she has always felt that she was fat and ugly. She complained about people who judge others for no reason, never taking the chance to see the inner person. This statement was very sad, and yet it also showed that Danielle had an intuitive insight and had given this some thought. Danielle felt that girls frequently have problems with self esteem and this may be a major reason for self-injury behavior, such as cutting.

Danielle felt that the blood was the repository of all her pain and when the blood left her body, the pain and other feelings flowed out with it. She expressed it thusly, “The blood held all the pain and anger. It’s a lot of hatred and a lot of anger and a lot of disgust for everything. It’s real emotion and it’s real pain.” Cutting was a conduit to release those feelings, “It’s just a good way to release anger and pain and hatred and stuff. I can go back to normal, no more pain, no more anger. I’m just relaxed, really relaxed. When the blood left my body so did all the emotions.” After the cutting was over, she felt her life returned to “normal” and she could finally relax. Danielle was very forthright in her admission that cutting became an addiction, stating, “I would need to cut like every night just to like relax. It was like an addiction. I needed the adrenalin and the endorphins…just to calm my mind.” She also described feeling the adrenalin rush and the “endorphin high” which resulted from the cutting, “I know I’ll get addicted to it (cutting) again. It’s a big problem for me. I need it to calm my mind.” Danielle admitted to past drug use, “I’ve done it about ten times. I started with that, stopped cutting, got off those, started cutting again. I’ve been in and out of the hospital twice and been arrested for fighting.”

I asked Danielle to remember the very first time she ever cut. She replied, “I was

in the 6th grade so maybe I was about 11. It was just me and my friend messing around in

the back of social studies class. He went like that (made a cutting movement with her

hand) with a pair of scissors and then I did it too and then the people at the school called

my house and freaked out and made it seem like I was an axe murderer or something.”

She continued, “We moved down here, the end of that school year and I started cutting

more in seventh grade. So I never really stopped. Me and my mom got into a big

blowup…and I locked myself in my room, in the corner, and got out the razors and that

was it. So, it’s just a good way to release anger and pain and hatred and stuff.” Danielle

stated she usually cuts herself with a knife or a razor she removes from her shavers. I

asked her where she usually cuts, and she pointed to her thighs. She was wearing long

pants, so I could not see the scars.

When I asked if she had ever tried to kill herself, Danielle replied, “I had a lot of

suicidal thoughts and I wanted suicide. I hated life. I hated everything about it and then in the 9th grade, I was still cutting but it wasn’t as bad…and I still wanted suicide but I don’t know. There’s always like something holding me back.” I wondered what was holding her back, but I let the silence hang over us briefly before I asked that question. At first, she said she did not know. However, she added, “My dad, because I know it would break his heart. I wouldn’t be able to do that to him.”

After the self-injury, she felt the need to hide her cuts by wearing long pants and long sleeves and lying about how she obtained the wounds, stating “I don’t tell people…otherwise they’d hate me. My dad thinks I’m morbid. It’s not something to be proud of. I really don’t like showing it to people. If people asked me about it, I lied about

it. Everybody said I was stupid and immature for doing it (cutting) and that it was dumb.”

I asked if her leather band was covering cuts on her wrist, and she nodded her head, but did not remove the band to show me the scars. She also liked the “Goth” look, wearing all black clothing. I asked Danielle what she thought of the term self-mutilation and she stated, “I don’t like it. That makes me think of cutting off body parts. I don’t mutilate myself.”

I asked Danielle if she had received any therapy for her cutting. She said, “When I was 6, I started going to therapy ‘cause [sic] my grandfather died. When we moved here,

I started going to therapy in 6th grade. Didn’t do anything, it just gave me someone to you know, say what I really had to say ‘cause I don’t tell people what I think. Otherwise they’d hate me.”

In spite of her traumatic history of abuse, self-hatred, and loneliness, Danielle still voiced dreams for the future. School is her biggest hope and distraction, keeping her busy enough to avoid her problems, as she stated, “School is the most important thing. It keeps me busy so I don’t have to deal with anything.” She said she wanted to be a psychologist or neurologist and she especially wanted to leave her present location and go back to her father.

I asked her to share with me what she would like nurses, parents, and teachers to know about cutting. Danielle wanted to tell them that teens who cut need understanding and not judgment. She expressed this, “I need someone to talk to, someone to vent to.

Journals work. Writing helped me to take out a lot of anger and whatever so I wouldn’t take it out on myself. Adults really need to listen and not judge. Judging is really painful to people especially when they’re cutting. Girls need to have ways to increase their self

esteem. If I had a way to increase my self-esteem, then most of these things would never

have happened. People need to be more understanding and not so judgmental.” I asked

Danielle if there was anything else she wanted to say about self-injury and she said no,

she had said it all. As I walked her back to the apartment, we chatted about school, her favorite subjects, her least favorite subjects and teachers, etc. Since I once taught at her school, I know the counselors and teachers there. I gave her a card with the name of a counselor and two teachers and told her if she ever needed to speak with anyone while she was at school, she could go to one of these persons and they would make time to listen to her. She smiled and seemed genuinely happy, saying, “Really? You mean I could just go and talk to them?” I answered yes; she could go to them anytime by using this card. I later spoke with the counselor and the two teachers. Without revealing

Danielle’s identity, I told them a student might come to them sometime if she needed to talk. I told them she would show them the card. They all assured me they would be available if and when she came.

Emma

Emma had just reached her 17th birthday when she agreed to be interviewed for the study. Her father came with her and I explained the purpose of the study, the tape recording procedure, and the consent forms. Neither Emma nor her father had any questions except to emphasize their desire for confidentiality. I assured them that all measures had been taken and would continue to be observed to guarantee the protection of Emma’s privacy. Emma then signed the minor assent form while her father signed the parental consent form. Her father gave me his cell phone number, then left to complete his errands and stated he would return in approximately one hour.

Emma was dressed in jeans and a loose blouse, hiding a full but well-proportioned

figure. She had dark brown hair which fell just past her shoulders. She had dark eyes,

wore no make-up, and was lovely. Her arms and legs were covered with long sleeves and

long pants, although it was warm outside. She sat in a big, fluffy chair and looked very

comfortable. I gave her a bottle of water and made sure she had no further questions

about the interview procedure. As I set up the recorder, I engaged Emma in light

conversation about school and her job in order to put her at ease.

I asked her to tell me about her experience with cutting. Emma began by

describing cutting as a means of regaining control over her life. She felt she could not control her parents’ divorce or the loneliness she felt during her childhood. Emma had no one to talk to and no friends. After the divorce, her parents developed new interests; her mother remarried, and her father had a new girlfriend. She stated, “I couldn’t control my parents’ divorce. My dad wasn’t really around because he had another girlfriend…right after the divorce, my parents kind of just went their separate ways. My mom got a new husband. I didn’t have them around at all…and they would never really pay attention to anything I had to say and I was feeling neglected, by my own parents, and that was hard.

I tried to look for help but I didn’t find it. Cutting was there for me, it didn’t abandon me.” The new lives of her parents did not include Emma and she felt that her parents neglected her, paying her no attention at all. However, I thought it was interesting that the act of cutting was a dependable variable in her life.

Emma did not fit in at school and had nothing in common with the other girls, who did not talk to her. Instead, she became the target of their jokes and cruelty. She felt abandoned by everyone and everything in her life, except for the cutting, which was

always there for her, never abandoning her. She confided, “I had no friends. I felt like I couldn’t talk to anybody so rather than just having any friends, I would just cut myself like rather than talk to them. I could never make friends. I was just alone; I had really no one to turn to. I was in a private school and everyone was rich. They felt like if I wasn’t rich, they couldn’t talk to me. It’s just like, you know you’re not the only one but you feel like you are especially when you don’t have friends.” Statements like these made me, as a researcher and as a nurse, feel very sad. I had to intentionally guard my facial expressions from revealing my feelings, as I did not want to lead her answers in any way.

Emma did not remember how she started cutting; however, she did recall that one day she was very upset, sad, and angry and had no one to talk to. She said, “I was sad, I was angry, I had all these mixed emotions and no one to talk to. Everything would make me upset. I was always sad. I’d get so upset I couldn’t sleep.” She took some razors out of her mother’s sewing drawer and cut her arm a few times. She felt an immediate relief.

She described these feelings, saying, “It was like a relief and I just felt so much better. I was in control of something because my whole life I was out of control. I just felt calmed, like there was no reason left to cry and then I would get kind of tired and usually it would be at night and I’d fall asleep. Seeing the blood just felt good, it made my skin tingle.

Like, it was just like, it made you feel like you actually had feelings ‘cause [sic] sometimes you just feel so angry and upset you just don’t even know where your feelings are and it’s kind of confusing. Physical pain is more tangible than emotional pain so you actually knew where your pain was. Cutting made me not want to die. I cut to feel alive.

So that’s where it started basically and then I was doing it on my arms. That is where the skin was the most sensitive and that’s where I feel the most. I never thought I could even

cut anywhere else and I basically just kept going on.” She continued to cut whenever the

confusing and mixed emotions became unbearable and she did not feel alive. The act of

cutting made her not want to die and the wound became a visible and tangible external

representation of the pain she felt internally, an outward symbol of an inner reality.

Seeing the blood produced a good feeling in her and her skin felt “tingly” after cutting.

Emma stated that cutting gave her pain a location upon which to focus, whether it was a leg or an arm. She said, “Whenever I’d get upset, I’d just go upstairs in my room, lock

my door and I’d just cut myself and…you know, it would range anywhere from like 3 or

4 cuts to 20 or 25 at a time. Every day, just to feel alive.”

Cutting became an outlet, a way for her to tell the story of her life. She said, “It

was like an expression. The scars are a reminder of everything that I went through. I can

cope better now by myself. Cutting was expressive…on my skin. Whatever I was feeling

at that time, I’d write with a razor blade like on my arm and my leg. You know, draw stuff. If I was feeling like heartbroken, I’d draw like a broken heart. Cutting gave me control” She cut the words “I’m ugly” and “I’m fat” into her skin. Cutting became her voice.

I asked Emma how she felt about the term self-mutilation. She answered, “It doesn’t actually feel like much too mutilation ‘cause [sic] for me it totally sounds like

something else. It sounds like totally messed up. I never really considered it like

mutilation. That could look pretty gross.”

I asked, “When you look in the mirror, what do you see?” Emma always felt self

conscious, fat, and “weird looking.” As a result, she never really liked herself, and

expressed these feelings by commenting, “I’m ugly, I’m fat. I’ve always been self-

conscious. I’m kind of different. I was laughed at growing up. I never liked myself.” But to prevent the judgment of others, she hid her cuts with long sleeves and long pants, preferring the color black and the “Goth” look as well. She realized “by cutting on my legs you wouldn’t be able to see it and it felt the same and you could cut deeper.” When others discovered her secret, they thought she was crazy.

Emma’s parents found out about the cutting during her 8th grade year when her mom found blood stained tissues around the house. Emma recalled, “She hadn’t known anything about it so she like looked on my arms. She saw like everything so she decided, you know, I needed to get help. Nothing that they could really say or do would help.

They say to take a red marker and draw on your arm or snap a rubber band on your wrist.

That was never the same thing, you know, as actually seeing blood, you know. That’s when I realized that cutting on my legs, you wouldn’t be able to see it. So I got more into that.”

Emma was hospitalized briefly and the counselors and nurses kept insisting that she admit she had attempted suicide, although she did not want to kill herself. “They just thought I was crazy and unstable. They thought I was trying to kill myself.” She felt that school counselors, psychologists, and parents just do not understand cutting and they typically overreact to it. She did not see anything wrong with it except for the “nasty scars.” With the help of therapy and now the support of her father, Emma has not cut herself in several months.

Emma has worked hard the past two years to bring her grades up as school has become her top priority. Prior to that she was tempted to drop out many times and her grades dropped. She said, “Getting through school is important to me. And keeping my

job. I’m surprised I’ve gotten this far through school because so many times I wanted to drop out and just give up. I want to help people who have gone through the same thing. I want to let them know that they’re not the only ones. I’d like being a nurse. That would make me happy.” She said she was very proud of her accomplishment in raising those grades. She wanted to finish school, keep her job, go to college, and become a nurse. I asked what changed in her, what made her want to stay in school. Emma stated she would like to help people who have experienced self-injury, especially those who have cut themselves. She would like to let them know that they are not alone. Because emotional pain “takes such a big toll”, she wanted to help people feel better about themselves.

Emma wanted adults to know that self-injury does not mean suicide because there are “faster ways to kill yourself.” She cautioned adults to be genuine and accepting of the persons who cut. She said, “I have unbiased people in my life now who don’t judge. And it definitely helps. You shouldn’t act shocked or weird around the student when you find out they’re cutting. Don’t act so taken back. Don’t make them think you think they’re crazy.” Emma stated she had one nurse in high school that made her feel welcomed and comfortable enough to discuss her self-injury. The nurse took time for her, would meet her for lunch and long talks, and just listened. She said she would do anything in the world for that nurse because that feeling of acceptance and caring meant so much to her. I was that nurse and I was very grateful that somehow I had been in a position to give her some encouragement and comfort. I asked Emma if she had anything else she would like to say about cutting. She said that she could not think of anything, but asked if it would be acceptable if she called me if she thought of something else. I told her that would be fine. She phoned her father, who picked her up shortly after.

Mary

Mary phoned me one evening and said she wanted to participate in the study. She stated she had just passed her 18th birthday and wanted to be interviewed if it could possibly help other girls like her. I explained the interview procedure to Mary and we agreed to meet the following evening at a local bookstore after I got off work. I arrived at the bookstore and found both Emma and Mary there, as Emma had provided the transportation for her friend. I greeted Emma and introduced myself to Mary. Emma left and told Mary to phone her when she needed to be picked up. Mary and I went upstairs to the children’s book section. It was late at night and that section of the store was deserted and quiet. I explained the interview procedure and the adult consent form to Mary. She voiced understanding that the interview would be recorded, stated she had no concerns, and she signed the consent form.

Mary was a very pretty girl, with long black hair, dark eyes, and pale skin. She wore a long sleeved black sweatshirt, the hood of which was hanging loose down her back. She was very thin and wore faded blue jeans. Any scars would have been completely covered by this cumbersome clothing; in addition, it was very warm outside for such clothing. As Mary sat down on a chair in the children’s section, she crossed her legs, and then crossed her arms in front of her, in a protective posture. In an attempt to put her at ease, I chatted a bit about our surroundings and the children’s books. Then she smiled and relaxed and we began recording.

I asked Mary to tell me about her experience with cutting. She began by saying, “I started cutting in seventh grade (age 12-13) and continued until this past summer.” (Mary is now in the 12th grade). She continued, “It started first as an outlet because I didn’t

have anybody to listen to me talk.” I asked her to tell me more about the purpose of the outlet. She answered, “I wanted to be the perfect daughter for the family. I don’t like my poor grades. I just think I could be a much better person. Because I know I have the intelligence. I just don’t have the motivation.” Mary felt she needed to be perfect but knew she felt short of that mark.

I wanted to further explore her feelings about herself. I asked her if she liked herself and she replied, “I don’t like myself. I don’t like how I look. I see myself as fat.

Everywhere, I just see flesh hanging off my body. I could be thinner.” I asked what she saw when she looked in the mirror, and she answered, “I just see fat. All through my childhood I was made fun of, because I was an overweight child. And I went to a private school, and my family was just middle class. I didn’t fit in at school. I never felt like I would be accepted. The others were rich and had money. They were all skinny and beautiful girls. I was the oddball out. So I was made fun of. That kind of stuck with me that I was ugly and didn’t fit in. I don’t really care if I fit in now, because I have a boyfriend that loves me.

Mary continued, “I used to be 165 pounds and I stopped eating and lost about 40 pounds in two months. When I did eat, I would make myself vomit. I don’t like eating.” I glanced at her thin frame and wondered how this self-perception had developed. Without my asking another question, Mary volunteered, “I think the show America’s Next Top

Model should be banned completely. My little sister watches that. She has hips and developing breasts. But she doesn’t think that’s normal. She thinks she should be a twig.

She doesn’t understand that she’s beautiful with her curves. With me, I don’t see curves. I just see fat, all around.” I realized that Mary was capable of seeing beauty in others, but

not in herself. In addition, she recognized the contribution the media has made to the poor

self image felt by girls.

I asked Mary to tell me about cutting. She stated that she used safety pins,

scissors, or a kitchen knife, and cut her wrists at first, but progressed to her thighs, where

the cuts were easier to conceal. She also revealed that, in the early period of her self-

injury, she would hold her urine, creating a full bladder, which caused pain. However,

she eventually began cutting because it was “a more satisfying experience, seeing the

blood, actually seeing the product.” She continued, “I saw cutting in the movies. I wanted

to see my own blood. I wanted to punish myself when I was mad at myself for different

things.” I asked if she felt self-injury was a form of self-punishment. She nodded her

head and answered yes.

I was curious if Mary had used any other forms of self-injury and I asked her about that. She stated that she sometimes had burned herself by lighting a match, blowing

it out, and pressing the hot tip of the match to her leg. This usually produced an intense

“flash of feeling” and left a big welt. She said self-injury was an addiction and she just could not stop herself. She liked the pain and the gratification. She stated, “I would get so upset that I just felt completely numb, and even when cutting myself, like I could feel the pain but it really wouldn’t click to me that it was pain. So the deeper I cut, the more I could feel. It became a part of me, a part of what I did to make myself feel better.”

When asked how she felt after she injured herself, Mary stated that “it felt good for a while, but it would always fade. I would feel guilty afterwards. My boyfriend loves me and he does not like that I hurt myself. So whenever he would see it, he would be

disappointed in me. So I would feel bad.” Mary also said she wears long pants and will

never wear shorts again because of the scars. She was not concerned about the scars on her arms, since they have healed, so she has worn short sleeves at times. She stated, “I feel comfortable dressing in black hoodies. They are like a safety blanket for me. It just makes me feel more secure. If I have something over me, people can’t see the shape of my body.” Her mother knew about her self-injury at one time, but does not know it has continued.

I asked Mary to tell me about her childhood. She replied, “My parents divorced

when I was one or two and my mom remarried really soon, but my mom and stepfather

had trouble in their marriage. They fought a lot and my stepfather was a very depressed

person. My father started dating when I was very young and I saw him hit a few women.

So I began to think that violence was okay. And I have a strong addiction to violence. I

enjoy seeing it and it gives me pleasure to see it.” When I asked if she had been abused during her childhood, Mary said no and shook her head from side to side.

When I asked Mary to tell me more about the violence, she said, “You may not want to hear it.” I told her I would listen to whatever she wanted to tell me and that it was her choice what she wanted to share. She proceeded to say, “I have rough sex often. I cannot get sexual pleasure without violence, without being hurt. My boyfriend does not like hurting me, of course, so he’ll pull my hair or punch my thighs to make me happy.

But it’s never to the extent that I want it to be. My boyfriend does not like me to hurt myself, so he decided that’s better than me cutting myself.” Since Mary had passed her

18th birthday, legally, she was a consenting adult. However, I was very concerned and asked if she had ever been seriously hurt and she denied it. I also asked about the age of her boyfriend; he was in high school in the same grade as Mary. I told Mary I was

puzzled about this information and asked if she considered this behavior to be self-injury since she was not inflicting the pain on herself. She answered, “Absolutely, because I am the one who insists upon it. It is a form of self-punishment.” I asked, “Why do you want to punish yourself?” Mary said, “Because of all the reasons I already told you why I don’t like myself.” I had no more to say and just allowed a few moments of silence to take the sting out of my thoughts at this point.

Mary has thought about her future and how she sees herself in a few years. She confided, “I would like to become a psychologist for children and I would like to help kids that maybe feel like an outcast, like I did. I asked Mary what she wanted others to know about cutting. She replied, “Don’t judge it. Don’t think that it’s a cry for help from children. It could be a very personal problem. Don’t think they’re just being silly and can control it. I did not have the willpower to stop. I saw about 3 different psychologists. It never helped. They never seemed to understand what I was saying and they just told me that it was all in my mind and I could stop if I wanted.” She continued, “Listen. Just listen to the people’s problems. Don’t be so quick to just say everything will get better.

Self harm and suicide are separate things. They (teens who cut) feel like there is nowhere else to go. They keep it inside and punish themselves. They don’t want other people to be disappointed in them.” Then Mary said something very haunting, “The therapists looked at me, but didn’t give me a face, just blended me in.” She not only felt no one could hear her; they also could not see her.

I asked Mary what else she would like to share about cutting and she had no more to say. I thanked her for her honesty and her willingness to share her very personal and private world with me. Mary phoned Emma to pick her up; while we waited, Mary and I

wandered about the bookstore looking at books together. I felt we both enjoyed the

company.

Data Analysis

Omery (1983) asserted that phenomenology must be free of “preconceived

notions, expectations, or frameworks” (p. 61). Descriptive phenomenology, in particular,

is to describe the phenomena under study by “direct investigation, analysis, and

description…as free as possible from preconceived expectations and presuppositions”

(p. 51). The data is to be gathered and analyzed by the researcher in an inductive method

with an open mind and without prior assumptions. Omery further stated, “The goal of the

phenomenological method is an accurate description of the experience or phenomenon

under study” (p. 61). Kleiman (2004a) reinforced this and described the necessity of

being open to the data as it is given while withholding any prior knowledge about the phenomenon in order to avoid corruption of the data. In this analysis, the researcher intentionally avoided any prior assumptions or knowledge about self-injury and cutting and instead relied upon the actual words of the participants themselves as they described their experiences with self-injury and cutting.

The five steps of Giorgi’s data analysis are:

1. The researcher reads the entire description of the experience to get a sense of

the whole.

2. The researcher reads the description again more slowly, identifying transitions

or themes in the experience.

3. The researcher eliminates redundancies in the themes, clarifying or

elaborating the meaning of the remaining themes by relating them to each other

and the whole.

4. The researcher reflects on the given themes, still identified in the concrete

language of the subject, and transforms that concrete language into the language

or concepts of science.

5. The researcher then integrates and synthesizes the themes into a descriptive

structure of the meaning of that experience. (Giorgi, 1997; Omery, 1983, p. 57-

58).

Themes

The participants provided detailed and rich descriptions of their experiences. The researcher first made an effort to recognize and hold in abeyance any biases about cutting and read the first transcript slowly to get a sense of the whole story. The field notes were also referred to in order to further enrich the words of the participants. The notes reminded the researcher of the observed facial expressions and body language of the participants. Then the transcript and field notes were read again, this time more slowly and with intent. Ideas emerged and were identified as well as any transitions to new or different ideas.

In order to provide a decision trail and more easily identify ideas and transitions, the researcher used colored markers. The first time Annie mentioned abuse, that statement was colored brown. Then each subsequent time she mentioned any kind of abuse those statements were colored brown as well. When there was a change or transition of ideas, a different color was used. Pink was used for any statements relating

to feelings of loneliness or abandonment. Blue represented statements about feelings of anger, tension, anxiety, or rage, while green was used for statements concerning relief, calm, release, and feelings experienced after the cutting, including any meaning attached to the scars. The color yellow represented anything said about hopes for the future, whether for self or others; purple was used for anything referring to body image, self- esteem, or self-worth. The color orange denoted the guilt or shame they voiced about cutting. This process was repeated with each interview, first reading, then reading again, referring to field notes, and then using colored markers to identify ideas and transitions in ideas.

In total, there were 25 statements colored brown, indicating some sort of abuse or trauma. There were 48 statements colored pink, which denoted feelings of loneliness, abandonment, or feeling like an outsider. These statements were then divided into two groups, with one group representing feelings of abandonment due to divorce, separation, or death and the other group representing feelings of loneliness that emerged from peer rejection or being friendless. The purple colored statements concerning body image or self-esteem numbered 35, while there were 58 orange colored statements about feeling guilty or ashamed. There were 42 blue colored items representing the negative feelings and 45 green colored statements about the relief, calm, and feelings of expression after the cutting. The green colored statements were divided into one group of feelings of calm and relief and another group which reflected feelings of meaning and expressivity. The

33 yellow colored statements represented feelings of hope for the future. Each group of statements was reflected upon and studied to identify a common theme which described the experiences within each group.

By reflecting upon the descriptions of the participants’ experiences, the researcher was able to identify discriminate themes representing each group of colored statements, which together formed the whole experience and articulated a structure for the data

(Giorgi, 1997). The themes which emerged are essential, or belonging to the essence of the phenomenon under study. The raw data were reviewed yet again to confirm that the data were exemplified adequately as described by the themes, which were still expressed in the language of the participants. After reflection, that language was synthesized into a

more conceptual form. Kleiman (2009) stated, “the descriptions or naming of the themes should directly reflect what was said in the raw data rather than some lexicographical fit that may not give the appropriate nuance observed for the context in which it resides” (p.

93).

In order to best express the experiences of the participants, the researcher chose to use words which express a continuous state of being. Gerunds, or words ending with ing, were used to convey the concept of an uncompleted action or a state of being and becoming. The shared themes are living with childhood trauma, feeling abandoned, being an outsider, loathing self, silently screaming, releasing the pressure, feeling alive, being ashamed, and being hopeful for self and others.

Living With Childhood Trauma

All of the participants shared stories of childhood trauma. Annie and Danielle revealed histories of physical abuse while Caroline experienced emotional and verbal abuse. Belle witnessed constant fighting in the home, as did Caroline, Mary, and Emma.

At times, the fighting became physically violent. The young women felt they were not equipped to deal with these traumatic events and felt they received no parental support or

guidance to help them. Belle and Emma expressed frustration at their lack of control over

these events and relationships in their homes. Trauma is defined as “an injury to living

tissue caused by an extrinsic agent or a disordered psychic or behavioral state resulting

from mental or emotional stress or physical injury” (Webster’s Ninth New Collegiate

Dictionary, 1990, p. 1256). One of the most common shared experiences of adolescents

who self-injure is a childhood history of abuse and/or neglect (Alexander, 1999; Cleaver,

2007; Conterio & Lader, 1998; Kubal, 2005; Levander, 2005; Murray et al., 2005; Santa

Mina et al., 2006; Whitlock et al., 2006). The respondents of an internet survey of

adolescents who self-injured revealed a high incidence of abuse experienced during childhood (Murray et al., 2005) while 66 percent of the respondents in Levander’s (2005) study indicated a history of childhood abuse. In fact, Levenkron (1998) stated that cutting one’s body could be an attempt to become unattractive to an abuser. Marital violence in the home has also been found to be a common experience of adolescents who self-injure

(Kehrberg, 1997; Kubal, 2005).

Feeling Abandoned

Each of the participants voiced feelings of neglect, isolation, abandonment, fear of being alone, and a disconnection from others. Belle and Danielle both expressed grief over the death of their grandfathers, Annie mourned the loss of her father, and all but

Belle described the divorce or separation of their parents as a catalyst for depression, tension, or anxiety in their lives. Caroline was fearful of being alone if her mother dies of ovarian cancer. Annie and Mary both stated that they felt they were calling for help, but no one responded and Annie said she had no one she could trust. All of the participants, with the exception of Belle, came from homes in which one parent was absent, due to

divorce, separation, or death, and they shared that they felt abandoned by the missing

parent. However, Belle’s parents may have now separated, since she and her mother have

moved out of state. In addition, Belle stated her father suffered from alcoholism.

Kehrberg (1997) and Kubal (2005) reported that the loss of a parent or loved one at an

early age is common among adolescents who self-injure as well as having an alcoholic

parent in the home (Alexander, 1999; Cleaver, 2007; Conterio & Lader, 1998; Kubal,

2005; Murray et al., 2005; Whitlock et al., 2006). In addition, Levander (2005) cited

neglect by one or both parents as a common complaint among adolescents who self-

injure.

Being an Outsider

All the participants, except Belle, confided that they felt they had no friends and

no one to talk to. Caroline, in particular, became very emotional when confiding that she

had no friends, but wanted to have girlfriends. Emma stated that cutting, however, had

not abandoned her; cutting had become a friend since she had no one else to talk to.

Several of the young women reported that their friends did not understand the cutting and

were uncomfortable with the wounds, especially the recent cuts which still had visible

scabs. Their peers made fun of them and called them crazy for cutting themselves. All the

participants reported feeling like they did not fit in with their peers at school; therefore,

they rarely participated in extracurricular activities at school. Conterio and Lader (1998) and Levenkron (1998) stated that adolescents who self-injure desire to be loved and accepted but do not feel that they are and they often have difficulty in establishing and maintaining relationships. Cerdorian (2005) cited social and school problems as a commonality among those who self-injure. If, as Cleaver (2007) cited, many of these

adolescents who self-injure feel more comfortable dwelling among the Goth youth

subculture, they are even more removed from the mainstream adolescent population.

Loathing Self

Self- hatred and low self-esteem were concerns shared by all the participants.

Each one stated that she felt fat and ugly and did not measure up somehow to anyone’s

expectations. They expressed an extreme distaste for their bodies and physical

appearances and generally felt worthless. Belle expressed a need to be perfect in her

school performance, and when she was not, she felt like she was a loser and was not

smart enough. Diet pills, diets, and eating disorders were common in the lives of all the

participants as they struggled to meet societal standards of beauty. There are many references in the literature which support this theme. Low self esteem or low self worth is common in those who self injure (Conterio & Lader, 1998; Kehrberg, 1997; Kubal, 2005;

Levenkron, 1998). Pipher (1994) and Strong (1998) asserted that adolescent females frequently exhibit low estimations of their self worth in response to society’s expectations of prescribed standards of beauty. Like Belle, many adolescents who self-injure are perfectionists and place high demands upon themselves, then experience frustration and self-disappointment if those demands are not met (Kubal, 2005; Whitlock, 2006).

Silently Screaming

A commonality emerged from all of the interviews which included feelings of anger, sadness, depression, anxiety, hatred, disgust, hopelessness, uncertainty, and inner pain. Each participant expressed an inability to vent these feelings and felt there was no

outlet, so the feelings continued to escalate until they were “pent up” inside. Danielle stated she felt her blood held her pain and anger while all the participants described

feelings of yelling or screaming “on the inside.” Annie described this as, “I have expression inside myself.” Estefan et al. (2004) described this feeling as being trapped, while Conterio and Lader (1998) reported the adolescents’ difficulty in expressing thoughts and emotions. Also, adolescents who self-injure experience feelings of frustration, depression, and anger (Abrams & Gordon, 2003) as well as anxiety and agitation (Pattison & Kahn, 1983). Sutton (2005) described these feelings as mental anguish which escalates into fright and anxiety and becoming all-consuming.

Releasing the Pressure

Self-injury, and cutting in particular, became the chosen, although hidden, outlet for the escalating emotions felt by the participants. Cutting released the pressure of these feelings and afterwards, the participants felt relief and calmness and were able to sleep.

Cutting was, at least, dependable and was always there, waiting. The participants all reported feelings of relief and calm after cutting themselves. Two of the participants stated they usually cut at night, and went to sleep after the self-injury. In her song lyrics,

Plumb (2006) revealed feelings of relief after cutting and Favazza (1996) reported that temporary relief from the escalating emotions is usually experienced after cutting.

Pattison and Kahn (1983) also reported a feeling of psychic relief after self-injury.

Feeling Alive

The act of cutting transformed the internal pain into an external, visible reality which made their emotions tangible, something they could feel, touch, and see. Belle wanted her pain to be visible to her; she wanted to see the blood. Emma stated that she could look at her arm and she could remember what problems she was facing when she made each of her scars. The scars gave her pain a visible and tangible location, although

the scars were the consequence of the self-injury and not the purpose of the self-injury.

Their cuts and scars became memories as each wound told a story in the history of their lives. Emma wrote messages in her skin to convey her emotions. One participant stated she cut so she cut feel alive and several reported that they cut when they felt dead or numb inside. Estefan et al. (2004) and Sutton (2005) stated that self-injury was the voice or conduit which provided a means of expression while Alderman (1997) claimed that self-injury was a means of expressing physical and emotional pain. In addition, Brumberg

(2006) asserted that self-injury was a form of communication with the body becoming the message board. Another interesting aspect was the concept of self-injury as a form of self-care, as reported by Strong (1998) and Conterio and Lader (1998). Strong asserted that self-injury could be a means of nurturing and preserving self while Kehrberg (1997) called it a method for self-healing.

Self-injury behavior is not synonymous to body modification. Selekman (2003) reported that body modification, in the form of piercing, tattooing, and scarrification, is practiced by many adolescents as an overt way of conveying individuality and expression. Adolescents, including the participants of this study, who self-injure, however, usually hide the results of their self-injury. Selekman also stated that body modification is sought to claim affiliation with a social group, to become more attractive, to demonstrate a rebellious nature, to commemorate a relationship or an occasion, or to get attention.

Being Ashamed

The participants hid their fresh cuts and their wounds, usually with long sleeves and pants. Caroline, Danielle, Emma, and Mary came to their interviews dressed in heavy

clothing which was inappropriate for the warm weather. Only Annie was dressed in shorts and a t-shirt. Since my interview with Belle, was by telephone, I could not see her manner of attire. They had all learned to cut high on their arms and legs where the wounds would not be seen. They lied to their families, friends, and teachers about the origins of the cuts in efforts to avoid the embarrassment and shame that surely would have followed. They knew that others did not understand and they felt stigmatized and alienated when friends eventually discovered their secrets. Physical education class, where students were expected to dress in t-shirts and shorts, became an obstacle. Caroline shared a traumatic experience when she was hospitalized involuntarily because of her self-injury. She stated the nurses and doctors were very negative in their approach and behavior and tried to make her admit that she had tried to kill herself, when indeed, she had not. Emma stated that her high school counselor began treating her differently like she was “crazy.” She said the counselor seemed to be very careful in choosing her words while speaking to her. It is common for adolescents who self-injure to wear clothes which completely cover their arms and legs, even in warm weather, in an effort to hide their scars and protect themselves from stigmatization and shame (Cerdorian, 2005; Cleaver,

2007; Hoyle, 2003; Shannon, 2005). Harris (2000) and Smith (2002) reported adolescents’ feelings of shame and humiliation, especially when confronted by parents, teachers, or nurses.

Being Hopeful for Self and Others

Although their backgrounds were sometimes tragic and oftentimes sad, each young woman expressed hopes for the future. Instead of using self-injury to attempt suicide, the participants said they used self-injury to stay alive. They all wanted to live

and experience the futures they hope to have. Each young woman voiced a desire to be able to stop cutting, although Emma stated she did not see anything wrong with the behavior. Other hopes were described, such as desires to finish school, find a job, and to be happy. Two participants stated they wanted to grow more as persons and to eventually have jobs which would enable them to help others.

The last question asked by the researcher challenged the participants to describe what they would want school nurses, parents, teachers, counselors, and school administrators to know about adolescent girls who cut themselves intentionally. Each voiced a desire to have a caring person in their lives, a person who would always just “be there”, a person who would listen, a person who would respect and acknowledge them, a person who would take time with them, a person who could be trusted. They wanted to be loved and accepted and they did not want to be judged. They needed understanding, direction, and assurance, and mostly, they wanted someone to respond when they called for help.

These adolescents had become, as described by Mayeroff (1971), their own guardians and they have begun to take responsibility for their lives, usually out of necessity. By cutting, they have made their problems bearable; therefore, they retain some hope for their future. In addition, in learning to care for self, they have gained a desire to care for others, as described by Boykin and Schoenhofer (2001).

The following table illustrates the themes which were identified and contains the qualities of those themes:

Table 1

Themes, Quotes, and Excerpts of the Data

Themes Quotes and Excerpts of the Data

Living With Physical, emotional, or verbal abuse

Childhood Trauma Divorce or separation of parents

Fighting and tension in the home

“My mom would beat the crap out of me. My stepdad

held me down while she hit me.”

Feeling Abandoned Detachment from others

Death of a loved one

Isolation

Fear of being alone

Called for help – no response

“My mom was never around. I just wanted her

around.”

Being an Outsider No friends

No one to listen to them

Disconnected, does not “fit in”

“I have no friends at all. I have no one to talk to.”

(table continues)

Table 1 (continued)

Themes Quotes and Excerpts of the Data

Loathing Self Self-hatred

Low self-esteem

Feels fat

Feels ugly

No self-respect

Poor body image

“If I didn’t get perfect grades, I wasn’t good enough.”

Compares self with the “pretty girls”

“I hate every cell inside my body. I’m fat and ugly.”

Silently Pent up emotions, such as anger, sadness, anxiety

Screaming No outlet for expression

Escalation of pent up anxiety and anger

“You get just so much expression inside yourself and you just

want to burst out and yell and scream.”

Releasing the Cutting produces calmness and relief

Pressure Cutting releases all the bad feelings

“Everything’s just gone away; I can go back to normal. Like

no more pain, no more anger. I’m just really relaxed.”

(table continues)

Table 1 (continued)

Themes Quotes and Excerpts of the Data

Feeling Alive Cutting as an outlet for expression

Pain is made visible in the wound and the blood

Scars are a voice and a visible story

“Cutting made me not want to die.”

“I look at the scars and they are kind of a reminder of

everything that I went through.”

Being Embarrassed by their scars

Ashamed Ashamed of their scars

Do not want parents and friends to know

Hide the scars with clothing

“I began cutting high on my leg so no one would see it.”

Lies about origin of wounds and scars

Negative experiences with nurses and doctors

(table continues)

100

Table 1 (continued)

Themes Quotes and Excerpts of the Data

Being Hopeful for Wants to stop cutting

Self and Others Hopes to be happy

Hopes to finish school and have a good job

Hopes to find success and happiness

Desire to transcend cutting

Desire for more-being

Wants authentic presence of a caring person

Wants someone to intentionally be there

Wants someone to listen to them

Wants acknowledgement

Wants someone to take time with them

Wants someone to trust

Wants someone to be nonjudgmental

Wants to be loved and accepted

“I want to help people who have gone through the same

thing, let them know they’re not the only ones.”

Wants a response when they call for help

Wants direction and reassurance

Wants to be understood

Wants to help others

101

General Structure

According to Giorgi (Giorgi, 1997; Omery, 1983), the last step in data analysis involves the integration and synthesis of the data into a structure which describes the overall meaning of the experience. The nine themes, which emerged from the language of the participants, were synthesized, by using an inductive method, into a general overall structure which describes the phenomenon of cutting by adolescent females.

The overall concept of loneliness emerged from the synthesis of the themes of living with childhood trauma, feeling abandoned, and being an outsider. The qualities of these themes, as expressed in Table 1, all reflect an element of loneliness. This loneliness arises from a host of causes, such as divorce, abuse, death, neglect, fighting, detachment, isolation, and rejection by peers. Each of the participants expressed at least one or more elements of experiencing loneliness.

The themes of loathing self, silently screaming, and being ashamed represented an

overall meaning of angst and desperation. Each of these themes possesses negative and

unpleasant qualities, such as low self-esteem, poor body image, and disrespecting self, as

well as escalating anger, anxiety, rage, embarrassment, hiding, and lying about the self-

injury. The participants each shared experiences with intolerable emotions, hatred of their bodies and selves, and their desire to hide their scars to avoid embarrassment and shame.

Relief and efforts to survive were represented by the themes of releasing the

pressure, feeling alive, and being hopeful for self and others. These themes have a more

positive quality in that they reflect the participants’ feelings after the cutting is over. It is

a recovery process from the act of self-injury. The participants all described a sense of

calm and relief after the cutting, even to the point of being able to sleep. In addition, two

102

of the participants found comfort in looking at their scars and remembering what precipitated the creation of those scars. At this point, they experienced a sense of healing

as the physical wounds were healed. There was an element of caring for self as they cared

for their tangible physical wounds, which represented their emotional pain. By caring for

their wounds, they had a sense of healing their emotional pain; and, as they watched their

wounds heal, they transferred that external healing to their internal wounds. The young

women all have experienced feelings that no one else is taking care of them, so they must

care for themselves in order to make it through every day.

Lastly, each participant expressed their hopes and dreams for the future and their

desires for people to better understand their experience of self-injury. They wanted to

enter into careers or jobs to help others, such as becoming a nurse, a nurse practitioner, a

child psychologist, and a veterinarian. The young women exhibited a spirit of strength

and resiliency in finding a way to cope with their problems and feelings in order to keep

getting up every morning, going to school, going to work, and going about the business of growing up in spite of the obstacles strewn in their paths.

These themes were integrated and synthesized into one general overall

structure which was based upon the meanings which emerged from the participants’

descriptions of their experiences with self-injury and cutting. The participants have

struggled to feel normal, in spite of their feelings of loneliness, abandonment, neglect, anger, frustration, and self-hatred. They alternate between these feelings, which occur prior to and during the act of self-injury, and feelings of calm and relief, which are the residual effects of self-injury. They are struggling to achieve and maintain a sense of normalcy, as compared to the escalation and de-escalation of negative feelings. The

103

general structure that emerged from a synthesis of the themes was that the experience of

self-injury by cutting for adolescent females is one where they are struggling for well-

being and hoping for more being by using their skin as a canvas upon which internal pain is expressed as tangible and real.

Evaluation Criteria

In order to achieve rigor in qualitative research, these factors will be discussed: credibility, fittingness, auditability, and confirmability (Sandelowski, 1986). The study has credibility because the researcher studied what had intended to be studied, that being the lived experience of adolescent females who self-injure by cutting. The descriptions were given in the language of the participants about their experiences as they are lived and perceived by the participants, without bias or corruption. The phenomenon, and not the procedure, was the focus of the study. The findings of the study compare with other qualitative studies of the same phenomenon. Also, credibility has been established because the descriptions given are faithful to the experience as told in the language of the participants.

The study achieved fittingness because the interviews were conducted in natural settings without controlling conditions. The participants were obtained by purposeful sampling of adolescent females who had experienced self-injury by cutting, and by snowball sampling, wherein a participant was recruited by another participant of the study. Sandelowski stated, “Sample size cannot be predetermined because it is dependent on the nature of the data collected and where those data take the investigator” (p. 31).

Sampling continues until saturation is reached and no new themes emerge. The data

104

produced findings which were grounded in the experiences of the participants, and the descriptions fit the data.

Identical repetition or reliability is not sought in qualitative research. Rather, the unique human situation and experience are the focus. These are not measured by the senses (Sandelowski, 1986). Auditability was achieved in the study as the decision trail of the researcher can be followed by another researcher from the beginning of the study to the end. The development of the study was conducted in a logical manner, the researcher’s experience and views were incorporated into the study, the method of data collection and theme emergence and development were explained, the time and settings of the interviews were described, and the data analysis was outlined.

Qualitative research cannot be totally free of objectivity as the relationship between participant and researcher is unique as compared to quantitative research. The researcher’s reflections are a part of the data along with the descriptions given by the participants. Confirmability refers to the findings of this study as the study has achieved auditability, fittingness, and credibility. The findings were confirmed by 3 researchers expert in the methodology and/or the human experience. In addition, the findings of the study were shared with 2 of the participants, Caroline and Emma. They both agreed with the findings and stated that the themes adequately and appropriately represented their experiences with cutting.

Chapter Summary

This chapter introduced the adolescent female participants who volunteered to be interviewed for this study. The descriptive statements of their experiences with cutting provided raw data which enabled the researcher to discover the

105

emerging themes. The themes were found to be woven throughout the dialogues of each participant, thereby providing saturation. The themes were illustrated by their qualities and by the descriptive statements in the language of the participants as revealed in their interviews. The stories of the participants were recorded in a descriptive manner. Each story revealed common themes of living with childhood trauma, feeling abandoned, being an outsider, loathing self, silently screaming, releasing the pressure, feeling alive, being ashamed, and being hopeful for self and others. The themes were then synthesized into a general overall structure. The general structure that emerged from a synthesis of the themes was that the experience of self-injury by cutting for adolescent females is one where they are struggling for well-being and hoping for more being by using their skin as a canvas upon which internal pain is expressed as tangible and real. In addition, the evaluation criteria were explained. The information represented in this chapter provides a description of the lived experiences of adolescent females who self-injure by cutting, and the descriptions come from the dialogues and language of the participants.

106

CHAPTER 5

Summary, Implications, and Recommendations

This chapter presents a summary of the findings of this study. Implications of the

findings for nursing practice, research, education, and policy development are offered.

Recommendations for additional studies on this topic are suggested as a way to deepen

the understanding of female adolescents who self injure by cutting. A poem written by an

adolescent sharing her experiences of cutting is presented as an aesthetic knowing and representation of this phenomenon.

Summary of Theory, Method, and Findings

The guiding philosophy of this study was to embrace the research participants as

the authors of their own experience. The participants were respected and treated with

kindness and an intentionally caring attitude. The researcher was open to hear the stories

of the participants in their own words. This approach reflected the influence of the

Humanistic Nursing Theory, as described by Paterson and Zderad (1976/1988). The practice of this theory enabled the researcher and participants to develop a relationship

sufficient in trust for the participants to share the intensely personal stories of their

experiences with cutting. The interviews were conducted in an atmosphere of non-

judgmental acceptance, openness, and reflection. The aim of the Humanistic Nursing

Theory is for both researcher and participant to grow in well-being and more-being. The

researcher and the participants were changed by the encounters, the researcher by gaining

107

understanding of the phenomenon and the participants by feeling they had contributed to

this understanding.

Phenomenology is the method of inquiry proposed by the Humanistic Nursing

Theory because it is descriptive of the nursing situation and is used to “for studying,

interpreting, and attesting the nature and meaning of the lived events” (Paterson &

Zderad, 1976/1988, p. 54).The phenomenological method of inquiry was utilized in order

to discover the lived experience of adolescent females who self-injure by cutting.

Phenomenology should describe the experience itself as it is perceived by the person

experiencing it (Husserl, 1967). The researcher enters the world of the participant as it is

lived and described by that person. The researcher must set aside or avoid any preconceived ideas or judgments concerning the phenomenon and be open to the

descriptions as given in the language of the participants. This method of qualitative

research is not used to seek a predetermined finding or result, or to answer a particular

question, or to determine causation. Phenomenology is, instead, the study of the

experience itself.

The Giorgi method of data analysis allowed for the researcher to engage in

intentional reflection of the transcripts and field notes. This reflection on the data and

dwelling with the data enhanced the personhood of the researcher as the world of the

adolescent female who cuts unfolded through the descriptions of the participants. The

researcher was invited to enter the world of adolescent self-injury and was provided a glimpse of what the experience of self-injury by cutting means to adolescent females.

During data analysis, themes emerged from the stories of the participants.

The themes contained expressive feelings of loneliness, of being left behind by missing

108

parents or by the death of a loved one. The young women also voiced emotions, such as

anger, frustration, and tension, that were difficult to verbalize and even more difficult to

dispel. The act of cutting provided a much needed relief and even provided a means of

expressing the intolerable emotions. Each of the young women believed herself to be fat,

ugly, and worthless, and had difficulty fitting in among peers and classmates. All

experienced some form of abuse during their childhood and early adolescence, and all

expressed feelings of guilt and shame over their self-injury acts. Yet each of the young women verbalized a desire not only to live, but also to help others, whether by participating in this study, or by entering a profession in which others would be impacted by their service. The themes which emerged were living with childhood trauma, feeling abandoned, being an outsider, loathing self, silently screaming, releasing the pressure, feeling alive, being ashamed, and being hopeful for self and others. The synthesized meaning, or general structure, emerged from the themes. The general structure that emerged from a synthesis of the themes was that the experience of self-injury by cutting

for adolescent females is one where they are struggling for well-being and hoping for more being by using their skin as a canvas upon which internal pain is expressed as

tangible and real. These findings contribute new information which may influence a

paradigm shift in the way we look at adolescent self-injury behavior, thus promoting a

stronger focus on caring and well-being.

The findings of this study provided important new insights into the lived

experience of adolescent females who self-injure by cutting. Since most of the research

on self-injury has been published in the disciplines of psychology, anthropology,

psychiatry, and sociology, this study will be a contribution to the literature in the body of

109

knowledge in the discipline of nursing. Since nurses are often on the front lines of health care, whether in schools, churches, private practices, hospitals, or emergency

departments, they may be the first health care professionals encountered by adolescents who self-injure. The findings from this study may inform these nurses, thereby assisting them to intervene as caring individuals in meeting the needs of adolescents who self- injure.

Implications for Nursing Practice

Living With Childhood Trauma

The findings of this study included reports of exposure to domestic violence, whether as a victim or as an observer. Evans, Davies, and DiLillo (2008) reported in a meta-analysis of 60 reviewed studies that up to 40 percent of adolescents have been exposed to domestic violence. This exposure often produces an internalization of feelings

such as depression, worry, anxiety, emotional withdrawal, and symptoms of post

traumatic stress disorder. In addition, many adolescents exposed to domestic violence

may externalize their feelings and become more prone to physical aggression and other

behavior problems. Nurses may be able to intervene if they suspect an adolescent has

been exposed to domestic violence, to protect the adolescent from further exposure, and

to access community resources to help the adolescent and the family.

The participants of this study reported many instances of abuse experienced

during their childhood. In matters of child abuse or neglect, the role of any nurse,

regardless of specialty, is clearly outlined. Nurses are federally mandated to report any

suspected abuse or neglect to the child protective authorities. School nurses have the

opportunity to become acquainted with a student over a period of years and build a

110

trusting relationship which would provide the student with a chance to confide in a trusted individual. In addition, school nurses have access to the student outside of the presence of the parent. In these instances, the student may feel free to speak. Pediatric nurses, advanced practice nurses, pediatricians, and family practice physicians have that same opportunity; however, they also have the ability to examine children during health check-ups, noting any unexplained bruises, scars, or injuries. Emergency room nurses have access to physical examinations as well as diagnostics and radiology when a child presents with an injury. These nurses can detect old fractures which were unreported as well as other signs of abuse and/or neglect. Community health nurses, including faith community nurses, may become acquainted with entire families and may observe family dynamics which might be indicative of abusive or neglectful situations. Nurses of any specialty have prescribed responsibilities in these situations.

Feeling Abandoned

The findings of this study included themes of abandonment and feeling like an outsider, especially among peers and classmates. As caring individuals, nurses can create healing and nurturing environments at the point of care in order to promote the well- being of the adolescent who self-injures. School nurses have the opportunity to welcome students into a clinic in which the nurse promotes an atmosphere that is inviting, caring, and nonjudgmental. The nurses in pediatric offices as well as advanced practice nurses could arrange office schedules so adolescents have more time in an office visit, especially with the parent waiting in another room. This would afford adolescents the opportunities to talk to caring adults and perhaps seek help for their self-injury.

111

The findings of this study can be beneficial to physicians as well, especially

pediatricians and family practice physicians who routinely care for adolescents in their practices. Social workers could also learn from the findings of this study to help identify adolescents at risk for self-injury and assist in accessing community resources to help adolescents and their families. It has been the experience of this researcher that grief support groups for adolescents are rare or non-existent in many communities. The faith community nurse could offer spiritual support groups for adolescents who have experienced the death of a loved one.

The findings of this study indicate a need for a paradigm shift for the practice of nursing. The focus of nursing is often on doing certain interventions or fixing problems.

Instead of focusing on “fixing” the problems of the adolescent who is lonely or troubled, perhaps nursing could focus on “a kind of being, a ‘being with’ or a ‘being there,’ that is really a kind of doing for it involves the nurse’s active presence” (Paterson & Zderad,

1976/1988, p. 14). Sometimes the presence of a caring person is the only intervention needed by the adolescent in that particular moment in time. Paterson and Zderad described this “being with” as, “turning one’s attention toward the patient, being aware of and open to the here and now shared situation, and communicating one’s availability” (p.

14). The observable acts of nursing, the acts of doing, are easier to measure and document. However, the acts of being can be felt by both the nurse and the adolescent, and while the acts of being are more difficult to measure and document, they provide rich interhuman experiences (Paterson & Zderad).

112

Being an Outsider

The young women expressed difficulty in fitting in with their peers and

classmates. The school nurse may be the nurse most able to address this area, especially if the nurse uses an interdisciplinary approach, working with school counselors and/or social workers. A focus group could be offered for students interested in talking about the difficulties they are experiencing during adolescence. If students discover that some of their peers are experiencing some of the same feelings, perhaps they will not feel so alone and they will have someone of their age to confide in. Faith community nurses could enlist the help of youth ministers to invite these adolescents to youth group social events and service projects, making them feel included in their peer group.

Loathing Self

Since adolescents spend more of their waking hours at school than anywhere else, again it is the school nurse who has the greatest opportunity to make a difference in their lives. The school nurse could collaborate with the health, nutrition, and physical education teachers to promote health and wellness programs which place emphasis on healthy behaviors and offer a healthy and realistic perspective on the definition of beauty.

The dangers of risky behaviors and eating disorders could be included in this curriculum.

A synopsis of the curriculum could be presented at parent meetings in an effort to cause a paradigm shift not only in the students, but in the families and the community as well.

Nurses can become powerful advocates for adolescents who are struggling with self-esteem issues, helping them along the journey to self-acceptance and feelings of worthiness. In order to assist others in the process of more-being and well-being, however, the nurse is encouraged to actively seek self-actualization. Kleiman (2009)

113

described the self-actualized nurse as “one who is engaged in the process of becoming true to herself/himself and to those with whom she/he goes through life’s experiences” (p.

69). If nurses place value on themselves, their jobs, and their profession, and practice

self-examination and reflection, they will learn to know themselves better. This will

translate into a higher quality of patient care and a more authentic presence with others

(Kleiman, 2009). Faith community nurses could speak to Sunday school classes and

church youth groups of the spiritual value of each person, helping adolescents to better

understand and rejoice in their value and worth. The biblical concept of respecting and

taking care of all created entities, including their bodies, could be encouraged in the

classes and/or youth groups.

Silently Screaming

The findings of this study included the theme of silently screaming, which

indicated an inability to verbalize the pent up emotions experienced by the participants.

The adolescents of the present generation experience more stress than ever before. They

are pressured to perform well in school, play sports, play a musical instrument, get

accepted into a good college, be a class officer, and a myriad of other expectations. The

present generation of adolescents has witnessed the impact of a deadly attack on the

United States on September 11, 2001, as well as numerous school shootings, and child

abductions. In addition, many are in a school environment with a heightened sense of

vulnerability and fear. Adolescents today are aware of national security issues and many

of them personally know a young man or woman serving in the military and stationed in

harm’s way.

114

Over half of today’s adolescents grow up in homes without two parents. They are exposed to more drugs and diseases than any generation that came before them. Many suffer from headaches, fatigue, and sleep disturbances as a result of stress. Lardy (2008)

defined stress as “the inability to cope with a perceived threat to mental, physical, emotional and spiritual well-being that results in a series of physiologic responses and

adaptations” (p. 49). Paterson and Zderad (1976/1988) asserted that adolescence is a time

filled with “intensity, turmoil, instability, and discomfort of spirit” (p. 43).

Adolescents who self-injure not only experience the normal frustrations and stress of middle and high school years; they also experience the abuse, abandonment, low self

esteem, and shame reported by the participants of this study. They have not learned or

have not been successful with other methods of coping with stress; therefore, self-injury

has been their only recourse.

Releasing the Pressure

The participants in this study described self-injury by cutting as a response to stress. Selye (1956) called a person’s response to stress the general adaptation syndrome.

Could self-injury be considered a response or an adaptation to stress? The findings of study have indicated just that. The participants in this study described feelings of anger,

anxiety, frustration, and tension, indicating stress in their lives. Nurses, especially school

nurses, faith community nurses, and psychiatric nurses, could provide opportunities for

students to learn to alleviate stress. This could be accomplished by teaching the students

stress relieving and stress management practices, such as deep breathing, meditation, and

relaxation, and encouraging the students to eat well, exercise, and to sleep an adequate

115

amount. An interdisciplinary approach would work well here, with the nurse involving

school counselors, educators, social workers, and parents in the process.

Lamberg (2008) reported that children who have suffered from post traumatic stress disorder or depression as a result of armed conflicts or trauma have benefited from programs which teach them to manage grief and loss. These programs have included therapeutic modalities such as expressive art, sports, songs, resiliency training, social activities, individual counseling, and discussion groups. Older adolescents found the most success in classes on the environment, health issues, youth violence, youth suicide, substance abuse, cultural traditions, and on increasing awareness of the health effects of pollution and smoking. Lamberg revealed the adolescents chose these topics because they wanted to choose issues for which they felt they could actually create change.

While the majority of adolescents who self-injure are not attempting suicide,

Murray et al. (2005) reported in the findings of their internet survey of adolescents that

self-injure, that a large percent of the respondents claimed to have attempted suicide. In

order to protect adolescents, nurses could benefit from an understanding of the ethical

codes (American Nurses Association, 2001) and legal guidelines of their practices.

While autonomy, the ability to make a decision for one’s self, is a cherished liberty, and

a moral good (Grace, 2004), Gadow (1980) asserted that the individual’s decision must

not endanger self or others. There are certain exceptions to the right of autonomous

decision making. Beauchamp and Childress (2001) reported the standards of

incompetence which, if proven, may preclude an individual’s right to autonomous

decision making. According to Marcontel-Shattuck and Gregory (2006), any student

who has the intent to harm self or others has forfeited the right of self-determination and

116

the “school nurse is mandated to seek assistance to stop that process” (p. 1114). The

nurse would be encouraged to determine whether the adolescent is indeed suicidal, and if

so, take the legal and protective measures of ensuring the adolescent’s safety and

admittance to an evaluation facility. In these cases, the duty to warn supersedes the

principle of confidentiality (Grace, 2004).

Feeling Alive

The theme of feeling alive also emerged in the findings of this study as the participants expressed finding meaning and expressivity in their blood, wounds, and scars. Nurses can help to redirect the expressive needs of the adolescents who self-injure

by encouraging and providing other activities which are expressive in nature. The

adolescents may be encouraged to register for creative writing, poetry, art, pottery

making, jewelry construction, and fashion design classes. The adolescents may be

persuaded to join the school or church choir, drama or speech club, American Sign

Language club, or a service oriented club. In addition, physical activity, such as dance or

sports, may be helpful. Accomplishing service on behalf of others often helps a person to

feel good about herself or himself, thereby raising their level of self esteem and feelings

of self-worth. School counselors could work along with teachers to guide these students

in the selection of their curriculum. Lamberg (2008) reported the success of programs

which included song, dance, expressive art, and physical activities in the therapeutic plan

of care for adolescents who have experienced stressful situations.

117

Being Ashamed

Nurses of any specialty have opportunities to help prevent feelings of guilt and/or

shame experienced by an adolescent who self-injures. Psychiatric and emergency

department nurses can encourage the adolescent to verbalize emotions without being

labeled as suicidal. This may help to preclude the projection of shame and stigmatization upon adolescents who self-injure. School nurses, pediatric nurses, and advanced practice

nurses could provide environments within their practices which promote wellness and

well-being; in addition, the nurses and ancillary staff could intentionally avoid

judgmental attitudes and statements. Within communities of faith, the faith community

nurses promote forgiveness, mercy, and grace which may help to alleviate feelings of

guilt and shame.

Being Hopeful for Self and Others

Many middle schools and high schools host career days during which time

persons representing a diversity of professions are invited to speak to the students about

their jobs. Nurses representing all specialty areas of the discipline of nursing could be

invited to share their experiences and stories. Physicians, social workers, counselors,

veterinarians, psychologists, and others representing professions of interest to the

students might be invited to discuss the preparation for their careers and the reasons

particular careers were chosen. Some high schools also have business classes in which

students are allowed to shadow someone in a chosen profession; in addition, many of

these programs allow a part time on-the-job training experience for the students. The

exposure to a variety of professions might prove to be very helpful and stimulating and

give adolescents something to hope and dream for. Paterson and Zderad (1976/1988)

118

asserted that “nursing’s concern is not merely with a person’s well-being but with his more-being, with helping him become more as humanly possible in his particular life situation” (p. 12).

Education

The nurse, especially the school nurse, has the opportunity to educate the public about self-injury. The parents, students, educators, and nurses of these students may benefit from educational programs and focus groups which discuss the themes brought

out in this study so that opportunities for early identification of and intervention with

students who are cutting would be created. These proactive measures could aide in the prevention of the stigmatization and labeling of students who self-injure, thereby perhaps

preventing the feelings of shame which emerged in this study. In addition, education

might be the most effective way in which to change the paradigm of thinking about self-

injury from the idea of self-mutilation or suicidal ideation to the concept of struggling

with maintaining well-being.

The school nurse could hold forums for parents to provide information about self-

injury so parents could better understand what their children are struggling with. Perhaps

this could assist parents and their children to learn how to better communicate, thus

providing their children opportunities to verbalize their feelings and emotions. This may

help in preventing feelings of abandonment and loneliness. Parenting classes could be

offered on the school and community levels to help parents cope with their own

frustrations and learn how to discipline without violent or abusive measures. Faith

community nurses could be instrumental in offering similar programs to their congregations, both to the parents and to the youth groups of the church.

119

Forums might also be provided for the students to learn more about self-injury in

order that students could better understand themselves and their peers; this may provide

motivation for the students to be more accepting and tolerant of their peers who seem a

little different or possess different outlooks or opinions. The students could be

encouraged to celebrate diversity and enjoy learning about different ideas.

Teachers need inservice hours for their certification; therefore, faculties might be open to receiving this information in order the assist the teachers to more easily identify their students who are at risk for self-injury and to report to the proper authority to arrange help for the student. Advanced practice nurses could put information in their waiting rooms or treatment rooms and create an open atmosphere wherein an adolescent patient or parent felt free to ask questions about self-injury. This might facilitate the beginning of a dialogue with an adolescent who is seeking help.

Inservice opportunities could be provided in health care delivery settings for psychiatric nurses, pediatric nurses, emergency department nurses, and advanced practice nurses. The negative attitudes that nurses revealed to two of the participants of this study could be precluded by providing information to the nursing professionals. The nurses may experience the efficacy of an intentionally caring approach to create a trusting relationship between the nurse and the adolescent. The participants in this study voiced the need for adults to be present, to listen, and to avoid judgment.

New information generated by the findings of this study could be integrated in the curriculum in the academic setting to both undergraduate and graduate nursing students, especially within the psychiatric, community, and the pediatric rotations, as well as continuing education offerings. In addition, the nurse practitioner courses might include

120

the study of self-injury in adult, family, pediatric, and psychiatric tracks. Adult nurse

practitioners also treat adolescents as do the other specialties. Courses developed for

school nurses, community health nurses, and faith community nurses may be beneficial.

The findings of this study and others could be presented at the local, state, and national levels at the annual conferences of associations of nurses, physicians, educators, and social workers.

Policy Development

Nurses have opportunities to develop policies in various health care settings. The school nurse could be instrumental in the development of policies in the school setting to address the needs of adolescents who cut. The policies might contain interdisciplinary cooperation for the identification of students at risk for self-injury as well as policies for intervention for students in crisis. In addition, the policy could contain protocol for contacting the parent or guardian and helping the family to access community resources to assist with therapeutic modalities. The same types of policies, with revisions fitting the setting, could be formulated by the advanced practice nurse, the emergency room nurse, the psychiatric nurse, the faith community nurse, the community health nurse, and the pediatric nurse. The policy might contain protocols for a designated person to remain with the student, calm the student, if necessary, notify the parent/guardian, and access available community resources for the family. The designee could be trained to determine if the adolescent has suicidal ideations and take the proper and legal steps to protect the adolescent. In the school setting, the school police officers are often responsible for determining the suicidal intentions of a student. The school nurse’s role might be outlined in the policy to work along with the officers in the determination of appropriate care for

121

the student, thereby perhaps preventing the sometimes inappropriate action of involuntary

committing a student to a psychiatric facility for evaluation.

There is no classification for self-injury as a disorder in the Diagnostic and

Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychological

Association, 2000; Lesniak, 2008). Therefore, adolescents who self-injure often are

assigned medical labels such as borderline personality disorder, bipolar disorder, and

others in order to justify treatment and compensation for care given them. This is a policy

which might be changed to reflect more current knowledge about adolescent self-injury.

Without proper coding, insurance benefits may not cover therapy or treatment and many

parents cannot afford to pay out of pocket for necessary care. Since advanced practice nurses use this coding system for justification of treatment and reimbursement, their professional specialty group might present a position paper encouraging the development of a classification for self-injury behavior in the code.

Recommendations for Future Nursing Research

New questions about adolescent self-injury behavior evolved from the findings of this study. The themes which emerged from the participants’ words provided a new conceptualization of this phenomenon; therefore, new questions for future research in relation to the findings are suggested here.

The participants in this study were white, middle class females. In the researcher’s school nursing practice, minority groups were not represented by the adolescent females who were cutting. Most of the existing studies involve white women and provide little or no insight into how the variables of race and culture factor into self-injury behavior.

Kennedy (2004) reported that the phenomenon exists across all racial and socio-

122

economic groups. It would be meaningful to explore the existence and extent of self- injury in all ethnic, cultural, and socioeconomic groups and what it means to each group.

The participants in this study expressed difficulty in dealing with their feelings and found no more effective outlet than cutting; therefore, they need help to learn how to verbalize and cope with these feelings. Therapeutic modalities were not explored in this study. There are a few treatment centers in the United States which offer intervention and therapy for adolescents who self-injure. Nursing researchers may desire to take the next step and begin to explore the various treatment approaches, measuring the outcomes in order to identify the most efficacious methods of treatments, noting the possible influence of misconceptions about self-injury which may be related to the difficulties of treatment.

In addition to studying the treatment centers, nurses also might find it informative to interview private therapists and counselors to discover the different models of care offered in private practices.

The importance of presence may be studied to discover if presence is a factor which may help adolescents to understand their self-injury and to move forward with their lives. The findings of this study, particularly in the theme of feeling alive, contradict previous studies associating self-injury with suicide and medical diagnosis, as the participants wanted to stay alive and wanted someone to just be with them, listen to them, and not judge them. Paterson and Zderad (1976/1988) stated, “To offer genuine presence to others, a belief must exist within a person that such presence is of value and makes a difference in a situation” (p. 6). The study of presence as a nursing intervention would be meaningful in providing understanding of the intersubjective relationship between the

123

nurse and the adolescent who self-injures. This may help nurses to move from doing and

fixing to a theoretical approach of being.

The participants in this study reported feelings of shame resulting from insensitive

treatment from nurses, doctors, parents, and educators who had become aware of the self- injury practiced by the participants. Sometimes this treatment was negative in nature and only added to the adolescents’ self esteem issues. Self-injury, and cutting in particular, elicits responses of shock, anger, and disgust from most adults. It would be a beneficial addition to nursing knowledge to survey the attitudes and perceptions of these professionals and parents. Why are they so outraged? There are risky behaviors practiced by adolescents that are actually more harmful than cutting, such as binge drinking, illicit

substance abuse, promiscuous sexual behavior, and driving while under the influence of

substances. Is it because there is blood involved and scars are left on the bodies of the

participants? The answers to these questions would be valuable in identifying attitudes

which are both helpful and not helpful to the adolescents. This type of study might result

in an intervention based research study to educate the public about self-injury, thereby precluding some of the stigmatization felt by adolescents who self-injure. Nurses are in the best position to conduct this type of research because the public respects and trusts the nursing profession above other professions (Gallup News Services, 2006).

Another cultural phenomenon which warrants a closer look is the Goth culture.

As expressed by the participants in this study, adolescents who self-injure often have

difficulties being accepted by their peers. From the observations of the researcher, the

students who identify with those who self-injure like to dress in black clothing, with long

sleeves and long, baggy pants. They frequently dye their hair black and have streaks of

124

red, pink, green, purple, or yellow in their hair. The fingernails are often painted black,

and the jewelry incorporates chains and leather.

In this study, Danielle and Amanda both came to their interviews dressed in black

clothing, with black hair (Danielle’s had red streaks), with black nail polish, and black

jewelry. In addition, Caroline and Emma both admitted they dressed that way for years,

although they came to their interviews in their work clothing. In observations noted

during the high school nursing practice and the high school teaching experience of this

researcher, the students who cut are usually on the outer margins of the school

population, tending to avoid the mainstream activities. One might wonder if these

adolescents cut because of their affiliation with the Goth culture or if they are drawn to

the culture because they cut and find acceptance, support, or understanding there. It

would be meaningful to know if self-injury is encouraged by this culture. Also, what are

the adolescents seeking by affiliating with the Goth culture? What is the meaning of

cutting in the Goth culture? In the practice areas of this researcher, there have been no

school rules prohibiting this type of expression through external appearances or clothing.

One last area of concern for research, and of particular importance to this researcher, would be the study of the influence of popular culture, beyond those of standards of beauty and self image. The media has portrayed, through film and music, various and numerous forms of self- injury. Many movie stars and celebrities have admitted participation in self-injury behavior, and perhaps some adolescents want to emulate the actions of their heroes or favorite actors. Therefore, nursing research would benefit from an exploration of possible media influence on adolescents and self-injury.

125

Summary

Nurses continue to be among the professionals most trusted by the public and are

many times the lifeline needed by the adolescent who is self-injuring. The school nurse,

the emergency department nurse, the psychiatric nurse, the pediatric nurse, the

community health nurse, the faith community nurse, and the advanced practice nurse are poised to have the greatest opportunity to identify these adolescents and to intervene in the self-injury behavior. There are implications for nursing which include opportunities

for practice, education, policy development, and future research. In conclusion, a poem,

written by a student, is offered as a look inside the silent scream of a female adolescent

who self injures by cutting.

126

The times when I’m at my worst I cannot even think clearly. My mind is a confusing, fuzzy haze that focuses on one thing--- THE BLADE. Sometimes even the stinging pain from my fresh wounds are d u l l e d And I become numb to everything. I keep cutting until I feel a little better, or sometimes just until I can feel anything at all. Sometimes I’ll get so depressed that I’ll think of trying to kill myself and just end it all— But I never seem to press the blade down DEEP enough. Maybe I’m scared— Scared that this is what I’ll end my life with.

I’ll end my life with absolutely nothing in this agonizing darkness. But after you’re dead, it doesn’t really matter—

Everything is over and there is no more hurt.

I just want to be alone and make E V E R Y T H I N G disappear

except for the comforting real feeling of the pain as the blade cuts my skin. I try to block everything out, but I can’t-- it’s all there

POUNDINGinMYhead

And will always replay in my memory. As my tears run down my face, I fall farther into a familiar abyss of

DESPAIR. Will I cut deep enough this time?

(Anonymous, 2001a).

127

APPENDIX A

Depiction of Various Influences Leading to

Self-injury and the Feelings Following Self-injury

128

DEPICTION OF VARIOUS INFLUENCES LEADING TO SELF-INJURY AND THE FEELINGS FOLLOWING SELF-INJURY

SELF-INJURY

TENSION RELIEF

ANGER CALMNESS

CYCLE OF SELF- ANXIETY RELAXATION INJURY

FRUSTRATION SHAME

ABANDONMENT STIGMA

(Lesniak, 2006)

129

APPENDIX B

Institutional Review Board Approval

130

131

APPENDIX C

Parent Consent Form

132

133

APPENDIX D

Student (Minor) Assent

134

135

APPENDIX E

Adult Consent Form

136

137

APPENDIX F

Institutional Review Board Amendments

138

139

140

141

142

APPENDIX G

Parent Consent Form

143

144

APPENDIX H

Student (Minor) Assent Form

145

146

APPENDIX I

Call for Participants

147

148

REFERENCES

Abrams, L., & Gordon, A. (2003). Self-harm narratives of urban and suburban young

women. Affilia, 18(4), 429-444.

Alderman, T. (1997). The scarred soul: Understanding and ending self-inflicted violence.

Oakland, CA: New Harbinger Publications, Inc.

Alexander, L. (1999). The functions of self-injury and its link to traumatic events in

college students. Dissertation Abstracts International,B60 (05), (UMI No.

9932285)

American Psychological Association. (2000). Diagnostic and statistical manual of mental

disorders (4th ed., text revision). [DSM-IV-TR]. Washington, DC: Author.

American Self-Harm Information Clearinghouse. (2005). Mission. Retrieved September

23, 2005, from http://www.selfinjury.org

Anonymous. (2001a). [untitled poem received in interview in qualitative study].

Unpublished raw data.

Anonymous. (2001b). Drop by drop. [Poem received in interview in qualitative study].

Unpublished raw data.

Anonymous. (2001c). When all is silenced. [Poem received in interview in qualitative

study]. Unpublished raw data.

149

Ayton, A., Rasool, H., & Cottrell, D. (2003). Deliberate self-harm in children and

adolescents: Association with social deprivation. European Child & Adolescent

Psychiatry, 12(6), 303-307.

Barry, C., & Gordon, S. (2006). Theories and models of school nursing practice. In J.

Selekman (Ed.), School nursing: A comprehensive text (pp. 25-43). Philadelphia:

F. A. Davis Company.

Best, R. (2005). An educational response to deliberate self-harm: Training, support and

school-agency links. Journal of Social Work Practice, 19(3), 275-287.

Boykin, A., & Schoenhofer, S. (2001). Nursing as caring: A model for transforming

practice. Sudbury, MA: Jones and Bartlett Publishers.

Brumberg, J. (2006). Are we facing an epidemic of self-injury? The Chronicle of Higher

Education, Section B, B6-B9.

Buber, M. (1970). I and thou (W. Kaufmann, Trans.). New York: Charles Scribner’s

Sons. (Original work published 1937)

Buber, M. (1965). The knowledge of man. New York: Harper & Row.

Cerdorian, K. (2005). The needs of adolescent girls who self-harm. Journal of

Psychosocial Nursing and Mental Health Services, 43(8), 40-46. Retrieved

October 4, 2005, from OVID Technologies, Inc. database.

Cleaver, K. (2007). Characteristics and trends of self-harming behaviour in young people.

British Journal of Nursing, 16(3), 148-152.

Cohen, M. (1987). A historical overview of the phenomenologic movement. Journal of

Nursing Scholarship, 19(1), 31-34.

150

Conterio, K., & Lader, W. (1998). Bodily harm: The breakthrough treatment program for

self-injurers. New York: Hyperion.

Derouin, A., & Bravender, T. (2004). Living on the edge: The current phenomenon of

self-mutilation in adolescents. The American Journal of Maternal Child Nursing,

29(1), 12-19.

Drew, N. (2001). Meaningfulness as an epistemologic concept for explicating the

researcher’s constitutive part in phenomenologic research. Advances in Nursing

Science, 23(4), 16-31.

Eells, G. (2006). Mobilizing the campuses against self-mutilation. The Chronicle of

Higher Education, Section B, B8-B9.

Estefan, A., McAllister, M., & Rowe, J. (2004). Difference, dialogue, dialectics: A study

of caring and self-harm. In K. Kavanagh & V. Knowlden (Eds.), Many voices:

Toward caring culture in healthcare and healing (pp. 21-61). Madison, WI: The

University of Wisconsin Press.

Evans, J. (2002). Addressing adolescent depression: A role for school counselors.

Adolescence, 3, 118-26.

Evans, S., Davies, C., & DiLillo, D. (2008). Exposure to domestic violence: A meta-

analysis of child and adolescent outcomes. Aggression and Violent Behavior,

13(2), 131-140.

Fassier, D. (2006). Adolescent depression: Early recognition leads to successful

treatment. The Prevention Researcher, 13, 8-9.

Favazza, A. (1996). Bodies under siege: Self-mutilation and body modification in culture

and psychiatry (2nd ed.). Baltimore: The Johns Hopkins University Press. 151

Frankl, V. (1984). Man’s search for meaning (Beacon Press, Trans.). New York: Simon

& Schuster. (Original work published 1946)

Gallup News Services. (2006). The most honest and ethical professions. Retrieved

October 23, 2008, from http://www.calnurses.org/media-center/in-the-

news/2006/december/page.jsp?itemID=29117737

Gelmann, G., & Selekman, J. (2006). Mental health concerns. In J. Selekman (Ed.),

School nursing: A comprehensive text (pp. 781-809). Philadelphia: F. A. Davis

Company.

Giorgi, A. (1997). The theory, practice, and evaluation of the phenomenological method

as a qualitative research procedure. Journal of Phenomenological Psychology,

28(2), 235.

Giorgi, A., (2005). The phenomenological movement and research in the human sciences.

Nursing Science Quarterly, 18(1), 75-82.

Harris, J. (2000). Self-harm: Cutting the bad out of me. Qualitative Health Research,

10(2), 164-173.

Hoskins, C. (1998). Developing research in nursing and health: Quantitative and

qualitative methods. New York: Springer Publishing Company, Inc.

Hoyle, M. (2003). The stigma of self-injury. Unpublished master’s thesis, University of

Hull, Hull, United Kingdom.

Husserl, E. (1967). Ideas: General introduction to pure phenomenology (2nd ed., W. R.

Boyce Gibson, Trans.). New York: Collier Books. (Original work published

1931)

152

Kehrberg, C. (1997). Self-mutilating behavior. Journal of Child and Adolescent

Psychiatric Nursing, 10(3), 1-7.

Kennedy, A. (2004). Self-injury on the rise: The growing phenomenon of harming the

body to ease the mind. Counseling Today, 20-21, 33.

Kleiman, S. (2004a). Phenomenology: To wonder and search for meanings. Nurse

Researcher, 11(4), 7-19.

Kleiman, S. (2004b). What is the nature of nurse practitioners’ lived experiences

interacting with patients? Journal of the American Academy of Nurse

Practitioners, 16(6), 263-269.

Kleiman, S. (2006). Josephine Paterson and Loretta Zderad’s humanistic nursing theory

and its applications. In M. E. Parker (Ed.) Nursing theories and nursing practice

(2nd ed., pp. 125-137). Philadelphia: F. A. Davis Company.

Kleiman, S. (2009). Human centered nursing: The foundation of quality care.

Philadelphia: F. A. Davis Company.

Klonsky, E., Oltmanns, T., & Turkheimer, E. (2003). Deliberate self-harm in a

nonclinical population: Prevalence and psychological correlates. American

Journal of Psychiatry, 160(8), 1501-1508.

Kubal, A. (2005). Perfectionism among woman seeking help for deliberate self-harm

and/or eating disorders: A comparative study. Dissertation Abstracts

International, B67 (02), (UMI 3204743)

Lamberg, L. (2008). Psychiatrists strive to help children heal mental wounds from war

and disasters. Journal of the American Medical Association, 300(6), 642-643.

153

Lardy, S. (2008). Decompress to fight disease: Why stress requires intervention. Advance

for Nurse Practitioners, 16(8), 49-52.

Lesniak, R. (2006). Adolescent self-injury behavior: A model for practice and research.

Unpublished manuscript, Florida Atlantic University at Boca Raton, Florida.

Lesniak, R. (2007a). Self-injury behavior: Two case studies. Unpublished manuscript,

Florida Atlantic University at Boca Raton, Florida.

Lesniak, R. (2007b). [Interview response in qualitative study]. Unpublished raw data.

Lesniak, R. (2008). Understanding self-injury behavior. Journal of Christian Nursing,

25(4), 186-195.

Levander, A. (2005). Self-injurious behavior: Assessment, treatment and the recovery

process. Nashville, TN: Cross Country Education, Inc.

Levenkron, S. (1998). Cutting: Understanding and overcoming self-mutilation. New

York: W. W. Norton.

Life Application Bible (New International Version). (1988). Wheaton, IL: Tyndale House

Publishers, Inc.

LifeSigns Self Injury Guidance & Network Support. (2005). Self injury awareness

booklet: Information for health care workers, family, friends and teachers of

people who harm themselves. Retrieved February 9, 2006, from

http://www.lifesigns.org.uk

Machoian, L. (2001). Cutting voices: Self-injury in three adolescent girls. Journal of

Psychosocial Nursing and Mental Health Services, 39(11), 22-29.

Mayeroff, M. (1971). On caring. New York: HarperCollins Publishers.

154

McAllister, M., Creedy, D., Moyle, W., & Farrugia, C. (2002). Nurses’ attitudes toward

clients who self-harm. Journal of Advanced Nursing, 40(5), 578-586.

McCance, K., & Huether, S. (2002). Pathophysiology: The biologic basis for disease in

adults & children. St. Louis, MO: Mosby.

McDonald, C. (2006). Self-mutilation in adolescents. The Journal of School Nursing,

22(4), 193-200.

Merleau-Ponty, M. (1956). What is phenomenology? Cross Currents, 6, 59-70.

Murray, C., Warm, A., & Fox, J. (2005). An internet survey of adolescent self-injurers.

Australian E-journal for the Advancement of Mental Health, 4(1), 1-9. Retrieved

October 4, 2005, from http://www.auseinet.com/journal/vol4iss1/murray.pdf

O’Connor, N. (1993). Paterson and Zderad. London: Sage Publications.

Oiler, C. (1982). The phenomenological approach in nursing research. Nursing Research,

31(3), 178-181.

Oiler Boyd, C. (2001a). Phenomenology: The method. In P. Munhall (Ed.), Nursing

research: A qualitative perspective (3rd ed., pp. 93-122). Sudbury, MA: Jones and

Bartlett Publishers.

Oiler Boyd, C. (2001b). Philosophical foundations of qualitative research. In P. Munhall

(Ed.), Nursing research: A qualitative perspective (3rd ed., pp. 65-89). Sudbury,

MA: Jones and Bartlett Publishers.

Ojeda, C. (2004). The degree of compulsiveness among self-mutilators. Unpublished

doctoral dissertation, Carlos Albizu University, Miami, Florida.

Omery, A. (1983). Phenomenology: A method for nursing research. Advances in Nursing

Science, 5(2), 49-62. 155

Paley, J. (1996). How not to clarify concepts in nursing. Journal of Advanced Nursing,

24(3), 572-578.

Paterson, J. G. (1978). The tortuous way toward nursing theory. In National League for

Nursing (Ed.), Theory development: What, why, how? (pp. 49-65). New York:

National League for Nursing.

Paterson, J., & Zderad, L. (1976/1988). Humanistic nursing. New York: National League

for Nursing.

Pattison, E., & Kahn, J. (1983). The deliberate self-harm syndrome. American Journal of

Psychiatry, 140, 867-872.

Pipher, M. (1994). Reviving Ophelia: Saving the selves of adolescent girls. New York:

Ballantine Books.

Plumb. (2006). Cut. On Chaotic resolve [CD]. Nashville, TN: Curb Records, Inc.

Ray, M. (1990). Phenomenological method for nursing research. In N. L. Chaska (Ed.),

The nursing profession: Turning points (pp. 173-179). St. Louis, MO: C. V.

Mosby Company.

Reece, J. (2005). The language of cutting: Initial reflections on a study of the experiences

of self-injury in a group of women and nurses. Issues in Mental Health Nursing,

26, 561-574.

Reznor, T. (2002). Hurt. On Johnny Cash: American IV, the man comes around [CD].

Nashville, TN: Lost Highway Records.

Reznor, T. (1994). Hurt. On Nine inch nails: The downward spiral [CD]. New Orleans,

LA: Nothing Records.

156

Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community

sample of adolescents. Journal of Youth and Adolescence, 31(1), 67-77.

Rudestam, K., & Newton, R. (2001). Surviving your dissertation: A comprehensive guide

to content and process (2nd ed.). Thousand Oaks, CA: Sage Publications, Inc.

Sandleowski, M. (1986). The problem of rigor in qualitative research. Advances in

Nursing Science, 8(3), 27-37.

Santa Mina, E. E., Gallop, R., Links, P., Heslegrave, R., Pringle, D., Wekerle, C. &

Grewal, P.(2006). The self-injury questionnaire: Evaluation of the psychometric

properties in a clinical population. Journal of Psychiatric and Mental Health

Nursing, 13, 221-227.

Selekman, J. (2003). A new era of body decoration: What are kids doing to their bodies?

Pediatric Nursing, 29(1), 77-79.

Shannon, J. (2005). Self-mutilation behavior in youth and adults: Causes, treatment and

prevention.Nashville, TN: Cross Country Education, Inc.

Sharkey, V. (2003). Self-wounding: a literature review. Mental Health Practice, 6(7), 35-

37.

Shaw, S. N. (2002). Shifting conversations on girls’ and women’s self-injury: An analysis

of the clinical literature in historical context. Feminism & Psychology, 10(2), 191-

219. Retrieved October 4, 2005, from http://fap.sagepub.com

Smith, S. (2002). Perceptions of service provision for clients who self-injure in the

absence of expressed suicidal intent. Journal of Psychiatric and Mental Health

Nursing, 9, 595-601.

157

Starr, J. (2004). Understanding those who self-mutilate. Journal of Psychosocial Nursing

and Mental Health Services, 42(6), 32-40.

Strong, M. (1998). A bright red scream: Self-mutilation and the language of pain. New

York: Viking.

Styer, D., (2006). An understanding of self-injury and suicide. The Prevention

Researcher, 13, 10-12.

Sutton, J. (2005). Healing the hurt within: Understand self-injury and self-harm, and heal

the emotional wounds. Oxford: How To Books.

Van Manen, Max. (1990). Researching lived experience: Human science for an action

sensitive pedagogy. New York: State University of New York Press.

Van Sell, S., O’Quin, L., Oliphant, E., Shull, P., Austin, K., Johnston, E., & Nguyen, C.

(2005). Help stop self-injury. RN, 68(11), 55-59.

Walsh, B., & Rosen, P. (1988). Self-mutilation: Theory, research and treatment. New

York: Guilford.

Warm, A., Murray, C., & Fox, J. (2003). Why do people self-harm? Psychology, Health

& Medicine, 8(1), 71-79.

Webster’s Ninth New Collegiate Dictionary. (1990). Springfield, MA: Merriam-Webster.

Whitlock, J., Eckenrode, J., & Silverman, D. (2006) Self-injurious behaviors in a college

population. Pediatrics, 117(6), 1939-1948.

Zderad, L. T. (1978). From here and now to theory: Reflections on “how.” In National

League for Nursing (Ed.), Theory development: What, why, how? (pp. 35-48).

New York: National League for Nursing.

158

159