THE LIVED EXPERIENCE OF ADOLESCENT FEMALES WHO SELF-INJURE BY CUTTING by 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 Copyright by Rhonda Goodman Lesniak 2008 ii 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. iv 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, v 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. vi To 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