Abstract
Purpose: Self-harm is common among adolescents, and is even more frequent among psychiatric populations. The aim of this study was to increase knowledge and understanding of different aspects of life for adults who, when adolescents, had engaged in severe self-harm during inpatient stays.
Material and methods: Individual semi-structured interviews were held with seven former inpatients with a history of severe self-harm during inpatient stay in their adolescence. The interviews were analysed using a qualitative method, and the results were described in the form of categories and sub-categories.
Results: Five categories, with 16 sub-categories, were found to be related to the former patients’ experiences of their lives. At the time of the interviews, the subjects were in their early thirties and had no ongoing self-harm. In childhood they had experienced a dysfunctional relationship with one or both of their parents, and self-harm was one of several destructive behaviours. Friendships outside the unit were difficult during adolescence. Soon after admission to the psychiatric inpatient unit, relationships with other patients became important and contributed to them wanting to stay at the unit. Meaningful relationships and being part of a social context with healthy expectations were seen as important factors for stopping self-harm at a later stage. The subjects’ experiences of their life today ranged from not enjoying it to accepting their current situation.
Conclusion: These findings are based on a small sample, but they indicate the importance of relationships and the social context in contributing to and then ending self-harm.
Introduction
Self-harm is an act of deliberately inflicting harm to oneself without suicidal intention [Citation1,Citation2]. Among self-harming adolescents, self-cutting is the most prevalent method [Citation1–3]. Many self-harming adolescents have, during childhood, been exposed to psychological, physical and, sexual traumatisation, risk factors associated with self-harm [Citation4]. Domestic violence, neglect, maltreatment and brutal separations are common [Citation5]. Self-harm during adolescence is associated with comorbidity, not only personality disorders but also depression, anxiety disorders, substance use disorders, eating disorders and post-traumatic stress disorders (PTSD) [Citation1,Citation3,Citation6]. Self-harm is linked with an increased risk for suicide, and comorbid mental disorders increase the risk [Citation3,Citation6]. In a survey from 2003, 18 percent of 3600 high-school pupils in Massachusetts reported that they had self-harmed in the previous year [Citation7].
Self-harm is a global phenomenon and a major concern in society, and the prevalence among adolescents in psychiatric care is about 50 percent [Citation8–10]. The prevalence of self-harm in the general population seems to increase in younger adolescence, peaking somewhere between the ages of 15 and 17 and then decreasing in the transition into young adulthood [Citation6,Citation11]. About one percent of self-harm individuals continue with the behaviour in young adulthood [Citation12]. Extended self-harm in adolescence increases the risk for continuing self-harm in adulthood. Self-harm that leads to admission to psychiatric inpatient care increases the risk of suicide in later life [Citation3]. Self-harm during psychiatric inpatient care increases the risk of iatrogenic harm [Citation13]. In a longitudinal population-based study, adolescents who self-harmed were found to have an increased risk for experiencing psychosocial problems later in life [Citation14]. Patients’ experiences are important in helping develop prevention programmes [Citation3,Citation12] and to increase understanding of the relationship between self-harm and emotional problems later in life. Their experiences can also improve treatment methods that shorten in-patient stays, reduce iatrogenic injuries, and lower health care costs.
In the mid-1990s at the Department of Child & Adolescent Psychiatry, Malmö, Sweden, we noticed increased morbidity and extended inpatient treatment periods among the patients presenting self-harming behaviour compared to the patients who did not. Despite extended treatment periods the patients presenting self-harming behaviour were often re-admitted. Only a few follow-up studies on inpatients with self-harm have been carried out, all using a quantitative research method [Citation3,Citation6,Citation12]. The aim of this study was to increase knowledge and understanding of different aspects of life for adults with severe self-harm during adolescent inpatient stays.
Material and methods
Design
The main methodological approach used in this study was qualitative, i.e. describing and understanding the life stories told during the interviews [Citation15]. The study also used retrospective quantitative data. The qualitative approach was based on in-depth interviews, focusing on the subject’s experienced life course from early childhood to adulthood. A semi-structured interview guide with focus areas was created to illuminate different aspects and ensure that everyone was asked about the same key areas. The guide comprised questions regarding inpatient treatment, self-harm, relationships, work and study, alcohol and drugs, turning points, and joys and sorrows in life. The focus areas were chosen as important aspects in life [Citation16]. If the focus areas were not brought up spontaneously during the interviews, specific questions were asked. The subjects could respond freely to the open-ended questions.
Participants
Inpatient characteristics, including self-harm history, from the Department of Child & Adolescent Psychiatry, Malmö, Sweden, in 1999 are presented in . Twelve of the 43 unique patients admitted had at least one occasion of severe self-cutting causing bleeding during the inpatient stay, which was the inclusion criterion for the study. The most common self-harm was self-cutting.
Table 1. Inpatient characteristics, self-harm and non-self-harm respectively, from Department of Child & Adolescent Psychiatry, Malmö, Sweden in 1999.
In 2015, we identified the twelve former inpatients with severe self-cutting during their inpatient stay in 1999. One had passed away and two were not located. The remaining nine individuals (two men and seven women) were contacted with a letter describing the study. Eight individuals responded and agreed to participate. Seven interviews were conducted, as one informant did not respond when the interview was scheduled, leaving us with seven participants – six women and one man aged between 29 and 32 (mean 31) – at follow-up. All seven participants lived in apartments or houses, four had partners, and six had either a job or were enrolled in an educational programme. None of the participants reported ongoing self-harm.
Procedure
The interviews were held between December 2015 and February 2016. The seven informants were interviewed face-to-face in their home, at an open care unit or at their workplace, according to their preference. All interviews were conducted by the first author (KH). The interviews had no time limit, and lasted between 50 and 130 min, with a total of 568 min. The interview began with an open-ended question about what they remembered from their inpatient stay in 1999. The interviews were semi-structured with an explorative approach, using open-ended questions to frame the story and more specific questions to examine the experience in greater depth [Citation17].
Data collection and analysis
The research findings presented in the introduction were used as a starting point. After permission from the informants, each interview was recorded and later transcribed verbatim. The data collected in this study are accepted as the participants’ memories and experiences of their childhood and further life course [Citation18]. The transcripts were used as data for analysis performed through seven steps () [Citation19].
Table 2. The interviews were transcribed, and the transcripts used as data for analysis performed through the seven steps.
The three authors read the transcripts independently, making their own judgements before comparing them with each other. The authors met five times, with each meeting lasting four hours. After thorough and repeated reading of the interviews, the transcripts, using an inductive approach, were organised into ‘meaning units’, i.e. those parts of the transcript that related to the study aims. The emerging categories were examined and discussed from the concrete and specific to the abstract and general [Citation20], and revised until consensus was reached. Representative quotations from the material were chosen to exemplify the themes, thereby enhancing the credibility of the study [Citation21]. The analysis process ended when consensus was reached, and all three authors could agree on the five categories and 16 sub-categories.
Validity and quality
Continuous enquiry is required to ensure retrieval of high quality and relevant knowledge [Citation18,Citation22]. This applies not only to the design, but also to the collection and analysis [Citation23]. To ensure high standards, Yardley’s four dimensions, ‘commitment & rigor’, ‘sensitivity to context’, ‘transparency & coherence’ and ‘impact & importance’, were applied [Citation22,Citation24].
Ethics
The study was performed with ethical considerations and discussions based on the Georgetown Mantra, i.e. with respect for autonomy; nonmaleficence; beneficence; and justice [Citation25,Citation26]. The study was approved by the Ethics Committee of Lund University (2015/362), Sweden. Written informed consent was obtained before inclusion in the study.
Results
shows descriptive data on the 43 patients treated as inpatients at the Department of Child & Adolescent Psychiatry, Malmö, Sweden in 1999. The mean age was 15.4 years, and 63 percent of the patients were girls. Depression and anorexia nervosa were the most common diagnoses. Previous self-harm and more inpatient days were more common among the self-harming patients (n = 12) than the non-self-harming patients. No other differences were seen between groups (). shows the five categories and 16 sub-categories identified and agreed upon.
Table 3. The five categories and sixteen sub-categories found.
Early experiences
Family dysfunction
The subjects’ relationship with their parents during childhood was challenging. There was a strong sense of not feeling wanted. Intense conflicts were described, and a sense of not receiving parental support: ‘I didn’t have anyone at home who could explain how to handle sorrow, anxiety or whatever.’ When admitted to psychiatric inpatient treatment, the participants’ relationship with their parents became even more complicated, and contributed to the subjects’ psychiatric issues and later re-hospitalisations.
Traumatic experiences
During their childhood several informants had been exposed to sexual or physical domestic violence: ‘I lost my virginity through rape.’ The participants described these experiences as contributing factors to their malaise, later presented with different manifestations: ‘From nursery the food problems began with…, it was assault in early childhood.’
A need to be understood and seen
Members of staff at the child and adolescent psychiatric unit were perceived as caring and having good intentions. Informants felt that they were listened to and their need to be seen was satisfied: ‘I was a young person who didn’t feel good and really needed adult support and understanding.’
Double-edged friendships with fellow patients
Relationships with fellow inpatients quickly became important, filling the friendship void outside the unit where relationships were hard to build up and maintain. After admission, friends at home became less important. At the inpatient units, actions of self-harm gave status, where more brutal self-cutting was considered more valuable and generated higher standing: ‘With everything they had gone through, I felt important when they [the patients] included me. After six days I didn’t want to go back to the chaos [home].’ Important but dubious friendships were created, at the same time as the relationship with parents and siblings deteriorated.
Self-harm and psychiatric symptoms
Self-cutting
Self-harm, especially self-cutting, was experienced as a way of controlling feelings but also of letting them out: ‘So, when I started with the cutting, it wasn’t… it was more like releasing it, like pricking a balloon.’ Later the behaviour could be experienced as a form of addiction, with the need to self-harm helping the patient feel well. The feeling was pleasant but could also represent a way of testing limits, exploring how far they could go in inflicting pain on themselves. Self-cutting at the unit was a way to enhance status among fellow-patients and getting extra care from staff. Severe and dangerous self-mutilation occurred.
Eating disorders
Thoughts and feelings about looks, weight and later self-disgust contributed to eating disorders. These problems had sometimes been present for months and years before admission, and were experienced as a sense of being emotionally abandoned, absent on the parents’ radar: ‘I was living with a mother who had a severe eating disorder, both mother and grandmother. It was a sick family system you could say.’ In some cases, eating disorders were the reason for the first admission to child and adolescent psychiatric inpatient care.
Alcohol and drug use
Alcohol and drug usage were common and a feeling of not being able to control intake was reported: ‘I went on Antabuse on three occasions.’ Some participants later stopped drinking, while others did not consider alcohol a major issue and still drank a lot: ‘If I drink it becomes too much. I don’t know when to stop, so I ended up stopping completely.’
Suicidal behaviour
Both suicidal ideations and actions were pronounced. These thoughts and actions were experienced differently to self-harm. A feeling of not enjoying life and not wanting to continue living was described: ‘I’ve wanted to die since I was fifteen. I feel that I’m living on overtime… It’s a bit miserable.’
Treatment impact
Treatment as a negative experience
Treatment was sometimes experienced as a factor with a negative impact on behaviour and mood. A feeling of guilt and staff sanctions stopped the inappropriate behaviour temporarily: ‘They used a great deal of punishment. As soon as I’d harmed myself, they got really mad, and I was sensitive to it.’ There was an experience of frustration in only being treated with drugs. Tube feeding for patients with anorexia nervosa was experienced as a trauma rather than a part of the treatment.
Treatment as a positive experience
Treatment contacts that lasted for several years, building up close relationships, were reported as valuable for improved health: ‘It was not until later I started to see a psychologist, and what a difference it made!’ Pharmacological treatment was felt to be useful when prescribed together with psychotherapy.
Turning points
‘Had enough’
The turning point came with the awareness that there was no way forward if self-harm continued. The feeling of having gone as far down the drain as possible in the health care system was a helpful experience in changing direction in life: ‘I started to reflect over this environment I was in. Do I want it like this? Is this how I want to live?’ A sense emerged that a behaviour adjustment could only be achieved in a healthy social context. Some individuals experienced that the change was promoted when they were assigned to help others in a health-related occupation.
A context of healthy expectations
Finding a context in which other people regarded the respondents as healthy was important. This context could be found within or outside the inpatient unit, e.g. in the therapy room, in a theatre group or on stage in a rock band: ‘Drama class I must say was perhaps the most crucial factor. I got an activity once a week. Ten friends in one so to speak.’ Having friends outside the psychiatric community and starting to recapture old interests and facilitating new healthy friendships was crucial: ‘When I later went back to school, I started to get interests, ending up with healthy expectations.’ The experience of a context where the roles as a self-harmer and, for example, a student were not compatible was important.
Being of value to others
A feeling of being important to others as a friend or a partner was described as a turning point: ‘I was completely lost, but [a friend] made me realise that I was involved, part of a group.’ A sense grew that self-harm was disrespectful to persons who cared about you. Self-harm became a bigger challenge in a context where it was not acceptable. For some participants self-harm stopped abruptly in response to emotionally strong life events, e.g. becoming a mother: ‘When I had a child it became better, that was actually a good turning point.’ After giving up self-harm, relapses did occur, but only rarely.
Present state
Improved relationships
For some participants, the experience of difficulties in the relationships with parents and partners was still present. However, compared with childhood, a more positive and forgiving attitude was described: ‘The family – the relationships are better now.’ An integrated feeling of loneliness and solitude was mentioned.
A feeling of not enjoying life
An experience of not enjoying life was described. Past mental illness still affected life, and a feeling of being passive and that life was neither fun nor worth living was revealed: ‘I’m at the level where I would start upper secondary school… ten years late.’ Important relationships were given as the reason for not ending life: ‘I don’t feel any joy. The cat brings me the most happiness, and meeting my grandparents.’
Acceptance
At follow-up there was a tendency among the participants to appreciate the ‘small world’, accepting things as they had turned out to be without giving in: ‘I’m trying to accept that what has been has been, and move forward…, not be so depressed and sad over the past.’
Their previous experiences as patients in psychiatric treatment were sometimes used to help others with self-harming behaviour.
Discussion
In this follow-up study using semi-structured interviews, we describe the life experiences of individuals with severe self-cutting during inpatient treatment in their adolescence. The lives of the former adolescents hospitalised in 1999 were examined 15 years after discharge. To the best of our knowledge this is the first study with this extensive follow-up period [Citation6].
After discharge all subjects had been treated in adult psychiatric and/or forensic treatment facilities for long periods of time. Most of the subjects had been exposed to severe traumatisation during their childhood [Citation5]. Our sample showed a similar gender distribution as earlier research, i.e. girls being more likely to cut themselves than boys [Citation6,Citation27,Citation28]. We also found our sample characteristic in terms of comorbidity and method of self-harm [Citation1, Citation6]. The most common self-harming method in our sample was self-cutting, which occurs in more than 70 percent of individuals who self-harm [Citation1]. One individual had committed suicide. Extended suffering without help is a risk factor for suicide [Citation3]. The function of self-harm behaviour, e.g. affect-regulation, anti-dissociation, anti-suicide and interpersonal-influence among the participants in the present study, was not evaluated [Citation1].
At the time of the interviews, when the subjects were in their thirties, no one had ongoing self-harm behaviour. Like the results presented by Groschwitz et al. [Citation6] our informants had also been affected by mental illness, e.g. anxiety and depression but, unlike data presented in that study, we were able to confirm the findings in previous research showing that self-harm with onset in adolescence decreases in early adulthood [Citation11]. One explanation could be our longer follow-up period, 15 years instead of five years in the study by Groschwitz et al. [Citation6]
The subjects’ experiences of their present lives ranged from being able to enjoy it to not really wanting to live. The subjects’ relationships were found to contribute to self-harm onset, its perpetuation and finally the recovery.
Relationships
The subjects’ relationships were important for how they adapted through their lives. Most subjects described an upbringing in a dysfunctional family context, with parental violence, abuse or neglect, as previously described by Favazza and by Beatens et al. [Citation5,Citation29]. However, not all subjects had these early experiences of family dysfunction. For subjects with comorbid anorexia nervosa, the family conflicts first emerged during psychiatric inpatient care. A strong correlation has been found between family distress and different forms of self-harm [Citation30]. Self-harming adolescents often experience that their relationship with their parents is characterised by negative feelings, low level of protection and lack of cohesiveness [Citation31]. In the present study, the family of origin clearly contributed to the participants becoming ill, and later in life, after years of treatment, a modified family constellation often contributed to improved health.
At the inpatient unit, fellow patients and staff members soon became important for the participants. The feeling of being acknowledged by staff and fellow patients filled a need to be seen and accepted. However, the new relationships also led to self-harm, which increased social status among fellow patients and engendered more interaction with staff. The new acquaintances complicated the subjects’ relationships with parents and friends outside the unit, as the patients’ behaviour in this context gave a clear negative reaction.
Self-harming adolescents have more problems with friends than adolescents without self-injury behaviour [Citation30]. Self-harming was reinforced by the raised status the behaviour generated during the participants’ inpatient stay. The subjects linked their self-harm to bad relationships with the staff, including punishment. This could be understood as the absence of a context of healthy expectations.
Turning points
The turning points came as awareness grew that continuation of self-harm was no longer a way forward. This can be interpreted as a certain degree of acceptance, as the subjects no longer felt a need to fight against negative feelings [Citation1]. This was felt to be a condition for mobilising a feeling of being ready to change, making it possible to start an adult life outside psychiatric inpatient units. Relationships with parents improved as the subjects grew older. Good relationships with both people and pets have been reported as suicide protective factors, despite a feeling of not enjoying life [Citation32]. Living in a context outside the psychiatric community, where the participants were no longer seen as psychiatric patients, was important for recovery. Helping the subjects cope with challenging feelings was facilitated by improved close relationships and a certain degree of acceptance. The recovery was empowered by individual factors, but mainly from a feeling of being wanted and in demand, and being met with positive expectations in society.
Strengths
To our knowledge this is the first long-term follow-up of former patients who harmed themselves severely as inpatients in adolescence, and analysed with a qualitative method. Eight out of nine former patients who were contacted agreed to participate, and seven came to the scheduled interview. The study shows the participants’ experiences of previous treatment and turning points, and contributes to a deeper understanding of the relational aspects of self-harm.
Limitations
The small sample of seven individuals is a limitation that challenges the generalisability of the study results. However, in qualitative research, samples with fewer than ten participants are not unusual, and Morse suggests a minimum of six [Citation33,Citation34]. We argue that our group of participants is homogeneous and the number of informants sufficient, as we experienced the material as saturated, i.e. additional subjects would not provide new information generating supplementary categories [Citation34].
Semi-structured interviews, to some extent, always rely on the researcher’s preconceptions. To minimise bias, we decided that one of the authors (KH), who had never met the former patients, should conduct the interviews. All subjects were recruited from the same unit, and the majority (6/7) were women. As self-cutting is more prevalent among women, we found the gender distribution acceptable [Citation35]. The sample also included patients who were suffering from depression, a diagnosis more common among teenage girls than in boys [Citation36]. More information relevant to this study could probably have been retrieved from the informants’ life experiences, but, due to ethical considerations and to avoid re-traumatisation, the interviewer was careful to avoid asking supplementary questions outside the protocol.
The present study is based on informants’ memories, which brings validity into question [Citation37]. However, other authors encourage the use of recollections from childhood, even though it is difficult to evaluate the ‘truth’ in these memories which, to a certain extent, underlie the individual’s potential to understand themselves today [Citation38]. The collected data are accepted as the interviewees’ memories and experiences of their childhood [Citation39]. The individuals’ memories are partly affected by the narratives in their present lives [Citation18]. Preconceptions about the course of self-harm may have influenced the questions asked and the conclusions drawn.
Future implications
A better understanding of the function behind self-harm, i.e. the variables that reinforce the behaviour, are challenging tasks for future researchers, and could probably improve prevention and treatment programmes [Citation1]. The impact of the social context on the course of self-harm should be further examined. Additional research is needed on how friendship between patients inside psychiatric institutions influences self-injury behaviour. The way the staff at psychiatric inpatient treatment facilities influence patient behaviour should also be investigated further.
Clinical implications
The results indicate the need for caution when admitting patients with self-harm into psychiatric inpatient care. If admission is required, the present study encourages ongoing relationships with the family and friends outside the unit. Facilitating normal activities and healthy behaviour is important. Treatment programs for self-harming adolescents should include a focus on improving communication and interaction within the family [Citation31].
Conclusions
These findings are based on a small sample, but they indicate the importance of relationships and being part of a social context for contributing to, as well as ending, self-harm.
Author contributions
BAJ initiated the study and wrote the first manuscript together with KH. KH conducted the in-depth interviews. BAJ, KH and LM analysed the interviews, first individually and then together. All three authors have made significant contributions by reviewing and approving the final version of the manuscript.
Acknowledgments
Jan Arlebrink and Ingegerd Wirtberg for valuable comments on the manuscript. Anna Lindgren for statistical calculations.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
Notes on contributors
Kristian Hansson
Kristian Hansson, MSc, clinical psychologist since 2010 with a 5-year experience at the Child & Adolescent Psychiatric Emergency Unit in Malmö, Sweden.
Lars Malmkvist
Lars Malmkvist, MSc, is senior clinical psychologist and family psychotherapist working part-time at the Child & Adolescent Psychiatric Emergency Unit in Malmö, Sweden.
Björn Axel Johansson
Björn Axel Johansson completed his PhD in Psychiatry at Lund University in 2006. Since then, his research has been based on child and adolescent psychiatric in-patients, with a focus primarily on mobile technology, acute psychotic conditions and long-term follow-ups. He is a Senior Consultant at the Child & Adolescent Psychiatric Emergency Unit in Malmö, Sweden.
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