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Deliberate Self-Harm in Adolescents: The Causes, Functions, and Implications as they Relate to Stress and Coping
Melissa T. Greene Lehigh University Final Paper: Fall Semester 2011

855120383: Pg. 2 Deliberate self-harm (DSH) is a troubling phenomenon that is unfortunately highly

prevalent in our society. Defined as deliberate and voluntary self-injury (cutting, burning the skin, banging or hitting body parts, interfering with wound healing, hair-pulling, etc.) without conscious suicidal intent (Favazza, 1988), DSH is unique behavior. Because individuals do not typically engage in DSH with the intention of ending their own lives, the purposes and functions of deliberate self-harm have recently become the subject of public interest as well as academic inquiry. Of particular concern is the occurrence of DSH among adolescents. Currently, estimates of deliberate self-harm range from 15%-39% in nonclinical populations of children ages 11 to 18, with the number having increased significantly in the UK and the US over recent years (Laye-Gindhu & Schonert-Reichl, 2004). While there are a variety of factors associated with the development of and reliance upon deliberate self-harm as a (highly maladaptive) coping behavior, there are a few of particular significance: there is a strong relationship between maladaptive cognitive coping strategies, emotion identification/regulation deficiencies, and attachment relationships and deliberate self harm in adolescents. Before delving into the particulars of the relationship between these factors and incidences of self-harm, it is important to first consider why self-harm begins and is particularly pervasive among adolescents. First episodes of deliberate self-harming behavior typically occur around age 13 (Favazza, 1998), a time during which many children begin puberty and the transition from childhood to young adulthood. This period tends to be one of the most confusing and challenging for adolescents. It is often associated with significant emotional upheaval and psychological distress (Place, 1998), as well as emotional immaturity and underdeveloped coping mechanisms. This combination of

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increased psychological and emotional demand and insufficient management techniques proves to be extremely difficult to reconcile for all teens: while only 15-39% of adolescents actually self-harm, many more report thoughts of self-harm without ever having completed the act (Evans, 2005). This concept is consistent with Lazarus and Folkmans transactional model, which posits that stress results from an imbalance between demands and resources (1984). In adolescence, children are faced with novel situations in physical, mental, emotional, and social domains, and few have previous personal experiences upon which they can model their behavior. Many of these new experiences in adolescence are awkward and uncomfortable for children, but more importantly, adolescence marks a period in which children struggle to establish themselves as autonomous individuals. These two factors combined may provide an explanation as to why some children do not seek help despite having it available and resort to self-harm instead; not only are the problems themselves difficult to discuss, but children in this stage of life are attempting to establish independence (Evans, 2005). For this reason, children primarily appraise their situations as extremely problematic, yet at the same time secondarily appraise their available resources as insufficient or nonexistent due to the perception that they must rely solely upon themselves to overcome their difficulties. Children are in this state of mind when selecting a coping strategy, and because they lack the maturity and experience to reappraise their situations and resources, they instead resort to direct action. In the case of DSH, the direct action is the physical release of emotional pain via self-injury.

855120383: Pg. 4 In addition to understanding the cognitive bases of DSH in adolescents, it is also

important to understand that the physiological changes adolescents undergo during puberty play a substantial role in decisions to self-harm, as indicated by McEwens 2005 paper on allostatic overload. Changes in neuroendocrine function are characteristic of pubertal development; puberty is commonly described as a period during which hormones rage, and this colloquialism is not without factual basis. Stress experienced in puberty and the common discrepancy between perceived stress and perceived resources interact to affect the hypothalamic-pituitary-adrenal (HPA) axis, and the continual release of cortisol and adrenaline in response to stress becomes maladaptive over time (Romeo, 2010 and McEwen, 2005). In the case of chronic stress, which may occur throughout puberty (puberty is marked by a substantial increase in many stress-related psychological and physiological disorders, (Romeo, 2010)), these mediators of the stress response are harmful for the individual and often result in allostatic overload, or deterioration due to chronic exposure to stress (McEwen, 2005). Some adolescents may resort to self-harm as a way to eliminate allostatic overload and return to a normal allostatic state. In addition to these cognitive and physiological explanations, young people also consciously describe experiencing benefits from making emotional pain tangible through deliberate self-harm (Hall, Haddow, & Place, 2009). This indicates that in addition to immature emotion-focused coping mechanisms, adolescents may also lack the communicative skills necessary to manage strong negative affect and may instead rely on the physical translation DSH provides as a primary method of expression. In accordance with the concept of an impoverished ability to communicate, deliberate self-harm is primarily a private phenomenon; it occurs as an attempt to cope with a sense of being

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burdened by insurmountable and inexplicable problems that cannot be discussed and for which guidance cannot be sought (Milnes et. al., 2002). Thus, self-harm is often interpreted as a means by which children interact with serious negative affect that they are otherwise unable to manage; they lack the ability to identify what, exactly, their emotions are, the capacity to understand the gravity of their emotional and physical experiences, and the experience to know how to effectively engage their support networks and implement adaptive coping strategies (Machoian, 2001). Although all adolescents undergo similar transitional experiences and may have similar difficulties in coping or communicating between the ages of 13 and 18, not all adolescents engage in deliberate self-harm. A variety of factors may contribute to a childs predisposition to self-harm, but the single strongest predictor of self-harming behaviors is the employment of maladaptive cognitive coping strategies. In almost all studies, children who scored higher in maladaptive coping strategies such as self-blame, distancing, self- isolation, rumination, and alexithymia (inability to identify, understand, and process emotions) were more likely to engage in deliberate self-harm than individuals who scored low on these measures (Hall & Place, 2010 and Borrill et. al., 2009). This finding is not surprising. The goal of self-harm as it is currently understood is to regulate emotion; because children who engage in avoidance strategies such as the ones previously listed do not actively deal with their affective states cognitively, self-harm becomes a means by which they can moderate their emotional pain without relying on advanced intellectual strategies. Scoliers and colleagues (2009) found that adolescents frequently describe their motivation for self-harming as a method by which they can get relief from a terrible state of mind, suggesting that they lack the maturity and experience necessary to practice other,

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more adaptive means of coping, or to realize they are having trouble coping effectively and seek help from parents or professionals. Self-harm is a form of escape from or avoidance of unwanted emotional experiences, and adolescents employ this behavioral strategy as an extension of cognitive avoidance strategies. While cognitive avoidance strategies may not work and may exacerbate the problem (Christan & McCabe, 2011), self-harm is very successful in achieving this dissociation in the short-term (Hall and Place, 2010). There are both psychological and physiological underpinnings to this success. Psychologically, self-harm serves to actually reduce experience of negative affect: self-harming adolescents report endorsement of negative affective states prior to self-harm and report a reduction in these states during and immediately after self-harm. Similarly, an increase in feelings of relief is also reported after acts of self-harm (Laye-Gindhu & Schonert-Reichl, 2004). This may serve as a means of both positive and negative reinforcement, which encourages repetition of self-harming behaviors (Carr, 1977); the self-harming behavior is negatively reinforced as the negative affective condition is lessened, and the behavior is positively reinforced as DSH provides feelings of relief. It is also beneficial to understand that these feelings of relief are not simply emotional, however: physically, the act of self-harm causes the body to release beta endorphinsendogenous opiods that are released in response to physical injury, act as natural painkillers, and induce pleasant feelings and reduce tension and emotional distress (Simeon et. al., 1992). The experience of a surge in beta-endorphins and the subsequent affective state may resemble the experience of illicit drug use. This explains why self-harm has an addicting quality and the majority of adolescents self-harm repeatedly (Hall, Haddow, & Place, 2009 and Laye-Gindhu & Schonert-Reichl, 2004). Likewise, it may also

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explain why some adolescents self-harm rather than use drugs and alcohol: it may be easier for children to self-injure than obtain drugs and alcohol, and the psychological and physiological benefits are similar. These psychological benefits also lend themselves to another distinct function of self-harm: self-harm may in some cases serve as a means by which adolescents punish themselves and attempt to gain control over what they consider to be frantic and unruly emotions. The role of control is of particular significance: as Taylor and Brown describe in their 1988 paper, individuals with realistic perceptions of personal control are more likely to be in a depressive affective state (Taylor & Brown, 1988). Adolescents may appraise themselves as having limited control over the new situations they encounter in puberty. Thus, they may also be subject to depressive affective states. Self-injury has been considered a means by which adolescents can manage the transitional phase and lack of control characteristic of puberty while at the same time regulating the negative affect that directly results from these states (Nock and Prinstein, 2004). The benefit is then twofold. Likewise, self-harm may also work to regain control over affective states after an extended period of avoidance: some children report engaging in self-injurious behaviors as a way to halt states of dissociation and depersonalization that they had previously consciously employed (Laye-Gindhu & Schonert-Reichl, 2004). While the discussion of psychological/physiological roots and intended goals of adolescent DSH are useful in gaining a broad understanding of why children choose self- harm, these findings fail to address why some children develop and come to rely on maladaptive cognitive coping strategies in the first place. Individual differences certainly

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play a role in a childs coping mechanism of choice, but there have been direct links between attachment style in childhood and prevalence of deliberate self-harm. Most notably, children who self-harm have been shown to have poorer attachments to their parents than children who do not self-harm (Hallab & Covic, 2010). Children who self- harm are more likely to come from single parent families; in such situations, stress levels are generally higher, making it difficult to nurture secure attachments (Laye-Gindhu & Schonert-Reichl, 2004). Similarly, self-harmers are more likely to come from families in which a parent has a serious illness or disability, increasing the likelihood that one or both parents focus is on the sick individual rather than the child. In such a situation, avoidant attachment is likely to result. As is characteristic of anxious/ambivalent and avoidant attachment relationships, children engaged in these types of attachments often do not develop the ability to comprehensively identify, interpret, and address emotion, particularly highly negative affect. Similarly, and perhaps more importantly, children with anxious/ambivalent and avoidant attachments to their parents often fail to utilize support networks. Studies show that self-harmers are generally less able to talk to people about their serious mental, emotional or behavioral problems than are adolescents who do not self-harm, and when asked to describe their coping strategies, self-harmers are more likely to stay in their rooms than are non-self-harmers, who try to sort things out or talk to others about their problems (Evans 2005). Interestingly, the same study indicated that all children, self- harmers or not, indicated that they had secure attachments with their peers. This solidifies the fact that parent/child attachment determines the quality and effectiveness of other

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external support networks, regardless of how positively the child interprets those relationships (Evans, 2005). This has very grave implications. Children who are able to cope successfully are securely attached individuals that have strong support networks both at home and at school. Utilizing these support networks allows children to successfully navigate and work through their problems, which increases self-confidence and fosters psychological resilience (Hall & Hall, 2002). This creates a positive feedback loop in which children effectively manage their problems as well as their affective states, providing a model for effective coping in the future. Children who are unable to do this due to poor attachment and lack in social support are more likely to have difficulty coping, increased stress responses, and little motivation to overcome such behavior (Hall & Hall, 2002). Findings from a study by Hall and Place in 2010 also concluded that social and active coping was in fact the only factor that significantly correlated with non-cutting behavior; thus, not only do children who have high quality support systems have an easier time coping than children who do not, but the support systems also work as a buffer and protector from self-injurious behavior (Hall & Place, 2010). While this is good news for the majority of children, it is seriously disadvantageous for children with poor attachment relationships with their parents. The exploration and explanation of deliberate self-harm in adolescents without a doubt begs the question of intervention: what can and should be done to effectively limit or halt the occurrence of DSH? Fortunately, because of the kinetic nature of childhood, puberty, and adolescence, many of the factors discussed are flexible and can change such

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that DSH behaviors are prevented or stopped before they escalate into more severe self- harm or suicide (Hallab & Covic, 2010). The common suggestion across the literature proposes that preventative measures originate in schools, with the implementation of screening measures such as the VAST vulnerability assessment used as early as the primary school years (Hall, Haddow, & Place, 2009). Schools have long been considered influential institutions in shaping behavior and emotional development, functioning, and regulation in children; additionally, schools serve a second function as environments in which large-scale therapeutic changes may be successfully implemented (Hall & Place, 2010). Because of this fact, schools particularly primary and elementary schools in which children spend the majority of their time with a single attentive teachershould phase in both behavioral observation measures that can indicate potential problems as well as skill- building practices that foster elements that make up social and active coping (Hall & Place, 2010). Again, because social and active coping was the only factor out of three (social and active coping, seeking external solutions, and non-productive coping) that correlated significantly with non-cutting behavior, it is important to ensure that social and active coping skills are taught and perfected as early as possible (Hall & Place, 2010). These skills are particularly easy to teach within an academic setting, and include elements such as working in groups successfully and feeling a sense of accomplishment, developing positive friendship networks, and engaging in positive diversions such as physical activity (Hall & Place, 2010). These skills are already taught in many schools, although more emphasis may be placed in them in light of recent findings related to childhood and adolescent adjustment.

855120383: Pg. 11 Additionally, many researchers suggest building and strengthening resilience in

childhood and adolescence as a way to enable children to cope actively and successfully. However, it is difficult to establish a causal relationship between resilience and social and active coping; it is unclear whether or not the ability to successfully engage in social and active coping fosters psychological resilience in children or whether psychological resilience as a trait lends itself to the utilization of social and active coping strategies. It seems instead that the relationship is bidirectional, and that this information is best applied such that resilience and active coping are taught concurrently (Hall, Haddow, and Place, 2009). It is also crucial that parents and educators focus on teaching effective emotion- based coping as well as active coping. As has been discussed, deliberate self-harm in adolescents almost always arises as a result of maladaptive cognitive/emotion-based coping strategies. It seems intuitive then that the solution to the problem may lie in correcting this defective underlying mechanism, and Southam-Gerow and Kendall propose the best way to accomplish this. They write, An emotion based approach in which emotions can be safely experienced with an emphasis on understanding that emotions, even extreme ones, are not permanent, are endurable, and are not harmful in and of themselves is advocated for children with emotion regulation problems (Southam-Gerow & Kendall, 2002, pg. 209). While they suggest this type of approach for children with already established problems, it seems that such a strategy would be useful and successful in teaching all adolescents emotion regulation skills.

855120383: Pg. 12 Perhaps a bit more controversial is the idea that educators should provide

instructions to adolescents on how to help each other when serious psychological or behavioral problems are communicated among friends. Because the majority of adolescent self-harmers report that at least one person knows about their self-harm and that this person is usually a peer, it may be beneficial to train kids in how to help their friends or how to seek out other external resources for their friends (Evans 2005). While this approach is criticized by those who believe that children are generally unsuccessful in thoroughly helping other children overcome extreme difficulties and disturbances, it is nevertheless important to educate children on how to best deal with such issues. Because both children with poor parental attachment as well as children with secure attachments indicate that their friends are their primary source of support, it stands to reason that adolescents should be instructed on how best to support each other. However, this initiative alone is not sufficient in tackling the problem of adolescent self-harm; rather, a comprehensive program should be developed that includes early screening measures, social and active coping skill-building, instruction in adaptive emotion-focused coping, and peer-based instruction in identifying and preventing adolescent DSH. While deliberate self-harm among young people is pervasive and problematic, it is not an insolvable quandary. Understanding the unconscious and conscious factors that contribute to self-harming behaviors among adolescents is the first step in overcoming the problem; the remainder of the solution lies in addressing those factors by either eliminating them or developing skills that serve to buffer against them. Parents, educators and peers may all contribute to these processes, and as institutional initiatives expand and improve, it is likely that the dilemma of adolescent self-harm will resolve as well.

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